This blog summarises care home visiting rules across the UK’s four nations of England, Scotland, Wales and Northern Ireland.
England - Inward visits
The Department of Health and Social Care "Guidance on visiting care homes" was revised on 4 March 2021 and again on 6 April 2021. 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 March version states that "visiting is a central part of care home life". 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 current 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 single 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.
The 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
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. The introduction of the essential caregiver role is a new feature of the 4 March 2021 version of the guidance.
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 version of this guidance (updated 7 April 2021) says the following:
"Outward visiting should be possible unless there is evidence to take a more restrictive approach in a particular care home".
Working age adults (and from 12 April 2021 every resident) may leave the care home.
If a resident leaves a care home he/she must comply with current national Coronavirus regulations and guidance (e.g. currently the resident would not be able to meet relatives inside their homes).
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.
Upon return from the visit, the resident should isolate for 14 days (the government recognises that this may well be off-putting and as a result many people will decide to have visits at the care home).
Supplementary guidance came into force on 4 May 2021. This new document says that residents should be enabled to leave their care home to spend time outdoors, without subsequent isolation for 14 days, in the following circumstances:
- residents may be accompanied by:
- a member of care home staff
- one or both of their nominated visitors
- their essential care provider (where applicable)
- care homes should discuss arrangements with residents’ nominated visitors, or essential care provider, in advance
- visits should take place solely outdoors, except for the use of toilet facilities
- there should be no visits to indoor spaces (public or private)
- the exception to this is that residents will be able to access polling stations
- visits should not involve the use of public transport
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 Northern Ireland Executive's guidance on the current lockdown says that care home visits are restricted.
The "COVID-19: Regional Principles for Visiting in Care Settings in Northern Ireland" document was updated on 26 February 2021. It contains a document about care homes, effective from 1 March 2021. There is also an Easy Read version.
The guidance states that a blanket ban on visits, and "a failure to adopt an individualised approach to the safety of visits will breach the Article 8 [ECHR] rights of both the patients and their families". Decisions to deny visits may only be made following a risk assessment, and must be communicated to the resident and their families.
Residents may nominate up to two people to be regular visitors. If one of these people becomes ill, another person can be nominated (as in the Welsh guidance).
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.
Curiously, the guidance is silent on whether the visitor requires a Covid-19 test before visiting. The guidance makes reference to the care home testing programme, which does covers staff and residents, but not visitors.
The guidance mandates care homes to take into account the different rules depending on the "surge level". Northern Ireland is the only nation to make reference to varying rules depending on the external Covid environment (similar to the previous tier system in England).