This blog summarises care home visiting rules across the UK’s four nations of England, Scotland, Wales and Northern Ireland.
England - Inward visits
The relevant government document is "Guidance on visiting care homes". The March revision came at a time when the rate of new infections was decreasing, and when the vast majority of care home residents and staff had been vaccinated. It clarified the situation whereby many care homes banned visits, despite the guidance saying that visits can take place with arrangements such as screens and pods. The April revision made small amendments.
The 19 December 2020 version acknowledged "the particular challenges visiting restrictions pose for people with dementia, people with learning disabilities and autistic adults, amongst others, as well as for their loved ones" - the March version contains no such language. The March version stated that "visiting is a central part of care home life".
From 17 May 2021, if there is an outbreak in a care home, visits are to be suspended for 14 (formerly 28) days assuming there are no variants of concern.
The guidance contains five main messages:
1 - Making decisions about visits
The registered manager of each care home is responsible for setting a visiting policy for that care home, on the basis of a “dynamic risk assessment”. The guidance contains tips for managers writing their visiting policy and when making visiting decisions for particular residents or groups of residents. It reminds providers of infection-control precautions and the need to communicate with family and others about the visiting policy and visiting decisions.
It is for the care home to decide on visit arrangements. The views, needs and wellbeing of the resident should be taken into account when decisions about visiting are made.
The guidance says that for people who lack capacity to consent to the care home's visiting policy a best interests decision must be made on their behalf. Decisions must be tailored to the individual and must be in line with the guidance, and comply with the Human Rights Act 1998 and the Equality Act 2010.
2 - Named visitors
Each resident can nominate two (and from 17 May: five) named visitors for regular visits. Where the resident lacks capacity to make this decision, the care home must discuss the situation with the resident's family and friends who have visited the resident, and a decision must be made in the resident's best interests. See Coronavirus (COVID-19): looking after people who lack mental capacity, last updated on 12 January 2020. Where there is a conflict, the care home should alert a social worker.
Each named visitor should have a rapid lateral flow test (LFT) before each visit. Separate guidance on such testing in care homes is here. If the visitor tests positive they should leave immediately and follow the self-isolation guidance.
The visitor must wear the same type of personal protective equipment (PPE) as staff, and follow infection control measures. If the resident being visited is believed to have COVID-19, or is coughing, and the visitor will be within 2 metres of them, the PPE should include eye protection such as goggles or a visor.
Visits should take place in a well-ventilated room. Areas used by visitors should be decontaminated several times throughout the day.
Visitors are "advised to keep physical contact to a minimum". This includes holding hands, but not hugging.
3. Essential Care Giver
This concept was introduced in the 4 March 2021 guidance. Residents with "the highest care needs" (undefined) may nominate an "essential care giver" to provide care that cannot easily be provided by staff. This could include intimate care such as help with washing and dressing where the resident becomes distressed unless it is carried out by a familiar loved one. Another example given a resident who refuses to eat unless they do so in the company of a loved one.
4 - Other people
Care homes may continue to offer outdoor, pod and window visits to other family and friends. There is no limit to the number of visitors or the regularity or duration of these visits.
Neither the resident nor the visitor need to have had a vaccination before the visit takes place (though it is highly recommended that they do so).
The guidance is silent on whether these 'other people' are required to have COVID-19 tests before visits.
5 - Exceptional circumstances
Visits in "exceptional circumstances" such as end of life should continue in all circumstances, including an outbreak of COVID-19 in the care home.
End of live means the last year of life, not just the final days or hours. The guidance recognises that calculating end of life may be difficult. The key is open communication between residents, relatives, health professionals and care home staff.
England - Outward visits
The government has issued separate guidance on visits by residents out of care homes. There has been considerable anguish that care homes have de facto detained every resident for several months. The latest guidance which takes effect from 21 June 2021 states that, "Outward visiting should be possible unless there is evidence to take a more restrictive approach in a particular care home".
Every resident may leave the care home. If a resident does so, he/she must comply with current national Coronavirus regulations and guidance.
The resident, as well as all members of a household with whom the resident is to meet, must have a negative LFT before the visit.
Previous iterations of the guidance contained a requirement for the resident, upon return from the visit, to isolate for 14 days. The current version removes this requirement, and states:
"There are certain types of activity where the risks are inherently higher and will mean that the resident should self-isolate on their return (to the care home). This is to ensure that, in the event they have unknowingly become infected while out of the home, they minimise the chances of passing that infection on to other residents and staff. These activities are:
- overnight stays in hospital
- visits assessed to be high-risk following an individual risk assessment
This remains under review, and it is our ambition that guidance on the need for self-isolation following overnight stays in hospital will be amended as soon as the data and evidence show it is safe.
All other visits out of the care home that are not assessed as high risk should be supported without the need to isolate on return to the care home, subject to an individual risk assessment (see section on individual risk assessments below). Where applicable, attention should also be given to any additional local guidance provided by the local director of public health (DPH) and director of adult social services (DASS)."
Care homes may allow indoor visiting for up to two designated visitors per resident, so that each visitor has one visit per week. Only one person should visit at a time.
The period of 14 days self-isolation should be observed wherever possible, so designated visitors would not normally be considered in this period.
The guidance contains a checklist with conditions for resuming indoor visiting:
- No outbreak.
- Infection prevention and control (IPC) compliance, including physical distancing.
- Visitor screening to exclude anyone with COVID-19 symptoms.
- Visitor testing of asymptomatic visitors, with lateral flow device.
- Staff testing.
- Designated visitors agreed between the care home and the resident/proxy, with an individualised care plan.
- Resident's vaccination (although this is not a prerequisite to visits).
- Clinical team have no concerns about the care home's quality assurance indicators.
- Local Directors of Public Health have oversight of visiting policies.
The guidance contains two snazzy acronyms: SAFE and HOMES:
Family and friends visiting can help by:
S - Staying at home if you are unwell
A - Arranging your visit in advance (and any changes)
F - Face coverings-—wearing these and any other PPE required by the care home
E - Engaging with the care home – you are partners in care and have a shared responsibility to follow advice to keep family and others safe and taking the test when offered it
The care home will help by:
H - Helping you to feel supported when visiting (e.g. informed, a safe and welcoming space, appropriate equipment, and providing on site Covid-19 testing)
O - (being) Open to your concerns and needs
M - Managing time with your loved one in a safe manner
E - Essential visits arranged in partnership with you and your family member
S - Showing you how to visit safely
The Welsh Government's "Visits to care homes: guidance for providers" was updated on 12 March 2021.
The guidance continues the concept of a “designated visitor” which means a single relative or friend of a resident who is the primary indoor visitor when COVID-19 circumstances allow. The purpose of assigning only one person is to reduce the footfall in the care home and thereby reduce the risk of infection. Each designated visitor may have a “deputy” if the designated visitor is genuinely unavailable (due to illness, for example), but the roles are not intended to be interchangeable.
In all other respects, the Welsh guidance contains similar provisions to the English guidance, above.
A curiosity about the Welsh approach is that the guidance contains an “Ethical framework”, a list of principles to guide care home managers' decision-making. The guidance lists “human rights” as a principle to be considered alongside abstract nouns such as respect, reasonableness, inclusiveness, flexibility, accountability, proportionality and community. (Those abstract nouns are also listed in the Westminster government’s Ethical framework for adult social care published on 19 March 2020.) The Welsh government’s position makes little sense and is in my view incorrect in law, given that a human rights approach should be the framework, not a subset of it. Where a resident's care is funded by the state, the care home is an organisation that carries out a public function and must comply with the Human Rights Act 1998. The suggestion that care homes must have regard to human rights alongside a list of lofty principles makes little legal sense because the Human Rights Act says that "It is unlawful for a public authority to act in a way which is incompatible with a Convention right" - s.6(1).
The Visiting With Care guidance states that "a local visiting policies should take account of theEuropean Convention on Human Rights (ECHR), and in particular Article 8, which provides a right to respect for private and family life. Whilst it is important that any visiting policies take account of the evolving evidence about the harm posed from the virus, these need to be carefully balanced with the evidence about the positive impact on health and wellbeing from seeing family and loved ones has on residents in considering what is necessary, justified and proportionate."
For 4 weeks starting 7 May 2021, visits take place under the heading "Cautious First Steps" set out in Appendix 1. The key features are that the number of visits increases to 2 per week (to be reviewed 2 weeks post implementation with a view to increasing to 3). Visits are limited to 2 people at one time and may last up to 1 hour. Visits will be accessible over a 7 day period as well as after 5pm. (It is envisioned that there will be a review 4 weeks after 7 May 2021, to enable the number of people able to visit at one time to 4 from no more than 2 households at any one visit and a maximum of 4 visits per week.)
Hand-washing replaces the use of gloves to enable handholding. Aprons and masks will remain.
Residents may resume trips out of the care home following the restrictions applicable to the general public. There is no isolation requirement upon return.
Care homes without an outbreak "should facilitate a variety of visiting arrangements" that taken account of the resident's health and care needs, "operate in accordance with the care home's dynamic risk assessment and visiting policy" - the guidance provides more detail on care homes should go about developing its risk assessment and visiting policy. Like the other nations, in Northern Ireland, visitors must wear PPE and comply with infection prevention and control measures.
Whilst testing and vaccination are both encouraged across the care home sector, neither are a requirement to facilitate a visit to a care home.
If there is an outbreak of Covid-19 in the care home, visits and outward trips may not take place.