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 Care Campaign For The Vulnerable

Care Campaign for the Vulnerable is learning of the pressures faced by conscientious led Care Providers striving to offer a caring and safe environment to both service users and staff. Safety monitoring is proving to be a invaluable care assist tool - bringing a more open and transparent culture into care homes as well as saving valuable resources within the care home sector and the NHS

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Visiting in care homes during Covid19. What are your rights?

27th April 2020

Visiting care homes during the coronavirus pandemic: what exactly are your rights?

Are you keen to see or at least talk to your older or disabled relative or friend in a care home but have been told by the home’s manager that the coronavirus pandemic has rendered contact with them out of the question? I write and lecture about older people’s issues and have heard reports of care homes banning all visits of residents by their loved ones, lest they unwittingly bring the virus into the home, while also refusing to facilitate any other direct contact.

Yet denying residents contact with their family and friends can cause untold suffering. Imagine the situation of a wife who visited her husband with dementia in a care home every day, only to find that since the start of the lockdown on 23 March she has been unable to see him.

In fact, however, care homes should be taking a nuanced approach to contact, if they are to comply with government guidance (which alas has been little-publicised amongst people who live in care homes and their friends and families). The official bodies in England, Scotland, Wales and Northern Irelandhave told homes that, while routine visiting should not be taking place during the lockdown, they may permit the visiting of residents in exceptional circumstances, in particular if a resident is dying. In other words, homes should be prepared to make an exception to the general restriction if a resident is coming towards the end of their life, whether as a result of Covid-19 or another illness or medical condition.

Care homes have also been told that they should enable all their residents to maintain contact with family and friends through alternatives to indoor, face-to-face visits, such as phone calls, video calls and meetings outdoors. So if you are being denied a form of contact which could be made without risk of cross-infection and which falls into any of the categories described below, consider challenging the decision.

Here are details of the official guidance.

England
It is absolutely clear that care home managers should be prepared to permit indoor, face-to-face visits if a resident in their home is dying. In guidance published on 2 April, the Department of Health and Social Care, the NHS, Public Health England and the Care Quality Commission said that, “Family and friends should be advised not to visit care homes, except next of kin in exceptional situations such as end of life. Follow the social distancing guidance.” ¹ The exception for residents who are dying was confirmed by the Department of Health and Social Care on 15 April: “Whilst we have recommended care homes limit unnecessary visits, we are clear that visits at the end of life are important both for the individual and their loved ones and should continue.” 2 The Care Quality Commission (the registration and inspection authority for care homes in England) restated this same policy on 21 April: “In exceptional circumstances, next of kin may have to visit, for example when someone is at the end of their life.” 3

The policy on permitting visits to people who are dying should apply whatever the cause of death. Homes will wish to take steps to ensure visitors do not unwittingly bring in the infection and conversely visitors will wish to ensure they are protected, if necessary through full protective clothing if their loved one has Covid-19. In the section below about the situation in Scotland, I explain the measures the Scottish Government has advised to ensure visits are safe – guidance which would be equally relevant in England, Wales or Northern Ireland.

To mitigate the mental anguish restrictions on indoor, face-to-face visits would be likely to cause, the Care Quality Commission has urged homes to provide other means by which people living in care homes in England can enjoy contact with their family and friends. It said on March 24 that homes, “Must support people to maintain connectivity with their friends and families” (my emphasis), and should explain to their residents how they can maintain contact with their relatives and friends. 4

The CQC went on to say that alternatives which homes should consider during the visiting restrictions include, but are not limited, to:

• keeping in touch using remote technology such as phone, internet, and social media phone calls
• video calling, and
• supporting people to see their relatives outdoors, in the home’s grounds or a local open space, while maintaining the two-metres distancing rule.
Contact through mobile phone has many advantages, not least mobility – for example, mobiles could be used by a resident and their friend talking through a window, so they can see and wave to each other. Video calls can be made using phones, tablets or other computers with an internet connection, using services such as Skype, Zoom, WhatsApp, Google Hangouts and Facetime. The Care Inspectorate (for Scotland) has published a useful guide to digital communication for use by homes during the visiting restrictions. 5

The Care Quality Commission is the only one of the nationalcare-home regulators in the UK to have proposed outdoor visits, but there is no reason why care-home residents and their relatives and friends in other parts of the UK should not also put forward this alternative to their care-home manager. It would allow a resident to enjoy not only the sights and sounds of theirloved ones, but also the many physical and mental health benefits of being in the open-air, not least a change of scene and contact with the natural world. An outdoor meeting could perhaps take the form of talking at a distance across a home’s boundary fence; or a resident sitting at an open door with their contact outside at least two metres away; or a meeting in which both resident and their loved one sit and talk or stroll in the home’s garden or a local open space, while maintaining a gap of at least two metres.

Any outdoor meeting must of course be carefully risk-assessed. A home should consider whether a resident might be exposed to any risk in moving through the building to an outside door and any possible risk eliminated, perhaps by taking an alternative route or disinfecting and ventilating any potentially hazardous sections of the route. At a time of great staff pressure on many homes, relatives and friends should be flexible and recognise staff resources might not always be available to facilitate an outdoor rendezvous. But such meetings can bring huge benefits.

Scotland
The Scottish Government has told care homes they can allow visits to residents with dementia who are distressed as well as those are dying. In a statement on 26 March it highlighted these two exceptions and also offered a useful checklist of the safeguards homes should put in place to reduce the risk of cross-infection during indoor visits. This is what it said:

“Visits should be restricted to end of life care situations or people with dementia who are distressed. In such instances there should be a named contact for visiting, and ideally visits should involve one person at a time; no children should be permitted. These visitors must not visit any other care areas or facilities. Where a resident has COVID-19, it will be appropriate for visitors to wear PPE in order to be able to spend time with them. Visitors should also be asked about symptoms on arrival; symptomatic people should stay away. A log of all visitors should be kept. Consideration should be given to alternative measures of communication including phoning or face-time. Visiting may be suspended if considered appropriate.” 6

In common with the CQC, the Care Inspectorate (the care-homes regulator north of the border) has said homes should provide alternative means for care-home residents to stay in touch with their loved ones while the restriction on the vast majority of visits continues. In a document published in March it said, “Where care homes are not accepting visitors, it is important that systems are put in place to enable people to keep in touch. This is a time of concern and worry for people about their loved ones and it is important that they can keep in touch. It is also important for the health and wellbeing of people who live in services to not feel abandoned by family and friends.” 7

This booklet, written specifically for care homes goes on to offera useful guide to digital communication, explaining for instance the free Apps available to make video calls and advising homes to provide staff to give any necessary help to a resident to make a phone or video call. If a resident cannot make a call in their own room, staff should make space available for calls to be made in private; when selecting the location for a call, theyshould consider background noise and lighting, as these can affect ability to hear and see clearly, the Care Inspectorate has advised. If a staff member has to be present during the call to help the resident use the device, all participants should be made aware of their presence. Importantly, the Inspectorate has also told staff that they, “Have a duty to ensure that all equipment they use in whatever setting is clean when used and effectively decontaminated between each use, either by staff or individuals in the care service.” 8

Wales
The official bodies in Wales have broadly copied the guidance on the exceptional circumstances under which homes should permit indoor visits referred to above for England. The Welsh Government told care homes on 23 March that, “Visits to a care home should now only take place when absolutely essential and not as part of routine visiting previously experienced at the home. … Any request for a visit for a specific purpose felt to be absolutely essential must be made to the care home manager for a decision. The visit, if agreed, should be one person to see the individual and should not include children. We recognise that sensitive discussion will need to take place around residents receiving end of life care. Any visit felt to be absolutely essential should be restricted to an agreed time of day and for an agreed period when staff can facilitate safe access to the person they are visiting.” 9

Continuing to echo the approach in England, the Welsh Government went on, “It is essential that moving to an essential-only level of visiting is supplemented with opportunities for social contact within the care home, particularly where residents spend time in their individual rooms. Regular telephone calls with family and friends should be encouraged and consideration could be given to visual mechanisms such as video calls e.g. Skype or FaceTime.” 10

Northern Ireland
Since the lockdown on 23 March, visiting has also been much restricted in Northern Ireland. However, homes should be prepared to allow exceptions, particularly if a resident is dying, so long as appropriate safety measures can be put in place. The Regulation and Improvement Authority (the care-home regulator in Northern Ireland) has told care homes that they, “Should seek to facilitate and increase other forms of contact as far as possible – for instance, telephone calls or video calls.” 11

A glaring inconsistency
The extent to which people with dementia experience distress varies greatly. Many do not seem distressed, particularly in the early stages of the development of the condition. However, somepeople with dementia are very distressed if they no longer see their loved ones: unable to understand the reason for their absence nor retain the memory of any explanation, they may believe they have been abandoned. Others who have lost virtually all their powers of comprehension and memory of words may be very distressed for most of the time. For such people, reality exists only in the moment, as with a baby, leaving them unable to contextualize their confusion nor understand the cause. They may constantly call out for help and find comfort only from the presence of one or more familiar individuals, usually family members or close friends.

If someone with a mental illness such as dementia is in hospital and not visiting would cause them to be distressed, NHS England and NHS Improvement said on 8 April that a close family member or carer should be able to visit. 12 As explained above, the Scottish government has said that care homes should also permit the visiting of “people with dementia who are distressed” during the lockdown. 13 I consider that this exception should also apply in England, Wales and Northern Ireland. Its extension to people with dementia who are distressed in those countries would reduce the likelihood of a huge amount of unimaginable suffering.

General advice on keeping in touch
Two charities – Dementia UK and the Relatives and Residents Association – have jointly published practical tips for relatives unable to visit (such as sending in photos, flowers and other treats) and for care home staff looking after residents in the absence of their family and friends (such as trying to maintain a positive attitude and being aware of milestone dates such as birthdays and wedding anniversaries which may affect a resident). 14 You may find some of their suggestions useful.

Marion Shoard
author: How to Handle Later Life

25 April 2020

References

1. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/880274/Admission_and_Care_of_Residents_during_COVID-19_Incident_in_a_Care_Home.pdf
2. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/879639/covid-19-adult-social-care-action-plan.pdf
3. https://www.cqc.org.uk/guidance-providers/adult-social-care/information-adult-social-care-services-during-coronavirus-outbreak#restricting-visitors
4. https://nationalcareassociation.org.uk/news-events/news/visiting-care-homes
5. https://www.careinspectorate.com/images/Supporting_people_to_keep_in_touch_when_care_homes_are_not_accepting_visitors.pdf
6. https://www.gov.scot/publications/coronavirus-covid-19-clinical-guidance-for-nursing-home-and-residential-care-residents/pages/2--measures-to-prevent-and-prepare-for-infection-in-residents/
7. https://www.careinspectorate.com/images/Supporting_people_to_keep_in_touch_when_care_homes_are_not_accepting_visitors.pdf
8. https://www.careinspectorate.com/images/Supporting_people_to_keep_in_touch_when_care_homes_are_not_accepting_visitors.pdf
9. https://gov.wales/visits-care-homes-and-coronavirus-guidance-service-providers
10. https://gov.wales/visits-care-homes-and-coronavirus-guidance-service-providers
11. https://www.publichealth.hscni.net/sites/default/files/2020-03/GUIDANCE%20FOR%20RESIDENTIAL%20CARE%20PROVIDERS%20-%20COVID19.pdf
12. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0030_Visitor-Guidance_8-April-2020.pdf
13. https://www.gov.scot/publications/coronavirus-covid-19-clinical-guidance-for-nursing-home-and-residential-care-residents/pages/2--measures-to-prevent-and-prepare-for-infection-in-residents/
14. https://www.relres.org/keep-in-touch/
15. http://www.marionshoard.co.uk/
16. http://www.amaranthbooks.co.uk/titles/how-to-handle-later-life/

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Care Campaign for the Vulnerable is learning of the pressures faced by conscientious led Care Providers striving to offer a caring and safe environment to both service users and staff. Safety monitoring is proving to be a invaluable care assist tool - bringing a more open and transparent culture into care homes as well as saving valuable resources within the care home sector and the NHS

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