Images that will be remembered from this pandemic are those of friends and family visiting their loved ones through the windows of care homes. These images are illustrative of how much harder it has been to stay in touch with someone who lives in a care home during the pandemic. Visits were severely restricted during the first lockdown and the guidance on visiting care homes has changed throughout the various lockdowns and tiered systems. However, in light of the improved facilities for visiting indoors and outdoors at care homes as well as increased access to testing and PPE, the challenges faced by care providers to facilitate visitors are slightly different during this third lockdown.
Visiting Care Homes during COVID-19 was updated on 12 January 2021 and applies for the period of the third national lockdown which began on 6 January 2021. The updated Guidance supplements The Health Protection (Coronavirus, Restrictions) (No.3) and (All Tiers) (England) (Amendment) Regulations 2021. The guidance highlights the importance of visits generally in that they are a central part of care home life and are crucial for maintaining the health and wellbeing of residents. Care providers should support and enable visiting wherever it is possible to do so safely in line with the guidance. Essentially it is about finding the right balance between the benefits of visiting for residents’ wellbeing and quality of life and mitigating the risk of transmission of COVID-19.
It is acknowledged in the updated Guidance that “Each care home is unique in its physical layout, surrounding environment and facilities. Residents vary in their needs, health and current wellbeing. Care home managers are best placed to decide how their care home can best enable visiting in a way that meets the needs of their residents both individually and collectively.” Therefore, in accordance with the updated Guidance, the Registered Manager is responsible for undertaking a dynamic risk assessment taking into consideration the needs of individuals within their home with regard to the advice of the local Director of Public Health.
The updated Guidance is easier to navigate for the primary reason that we are not currently working in a system of tiers. When we were in a tiered system, those living in Tier 4 were allowed to visit friends and family in a care home. Visiting a member of one’s household, a close family member or friend was listed in Schedule 3A(2)(7)(e) of The Health Protection (Coronavirus, Restrictions) (All Tiers) (England) Regulations 2020 as a reasonable excuse/exception to the general restriction that “no person who lives in the Tier 4 area may leave or be outside of the place where they are living without reasonable excuse”. However, if the care home was in Tier 4, the visit should be outdoors or ‘screened’. If the care home was in Tiers 1, 2 or 3 the visit could be indoors where the visitor had been tested and returned a negative result. The substance of the previous version of the Visiting Care Homes during COVID-19 guidance is largely the same as the current version. The current guidance is easier to navigate in that the guidance that applied specifically to Tier 4 now applies nationally.
The key message is “All care homes, except in the event of an active outbreak, should seek to enable outdoor visiting and ‘screened’ visits…visits in exceptional circumstances including end of life should always be enabled”.
Outdoor visiting is challenging to facilitate during winter. Whilst some care providers have temporary outdoor structures, sometimes referred to as ‘visiting pods’, this is not the case for all. Alternatives to visiting pods include the familiar window visits or use of an awning, gazebo, open-sided marquee or a conservatory. It would appear that where a visiting pod or conservatory is used for visiting, the visit is considered as an indoor visit so there would need to be a Perspex screen between the resident and the visitor (designed to reduce the risk of viral transmission), for it to fall into the category of a ‘screened’ visit. That said, the guidance refers to the use of screens for all visits whatever the building structure. In addition, the following guidance should be observed:
- Visitor and resident should remain at least 2 metres apart.
- The visiting space is used by only one resident and visiting party at a time.
- There is good ventilation.
- Visitor numbers should be limited to a single constant visitor wherever possible.
- Appropriate PPE must be worn throughout the visit.
- High-quality infection prevention and control (IPC) must be maintained throughout the visit and through the wider care home environment.
On the topic of IPC, care providers must ensure that the care homes visiting policies set out what will be done in respect of infection control during visits as well as the care homes wider IPC practice. In IPC inspections, the CQC assesses care homes adherence to infection control measures for visitors. When inspecting the CQC looks at the measures in place to prevent friends, family, professionals and others visiting from spreading infection at the entrance and on entering the home, the procedures people have to follow during the visit, how they’re explained and how well they are followed by visitors. The updated Guidance sets out consideration for IPC measures for visitors including care homes having relevant guidance, procedures and protocols readily available for visitors to read, hand washing and hand sanitizer facilities and screening visitors for COVID-19 symptoms.
The CQC introduced IPC inspections in August 2020 and at the time, they focused on identifying best practice. By the time the results of the IPC inspections were published in November 2020, the CQC had carried out 440 inspections. Whilst IPC for visitors obtained the highest level of assurance (91%), the CQC noted the negative impact visiting restrictions were having on residents not seeing their families and friends in the way they were used to. It is worth noting that the CQC identified that care homes found it challenging to ensure social distancing during visits and in some cases signage and screening procedures could have been improved.
The CQC are continuing to conduct IPC inspections and are on track to complete 900 inspections by the end of January 2021. However, the CQC are no long focusing on “good IPC” practice, but are carrying out risk-based IPC inspections. Visitors is one of the eight different areas that the CQC assess at an IPC inspection, the other areas being shielding, admission, use of PPE, testing, premises, staffing and policies. Moreover, the ratings are different, and instead of rating a service as ‘outstanding’, ‘good’, ‘requires improvement’ and ‘inadequate’, the CQC report on whether they are ‘assured’, ‘somewhat assured’ or ‘not assured’. The CQC have been known to convert an IPC inspection into a focused or comprehensive inspection and to take enforcement action. Care providers have 10 working days to challenge an IPC inspection draft report and should do so if unhappy with its content. Our highly experienced team of lawyers provide robust factual accuracy challenges against CQC draft inspection reports.
There is no one size fits all approach with visiting policies, furthermore, care providers must be equipped to deal with exceptional circumstances. Care providers should undertake individual risk assessments taking into account any significant vulnerability of residents and at the same time comply with obligations under the Equality Act 2010 and the Human Rights Act 1998. For some residents with dementia and learning disabilities, they may lack capacity to consent to a provider’s visiting policy and the safeguards provided by the Mental Capacity Act 2005 (MCA) apply in which friends, family, advocates or those with power of attorney are consulted and if necessary a tailored visiting policy is developed. Care providers should not be making blanket decisions for groups of residents. End of life visits continue in all circumstances, including in the event of an outbreak in a care home. Families and residents should be supported to plan such visits and communication needs to be timely. Care providers must adhere to the MCA, non-compliance can result in criminal and civil sanctions. It is wise to seek legal advice to ensure compliance with all aspects of MCA, including the implementation of lawful policies and procedures.
With the number of COVID-19 cases increasing, it can seem easier to stop visits altogether, but such an approach leads to inequality for those with disabilities and has a detrimental effect on the health and wellbeing of residents. Visiting takes careful planning and risk assessment. It is for care providers to assess the specific circumstances of the care home and those living and working within it. This could mean that the frequency of visits are controlled, alternative ways of communicating are offered between visits and resident’s friends and family are provided with regular updates.
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