Welcoming visitors back to care settings

The following text is an excerpt taken directly from the CPA website:

Introduction

This protocol has been produced following understandable calls from residents, friends and families, providers and staff to enable visiting to residential homes after a long and protracted period of ‘lockdown’, in line with changes within the wider community. It has been produced in response to this request from some very practical help.

At the point of writing there has not been updated guidance from government about how more regularised visiting should be managed. However, the CPA is aware that this is in the process of being developed. In addition, the government has not committed to routine and regular testing for all staff and residents.

We know that for some organisations the absence of updated guidance and routine and regular testing will mean that opening up visiting at this point will not be possible, and we support them in that decision. However, for others this is something that they have been considering and discussing with residents, relatives and staff and we hope that this document will support them in achieving their objectives to open up the home more regularly in a way which is safe and proportionate to their localised understanding of risk.

Purpose

This protocol aims to provide a set of principles and top tips to help people using care and support to have the opportunity to safely receive visitors during the COVID-19 pandemic, while minimising the risk of its introduction to, or spread within, the care setting.

It is primarily aimed at care settings which cater for older people, including people with dementia, such as residential and nursing homes. However, it will be of help for other care settings such as those supporting working age people with a range of vulnerabilities, including physical, sensory or learning disabilities. The CPA will be producing protocols for other settings, including home care and supported living.

This protocol recognises how difficult it has been for both people using care and those who care for them (loved ones and staff) to restrict visits, and the importance of finding ways to start to enable visits again in a risk-based, balanced way, and help to reduce the inevitable anxiety experienced by the families and friends of those in care settings as they have been unable to visit them for some time.

This is intended to complement and not to replace the very creative and innovative ways in which care providers have been facilitating ‘virtual’ visits, connecting people via technology to keep in touch, while acknowledging that these have, understandably, been more effective for some groups than others.

Background

The protocol is intended to help during the COVID-19 outbreak, which is anticipated to last for a sustained period, compared to the usual period for other infectious outbreaks. As we see other parts of our community experiencing a small degree of easement of the lockdown rules in England, it is important to recognise that for those in residential care settings, there is a need to balance the continued management of COVID-19 risk, with a cautious approach to enabling the opportunity to receive visitors.

Human rights recognise that all people living in care settings have the right to freedom of movement and association, including the right for residents to see their families. This protocol seeks to balance the rights of an individual with the rights of the others within the care setting (residents and staff) and the duties and responsibilities of the care provider.

For many people living in care settings, it is very important that they are able to experience ‘in person’ visits; especially, for example, those with cognitive impairment or dementia whose understanding of the current situation may be limited and who may be significantly affected by the absence of visits, with a deterioration in their overall health and wellbeing. Levels of anxiety and distress resulting from the absence of visits may be increased, while nutrition and hydration may be decreased as often their visitors play an important role in supporting these daily routines in the care setting. People with communication difficulties are another group for whom ‘in person’ visits are key as ‘virtual visits’ can be very challenging.

Thinking about people in care settings more broadly, there is good international evidence that lockdowns are resulting in mental and physical deterioration of residents. Comas-Herrera tells us:

“Family visitors play a large role in the wellbeing and care of care home residents, providing not just love and company, but often help residents with feeding, grooming and recreation. They also play a role in advocacy and timely detection of changes in health of residents. It is likely that without visitors and excursions, and with spatial distancing reducing group activities, residents will feel even more lonely and bored. These feelings might be expressed through aggressive or agitated behaviour or social withdrawal and apathy [35], which might be treated with psychotropics if staff are not able to manage. Limited opportunities for physical activity may also result in loss of muscle mass and strength, this deconditioning occurs within a few days of hospitalisation in frail older people [36]. Limited opportunities for cognitive stimulation and activity may result in greater cognitive decline in people with dementia [37].”

Many of those who are living in care settings – such as care homes and nursing homes – are at higher risk of catching COVID-19 and of having poorer outcomes due to co-morbidities, and many will be shielding. The approach to enabling visitors has to be based on the circumstances of the individual care setting (including both residents and staff), the individual needs of the residents within that setting, and the external COVID-19 environment around that care setting.

There are a range of responsibilities on and expectation of visitors to care settings which the care provider will need to be clearly set out in any visiting policy.

Given the uncertainty about the future progress of COVID-19 and difference in local transmission rates, providers and the whole care home community will be working in a dynamic situation that will require constant vigilance.

Principles for considering how to enable visitors to care settings

Care providers should take a dynamic risk-based approach to how they facilitate and manage visits to care settings, which will need to consider the safety of all their residents, staff and visitors and minimise the risk of any COVID-19 infection.

This will have to balance the risk of harm to residents not having visits, with the risk of harm to residents, staff and visitors. Care providers will need to ensure they take a person centred approach to their visiting policy, taking account of individual needs and capabilities.

Types of visits

Visits may occur in a number of ways:

• Window visits: This will need safe ground floor window access for both residents and their visitors and the relevant social distancing and PPE measures will need to be observed.
• Garden visits: Relevant PPE measures and social distancing will apply. Independent access to the garden will be needed to avoid visitors moving through the care setting to the garden. Providers will need to consider how to facilitate garden visits in different weather conditions, how to ensure cleaning of areas and any items used between visits and keep everyone safe, whatever the weather.
• Drive through visits: These are facilitated visits in the car parks of homes. Again, any relevant PPE measures and social distancing will apply.
• Designated areas within a care setting where settings allow for this: depending on the physical layout of the care setting, it may be possible to enable visits to an identified location inside the care home reserved for this purpose, that facilitates good ventilation, social distancing, ease of access by residents, and limits visitor journeys through the residential areas. An example might include the use of a conservatory as a designated visiting area.
• In-room visits: These visits may continue to be facilitated as appropriate, in line with national guidance in relation to essential / end of life visits to ensure the person can die with dignity and comfort, taking into account their physical, emotional, social and spiritual support needs.

The range of visits made available will be negotiated between the care providers, their residents, their staff and their visitors. It may be possible for residents and visitors to have visits in a variety of these forms, as circumstance allow.

Policies and procedures

Care providers should work closely with their staff teams and care managers to provide appropriate support, policies and procedures to enable staff to facilitate visits safely and in line with all the relevant guidance.

Care providers may wish to consider developing a short individual visiting plan for each resident (My Visiting Plan) with the overall care plan, tailored to their visiting wishes and preferences, taking account of their individual needs and capabilities and the circumstances of the family/ friends who the resident would like to be able to visit them.

Care providers will want to carefully regulate and limit the number of visitors initially in order to minimise the risk of the introduction of COVID-19; for example, enabling one person to visit at a time, with a maximum of two visitors from the same household any one time to the individuals identified by the resident/ person receiving care, or in discussion with the relevant person with decision making authority of the resident if the resident cannot make that choice.

It is not possible to enable visits by children at present, given the current guidelines and PPE and social distancing measures as of June 2020.

Visits between residents and their visitors must operate fully in line with the latest infection prevention and control guidance including provisions relating to the use of designated areas for visits and the use of social distancing practices, good hand hygiene, use of PPE for visitors and residents.

Visits will need to be booked in advance for a specific day, time and length of visit, to enable visiting to be re-established within the setting. Visitors must check in with the care provider on the day prior to their visit, just in case the situation in the care setting has changed.

Providers may wish to create a ‘ Responsible Visitor Code’ which sets out a range of responsibilities that visitors must abide by prior to and during any visit.

The code could state that visitors must:

• book visits in advance for a specific day, time and length of visit
• check in with the care provider on the day prior to their visit, to ensure the situation in the service has not changed
• be free of any COVID-19 symptoms on the day of their visit
• not be unwell on the day of their visits
• provide the necessary information required by the provider at the visits (e.g. honest response to screening requirements about COVID-19 risk factors)
• comply with the infection prevention and control measures, including a temperature test, mandatory hand hygiene, the use of PPE as required and social distancing requirements, remaining in the designated visiting area
• ensure that any gifts brought to give to the individual they are visiting can be sanitised, in line with relevant infection prevention and control (IPC) guidance.

Care providers will discuss with potential visitors the best way to get to and from the home. Wherever possible, visitors should a try to walk or travel by car and avoid public transport when visiting the home, in line with the latest government advice on travel during COVID-19.

Ability to suspend visiting

In the event of any suspected or actual outbreak of COVID-19, or a suspected or known case of COVID-19 within a home, visitor restrictions may need to be immediately implemented which suspend some of these enabling approaches and will include exclusion of any non–essential visitors. This should be implemented in a transparent manner with open and clear communication to residents and relevant family members.

Care providers will vary their own responses to enabling visits in person to care settings as COVID-19 risks change within their local community, using their dynamic risk-based approach.

Effective communication

Care providers will ensure that they communicate effectively with relatives and other key stakeholders in an open and transparent way about their approach to visiting, in line with the recent joint statement: Keeping Connected: transparency.

Learning as the situation develops

Care providers will be able to review their visiting policies as they learn from their implementation of opening up to visitors and as the wider COVID-19 situation and guidance/ advice evolves.

Suggestions for future consideration from consultees of family representatives on this protocol include: exploring ways in which children may be enabled to visit safely and how a potential ‘staff support volunteer role’ may be possible to enable those relatives who used to visit regularly and spend a lot of time at the care setting and assist with meals/ other activities to return in the longer term.

Rights and responsibilities

This protocol includes a set of rights and responsibilities for both care providers and visitors which put the welfare and wellbeing of residents/ people receiving care at the heart of the approach to developing their visiting policies.