Visits to care homes: guidance for providers

Version 6 of the guidance supersedes previous versions.  It has been revised to support routine indoor visiting by two designated visitors (or designated deputies). Advice on physical contact is set out within Appendix 2.

In response to the COVID-19 pandemic, the Welsh Government imposed restrictions on citizens. These were put in place to prevent, protect against, and control the spread of coronavirus in Wales. 

The restrictions set out in the Welsh legislation may differ from those elsewhere in the UK, so it is important you understand the law and guidance as it applies in Wales. If you provide care and support services in more than one UK nation, you must apply the legislation and guidance of the country in which each individual care home is located.

This guidance is intended for providers of all care home services for adults and/or children.

The guidance has been produced to assist providers in supporting residents to reconnect safely with their families, friends and professionals during the pandemic. It must be implemented in conjunction with visitor testing, infection prevention and control (IPC) measures, including social distancing, hand hygiene and use of personal protective equipment (PPE). Separate guidance for providers of supported living services and supported housing services is available. 

Balancing the rights and responsibilities in relation to people living in, working in and visiting care homes during the COVID-19 pandemic is not easy or straightforward. Staying connected to family, friends and professionals is important for maintaining people’s well-being and quality of life.

The guidance contains information for care home providers to consider how they can support people living/staying in care homes to reconnect safely with their families and friends. The information is not exhaustive. Care homes and their environments are all very different, as are the people living/staying in care homes. Therefore, it is important that providers do not adopt a ‘one size fits all’ approach. Consideration must be given to the individual needs of people receiving care and support and individual characteristics of services. 

While care homes will be guided by the local Incident Management Team (IMT) on the risks, the ultimate decision on whether, and in what circumstances, care home visits take place rests with the individual care home provider. We understand some providers will find it more challenging to facilitate visits than others and the risks for children and staff in care homes for children are different to those for older people, for example. However, we know that staying connected to family and friends is important for people’s well-being. 

The guidance contains an ethical framework and information, which is consistent with the requirements of the wider coronavirus restrictions.

Decisions on visiting must be based on individualised risk assessment, which upholds people’s rights and weighs the impact on well-being and risks. Decisions should involve the resident, their representatives / advocates, the provider and other relevant professionals such as social workers and clinicians where appropriate. Public Health Wales has developed guidance to support care homes in undertaking risk assessments to support visits to and visits out from care homes. 

All decisions should be taken in light of general legal obligations, such as those under the Equality Act 2010 and Human Rights Act 1998, as applicable.

We expect and encourage providers to facilitate visits wherever possible to do so, in a risk managed way.

Please see links to the current guidance for care homes:

PHW guidance to prevent COVID-19 among care home residents and manage cases, incidents and outbreaks in residential care Settings in Wales

PHW advisory note on PPE for use in care homes

PHW risk assessment guidance for visiting into or out of care homes

Frequently asked questions – guidance for children’s care homes and COVID-19

When using visiting structures/pods, providers should:

• ensure that the visit is risk assessed including assessing whether staff are required to be present during the visit
• ensure that IPC measures are in place as detailed within this guidance including social distancing, hand hygiene, and cleaning of the area including furniture after each use.  Face coverings should be worn by visitors on entry to the visiting structure - these may be removed once seated if there is a fixed floor to ceiling, wall to wall screen in place between the visitor and resident 
• consider the structure from an IPC perspective and risk assess accordingly

Issues to consider include: 

• number of entrances (if single entrance consider how the visit will be managed in terms of who enters/leaves first to ensure that safe distancing and seating arrangements can be maintained effectively) and whether there is a substantial screen between the resident and the visitor designed to reduce the risk of viral transmission (the need for this will vary depending on the alert level)
• if using screens consider whether fixed, floor to ceiling clear screens, or a retractable clear screen is appropriate
• ventilation - opening windows or other mechanical ventilation options which circulate fresh air; adequate heating (not blow heaters)
• easily sanitised and cleanable surfaces (not carpet)
• consider the use of speakers, or assisted hearing devices (both personal and environmental) where these will aid communication and will avoid the need to raise voices

It is important everyone continues to play their part in reducing the transmission of COVID-19 to those living and working in care homes. This includes providers, visitors and people living and working in care homes.

There are huge benefits for people reconnecting with friends and family. At the same time, preventing the introduction and re-introduction of COVID-19 infection in care homes remains a priority. Visits are not without risk and providers should take account of the advice to minimise risk as set out in this guidance.

A robust process for risk assessed visiting with a focus on effective IPC is required to ensure risks to people are minimised. 

Visiting policies and all visits should be based on a dynamic risk assessment, which takes into account the vulnerability of people living and staying in the care home and risks to people living, staying, working in and visiting the care home. This approach is based on the circumstances and needs of the individual care home including people living, staying and working in the care home and the level of COVID-19 at a local or national level. 

The provider’s responsibility is to focus their dynamic risk assessments specifically on their premises, and those who live and work there, and visitors to their care home. They will be supported in this by advice given from their local IMT conveyed to them from their local authority. Approaches to this will be different depending on the needs of and risks to, people living at the home as well as the layout and environment of the care home. Where the setting has an ongoing COVID-19 outbreak, advice will be provided by the local authority or Public Health Wales in relation to necessary control measures, including visiting.

Visitors should be advised that their ability to visit care homes is subject to the specific circumstances of the care home and those living, staying and working in it. This is likely to mean that the frequency and duration of visits is limited and/or restricted.

The local authority will inform you if transmission of COVID-19 increases in your area and if you need to take further steps to keep your home COVID-secure.  

Local authorities may advise that visits to care homes are restricted or cease in their area, based on public health advice received at IMT meetings. Restrictions on visits to care homes may be placed on homes within a certain area of the local authority, the entire local authority area or nationally by Welsh Government, depending on the risks to this vulnerable population.

If there is an active incident or outbreak of COVID-19 at the care home visiting will be restricted to exceptional circumstances. However window visits are permitted during an outbreak where this can be supported safely.  

The provider should inform all visitors not to visit if:

• they have any symptoms consistent with COVID-19
• they have tested positive for COVID-19 within the last 10 days
• anyone in their household or anyone they have been in close contact with has symptoms of COVID-19
• they have been advised to self-isolate by a contact tracer from NHS Test Trace Protect
• they have returned from overseas travel in the last 10 days from a non-exempt country and are required to be in quarantine

Records should be kept of visitors to the home, when they visited and whom they had contact with. All breaches in relation to safe visiting requirements / procedures, including the type of breach, date and time should be recorded.

The COVID-19 vaccination programme across our care homes and population of Wales offers hope that we will be able to return to a more normal way of living with increased care home visiting. However, until the full programme of vaccination and the evaluation of the effects has happened, all the infection prevention measures in this guidance need to still be followed. Precautions must not be relaxed and those who have been vaccinated should not be treated differently to those who have not, for example in relation to visiting the care home.

We know that two doses of vaccine will reduce the chance of individuals becoming seriously ill. We do not know yet whether it will stop people from catching and passing on the virus or any impact of new variants on its effectiveness in the months to come. Therefore it is important that providers continue to follow the COVID-19 guidance to protect staff and residents.

To protect  people living in care homes, visiting family and friends and care home staff providers still need to ensure that the home is: 

• practising social distancing
• ensuring hands are washed or sanitised carefully and frequently
• ensuring the environment is clean
• following the current guidance 
• continuing to use appropriate PPE in the care of care home residents 
• enabling and promoting staff vaccination

The purpose of designated visitors is to reduce the footfall into the care home and to minimise the risk of infection from COVID-19. The intention is everyone should nominate designated visitors (family member/friend) depending on the alert level, along with a nominated deputy if a designated visitor is unavailable to visit due to illness or absence. The two roles are not intended to be routinely interchangeable.

It is important people are supported to nominate their designated visitors. Where people lack capacity this should include support from an advocate. We recognise that in some situations having designated visitors may cause friction between the family members and friends of the care home resident. Care homes should be aware of these potential situations and handle sensitively, making residents relatives/friends aware that the purpose of designated visitors is to minimise the risk of infection and protect residents.

Designated visitors and deputies should consider the level of risk they are exposed to through their social or occupational contacts before taking on this role. For example, key workers like healthcare or emergency workers may be considered high risk. Similarly, they should be willing to accept responsibility for ensuring that their behaviours do not lead to an increased risk of COVID-19 infection.   

We suggest that providers emphasise the important role and responsibility that designated visitors and nominated deputies have in minimising the risk of transmission of COVID-19 infection into the care home. 

The arrangement for designated visitors does not apply to visits arranged for exceptional circumstances.

Current arrangements as we move from Alert Level 4 to Alert Level 3, and when we move fully into Alert Level 3 from 3 May:

Indoor visiting

• two designated indoor visitors are allowed (a deputy visitor to be designated for each visitor in the event that either of the designated visitors are unable to fulfil this role. The deputy and designated visitor roles are not intended to be routinely interchangeable)
• routine indoor visits by a designated visitor should, where possible, take place in a designated room to avoid visitors moving around the building. Ideally the designated room would be close to the entrance of the building, and be well ventilated
• indoor visitors will be subject to testing. Only one designated visitor may visit indoors at a time
• face coverings should be worn by any visitor for the duration of an indoor visit. Where there is likely to be direct contact with the resident i.e. during a visit in exceptional circumstances such as end of life, then PPE should be provided with support to wear safely

Visits within visiting pods or similar enclosed spaces

• visitors undertaking visits in visiting pods and similar enclosed spaces should be from the same household if attending at the same time
• visitors undertaking visits in visiting pods and similar enclosed spaces will be not be subject to testing if there is an outside entrance for the visitor, a fixed floor to ceiling screen and appropriate safeguards in place i.e. cleaning between visits
• visitors undertaking visits in visiting pods and similar enclosed spaces without an outside entrance for the visitor, and a fixed floor to ceiling screen will be subject to testing, including children aged 11 and over
• in visiting pods and similar enclosed spaces which are self-contained and which do not allow the exchange of air from one side to another, face coverings may be removed

Outdoor visiting

• there is no prescribed limit to the number of outdoor visitors, however care homes should manage this according to their local situation, based on a risk assessment
• testing is not required for outdoor visits
• during outdoor visits where 2 a metre distance is maintained, face coverings may be removed while seated

Alert level 2 and alert level 1

Arrangements for designated visitors and visitor testing at Alert Level 2 and Alert Level 1 will be determined closer to any wider move to reduce alert levels in Wales.

Window visits

Window visits can take place at a home where there is an outbreak of COVID-19 in any alert level if:

• this could be supported by the care home staff
• the layout of the care home means visitors do not enter the home
• the resident is able to come to a window without exposing other vulnerable   residents if infected, or being exposed to infected residents (visitors undertaking window visits will not be subject to testing)
• the visitor remains 2 metres from the window

Visits to care homes by children and young people aged under 18 may be supported, however providers should be aware of the difficulty of young children maintaining social distancing, and the risk this presents. Therefore it is generally preferable to avoid indoor visits from children to care homes for older people.  As with other visits, visits involving children should be planned and agreed with the care home in advance of the visit, so this can be risk assessed by the home.

Babies and very young infants who are not mobile do not need to be counted as an additional visitor, where designated visitor restrictions are in place.

There is scope for additional flexibility on numbers when considering visits from children to a sibling or a parent living in a care home. These visits should be risk assessed and accommodated if considered appropriate, however the number of children should be kept to a minimum so that space is not compromised and the room remains well ventilated.

Children aged 11 and over should wear the same PPE as adult visitors, where indicated. 

Children aged 11 and over should be tested prior to indoor visits and visits in visitor pods or similar structures where a fixed floor to ceiling screen is not in place.  Parental consent should be given prior to any test.

Indoor visits by professionals (including advocates, chiropodists, dentists, dietitians, community nurses, social workers, inspectors, Public Health Wales and local authority environmental health officers etc.), may be facilitated in line with the advice set out in this guidance.  

Indoor visits from hairdressers can take place on the understanding that they are fully compliant with the current guidelines, and that safeguards are in place including using designated, well-ventilated areas, minimum footfall, and regular cleaning. Records of visits from hairdressers should be kept, in line with other visitors.

Other services supporting people’s well-being such as entertainers may be facilitated in line with the advice set out in this guidance. We advise that these are not facilitated indoors at this time.

Visits should be agreed in advance with the service provider, unless there is a need for the visit to be unannounced.

Visiting professionals should take suitable measures to keep themselves and others safe including observing appropriate IPC measures and using appropriate PPE. They should also follow advice issued in relation to their profession. Other supportive services will need to be supported during their visit by care home staff, to ensure appropriate IPC and PPE procedures are being followed.

People will naturally wish to leave the home, i.e. for a short walk or, where the alert levels permit, to visit family and friends, as well as attend places of worship etc. If an adult with capacity wishes to leave the home then members of staff at the home cannot prevent them from doing so. 

Where there is no outbreak or incident at the home the provider should risk assess with the person (and their family / advocate as appropriate) any decision to go out in the community or to visit family or friends. Respiratory hygiene, social distancing, hand hygiene, and face coverings in line with regulations, should be maintained when people are away from the care home. Public Health Wales has developed risk assessment guidance to support this process.

PPE would not usually be required for visits taking place outdoors, however please see the transport section below about the use of face coverings when travelling in a vehicle on the way to a visit. 

Transport will require careful consideration when residents are going out of the home. In the event that public transport is used the national public transport rules will apply on minibuses and similar vehicles. If the care home is using its own vehicle then cleaning protocols will need to be in place. If family members are picking up a resident for a day out / home visit, minimise the numbers in the car – ideally driver only and if possible the person uses the back seat, open windows if tolerated to improve ventilation and all to wear face coverings.

Consideration could be given to ‘social bubbles’ within the care home so that a consistent group which has closer social interaction such as eating and socialising together is able to go out on a trip together. Trips out organised by the care home should be restricted to outdoor spaces. 

The advice from Public Health Wales is that visits to the homes of relatives and friends, including overnight stays, when permitted by regulations, present a risk. The risk is easier to control and manage if visits are made to the care home. People living in care homes and their families must be informed of potential risks and options to enable them to make an informed choice. Where people lack capacity to do this, an advocate may be needed. Risks will differ from person to person and blanket decisions should not be made. 
If there is an active incident or outbreak in the care home, people living in care homes should not leave the setting, unless this is for an essential reason i.e. an urgent healthcare appointment.  

In all cases where people are being restricted from going out, care homes should follow guidance around the deprivation of liberty, in particular the need for the Deprivation of Liberty Safeguards (DoLS) process to continue be followed. As is the case under normal circumstances, deprivation of liberty should always be seen as the last resort.

Please see the control plan for guidance relating to size of groups for visits to public places and visits to private homes. 

During this pandemic, it is especially important that people are supported to maintain their relationships with families and friends and have access to professionals when needed. Providers have been supporting people to maintain contact in a variety of ways via telephone calls, video calls, newsletters, cards, photographs and e-mails. Providers will need to be mindful and prepared for increased demand for contact during cultural festive periods and special occasions such as birthdays, anniversaries etc.

This guidance is intended to support you in enabling visits to your care home. However, we recognise that all homes are different and that rates of COVID-19 infections will vary by area and over time. Public Health Wales is always willing to support care home providers with complex questions arising from their completed risk assessments not covered by the guidance. Please contact them on 0300 00300 32 or your local authority Environmental Health Officer.

Responding to the COVID-19 pandemic has meant difficult decisions have been made under new and exceptional pressures. These decisions have had a personal impact on everybody and impacted delivery of our health and social care services.

We recommend that care home providers use an ethical principle based framework to support their ongoing response planning and decision-making in relation to COVID-19. The ethical framework needs to be considered alongside professional codes of conduct and the most recent applicable official guidance and legislation, including in respect of human rights. An ethical framework helps to ensure that consideration is given to a series of values and principles when organising and delivering social care.

A judgement will need to be made on the extent that a particular principle can be applied in the context of each decision. In all instances, respect and reasonableness should be used as the fundamental, underpinning principles that guide planning and support judgements. Resident’s views on visits should be sought as part of this process wherever possible.

The principles detailed and defined below are not an exhaustive list and are not ranked in order of significance.

Ethical framework - principles

Respect 

Recognising that every individual and their human rights, personal choices, safety and dignity matters.

Reasonableness

Ensuring that decisions are rational, fair, practical, and grounded in appropriate processes, available evidence and a clear justification.

Inclusiveness

Ensuring that individuals are given a fair opportunity to understand situations, are included in decisions that affect them, and can offer their views and challenge. In turn, decisions and actions should aim to minimise inequalities as much as possible.

Minimising harm

Striving to reduce the amount of physical, psychological, social and economic harm that the outbreak might cause to individuals and communities.

Human rights

Recognising people’s human rights when making decisions that will affect individuals in your home, for example their right to liberty, right to respect for private and family life) and the right to freedom of religion. 

Flexibility

Being responsive, able, and willing to adapt when faced with changed or new circumstances. It is vital that this principle is applied to the social care workforce and wider sector, to facilitate agile and collaborative working. 

Accountability

Holding individuals, and ourselves, to account for how and which decisions are made. In turn, this requires being transparent about why decisions are made and who is responsible for making and communicating them. 

Proportionality

Providing support that is proportionate to needs and abilities of individuals, communities and staff, and benefits and risks are identified through decision-making processes. 

Community

A commitment to get through the outbreak together by supporting one another and strengthening our communities to the best of our ability.

Actions that care home providers can take to support people to reconnect with families, friends and professionals 

Balancing the rights and responsibilities in relation to people, visitors and staff is not easy or straightforward. To assist care home providers to think about how they can support people to reconnect safely with their families, friends and professionals we have set out in the appendices below some points for consideration. This list is not exhaustive. One size does not fit all. Therefore, consideration must be given to the individual needs of people receiving care and support and individual characteristics of services. 

Next steps

We will keep this guidance under review to ensure it remains consistent with wider regulations and guidance.
 

Points for consideration when supporting people to reconnect safely with families, friends and professionals: 

• visiting policy and communication (appendix 5 contains a template protocol for visitors which care home providers may wish to use/adapt)
• have a clear and accessible visiting policy in place that is communicated with relevant individuals, regarding visiting during COVID-19 restrictions. Include the procedures for IPC, including PPE
• consider enabling visits by appointment only, and the duration of these. If the care home has previously operated an ‘open door’ visiting policy, inform people and visitors of the change of arrangements and why this is necessary
• make visitors aware of the arrangements for cancelling their visit and what will happen if they arrive late for their pre-booked visit
• let people and visitors know of the exceptional circumstances that may warrant consideration of a change of arrangements for visits
• ensure people and visitors are aware that visiting may have to be suspended if an outbreak or increased numbers of residents with symptoms of COVID-19 (or other infection) occurs in the home or they have been advised that the number of cases occurring locally would put residents and staff at increased risk
• have risk assessments in place for all types of visits and circumstances. Ensure both the resident and the visitor, and where required their representatives, are involved in developing and reviewing personal plans and risk assessments
• personal plans and risk assessments should reflect the arrangements for supporting well-being, relationships and social connections
• if people living or staying in the care home go out, consideration should be given to the method of transport used
• if there is a restriction to visitors in place, alternative ways of communicating between people and their families and friends should be discussed and offered. Where appropriate the service should provide regular updates to families and friends on their loved ones’ mental and physical health, how they are coping and identify any additional ways they might be better supported, including any cultural or religious needs
• consider what needs to be done to adhere to latest official guidance, statutory duties, and relevant regulations
• ensure people are supported to understand situations, contribute to decisions that affect them, and offer their views and challenge i.e. use of advocates, clear appeal and complaints processes
• ensure people’s individual personal choices are respected, whilst considering and communicating implications and risks
• where a person may lack the relevant decision-making capacity (as defined in the Mental Capacity Act 2005), the decision maker making a best interest decision under the 2005 Act, should consider all the relevant circumstances, including the person’s wishes, beliefs and values, the views of their family and what the person would have wanted (where known) if they had the capacity to make the decision themselves
• ensure there are adequate processes in place to maintain infection prevention and control before, during and after visits (including visits out) including supporting people to maintain social distancing
• consider how feedback from visitors might be sought, to inform arrangements for future visits
• consider staffing levels to support safe visiting arrangements
• consider how the service will respond and adapt to changes as and when they occur e.g. in the event of new information arising or changed levels of demand
• keep people and visitors as informed as possible of what is happening or what is expected to happen in any given circumstance
• base decisions on the evidence and information that is available at the time, conscious of the known risks and benefits

Preparing people for visits

• consider what needs to be done to prepare residents and visitors for visits. For example, support visitors on how to prepare for a visit including providing information how they can minimise their risk to the resident, providing information about where the visit will take place and what to expect. Give tips on how to communicate, as generally face coverings are required, such as: 
  • speaking loudly and clearly
  • keeping eye contact
  • not wearing hats or anything else that might conceal their face further
  • wearing clothing or their hair in a way that a person would more likely recognise
  • the use of message or symbol boards or electronic devices
• provide reassurance to residents and visitors, some people, for example people living with dementia, may struggle at first to remember or recognise people. The provider should try to prepare people for a visit and consider individual approaches to support this, for example looking at photographs of the person who is due to visit, and talking to them about their relationship
• visitors should be discouraged from bringing gifts and flowers to the service. If visitors bring gifts including food, this is restricted to gifts in sealed unopened packages that can be wiped down and are not placed in refrigerators or communal areas
• food, drink and other items should not be shared between people and their visitors where visits take place 
• consider how the internal and external areas of the home are organised to assist in facilitating safe visits e.g. zoned areas with clear two-metre social distancing, designated visiting areas, access to and from visiting areas
• consider coverings such as gazebos and garden umbrellas for outdoor visits (these should not be enclosed) to protect people from weather conditions
• consider the types of outdoor visit that could be offered where safe and appropriate to do so, which could include:
  • a window visit in which the visitor can talk to their relative/friend through an open window on the ground floor of the home/service. A two-metre distance from the window is maintained
  • a garden visit in which a two metre social distancing is maintained
  • a drive-through visit in which the person living at the home sits two metres away from the visitor’s car and is able to see and talk to their visitor through an open car window
• any signage for navigating a visit should be visible, so visitors know where to park there is a clear and signposted route to the visiting / meeting area, ideally directly into the visiting / meeting area. Where visitors may need to walk through the home to access a meeting area, they are guided through, and do not touch anything and do not visit any other areas aside from the visiting area.
• visitors should ideally not access toilet facilities at the home, but if the need arises, the home should have a designated toilet for the use of visitors only during visits. Staff or people living at the home should not use the visitor toilet during visiting hours. If possible, the visitor toilet is located close to an entrance so that unnecessary travel through the home is avoided. Toilets used by visitors are cleaned between every use.
• all chairs and equipment used during visits should be easy to clean and impervious to fluids and cleaned after each visit in preparation for the next
• advise and support visitors to put on a face covering before entering the home, perform hand hygiene on arrival at the home, and at appropriate times during their stay and before leaving. Washing hands with soap and water is preferred, but alcohol hand gel should be provided if hand-washing facilities are not accessible e.g. in the garden / outdoor meeting area / temporary or semi-permanent visiting structure/pod.
• consider if there are sufficient waste points provided and strategically placed to avoid litter and disposable of face coverings and additional items
• staff facilitate safe access to the individual being visited. Wherever possible visitors are discouraged from touching surfaces i.e. handles, switches etc. Any surfaces touched are cleaned thoroughly afterwards.
• during the visit, room doors are kept closed but keep windows open for ventilation where possible and safe to do so. Entry and exit from the room is minimised. Visitors should remain in the room that is being used for the visit
• consider if use of screens is possible and appropriate
• visitors do not have access to other people living in the home and contact with staff is limited (any interaction with staff occurs at a two meter distance) and IPC requirements are adhered to
• the room/visiting area is cleaned immediately following the visit and there are robust IPC procedures in place.

Points for consideration when undertaking risk assessments in relation to visiting: 

• Public Health Wales has developed guidance to support care homes in undertaking risk assessments to support visiting
• care home providers, staff, residents and visitors all have a responsibility to make visits as safe as possible. It is not possible to eliminate all risks
• it is particularly important that visitors follow the home’s visiting policy and procedures and any requirements relating to infection prevention and control and social distancing
• visitors have a responsibility to ensure that their behaviours prior to the visit do not increase their risk of acquiring and transmitting COVID-19. Visitors should be encouraged to discuss any potential risk and concerns with the home
• prior to visits being allowed in care homes which do not have a current incident or outbreak, the provider should consider the suitability of visits in the care home, taking into account their ability to provide a safe environment, and being confident the IMT is content that infection rates and community prevalence allow for indoor visiting as well as relevant legislation and guidance
• individuals who have been identified as a contact of someone who has tested positive for COVID-19 by NHS Test Trace Protect are required to isolate for 10 days.  Even if they have a test and the result is negative they must still isolate for the full 10 days and should not visit
• results from any routine testing of staff and residents. This data will enable the risk assessment to be well informed. Evidence of outbreaks and recovery from outbreaks should also be considered
• individual risk assessments should assess people for COVID-19 risk factors e.g. underlying conditions
• the readiness of the care home to respond quickly when there is a confirmed or suspected COVID-19 case within the care home, to immediately return to essential/exceptional visits only e.g. end of life/compassionate visits
• appropriate level of staff to enable safe visiting practices
• the resident’s health and well-being needs, risks e.g. whether their needs make visits particularly important, whether restricting visitors would have a detrimental impact on their health and well-being
• a balance of the benefits of receiving visits to the residents living and staying in the care home, against the risk of visitors introducing infection into the care home, or spreading infection from the care home to the community
• people, and where applicable their advocates, are consulted regarding identifying priority of visitors i.e. who should visit
• the ability of the provider to put in place practical measures to undertake testing of visitors (dedicated room to deliver the test safely, waiting area, trained staff to undertake the test and to guide the visitor in the use of appropriate IPE measures)
• the practical effectiveness of social distancing measures between the visitor and the resident(s), having regard to the cognitive status of the resident(s) and their communication needs
• where volunteers / family carers usually support residents the provider or manager should carefully consider whether their support is more aligned to that of a staff member or a regular visitor and apply the appropriate oversight and infection-control procedures
• prior to arrival visitors will be informed about the requirement to use face coverings and use of PPE (face masks, aprons and gloves) if direct contact with the resident is anticipated i.e. exceptional circumstances visit for end of life
• visitors in the extremely clinically vulnerable category are advised to wear a medical mask and perform hand hygiene frequently in a social care setting
• visitors should be advised to wash hands thoroughly (or use hand sanitiser) before and after putting a medical mask on and taking it off (a face covering is not a medical/surgical mask)
• end of life visits to COVID positive residents would require the use of PPE as per the guidance for care home staff
• any behaviours of the resident or visitor that may place the person, visitor or staff at increased risk of infection, should be identified and mitigating action taken if required
• we advise visits take place in outdoor areas (if appropriate), a designated visitor’s area, (which may include a temporary/semi-permanent visiting structure/pod), which will only be used by one resident and their visitor(s) at a time , or the person’s own room. Visiting areas should be cleaned after each visit. Visitors should be accompanied when in the care home and when accessing designated visitor areas and should have no contact with others
• the need for staff to be present during visits should be identified as part of the risk assessment process
• for outdoor visits within the grounds of the home, the number of households from which visitors are drawn should be minimised. As a guide, it is suggested that visits be limited to visitors from one or two households per week. This should take into account the person’s individual circumstances. Social distancing should be maintained throughout the visit
• indoor visits from  children  may be supported but providers should be aware of the difficulty of young children maintaining social distancing, and the risk this presents. Babies and very young infants who are not mobile do not need to be counted as an additional visitor, where designated visitor restrictions are in place
• visits from children are carefully managed and are at the Care Home Manager’s discretion
• prior to and on arrival, visitors are asked:  
  • to confirm they do not have any COVID-19 symptoms or a positive COVID- 19 test in the previous 10 days. The primary symptoms of COVID-19 are a high fever, continuous cough of recent onset, loss of taste / smell
  • to confirm they are not self-isolating or living in a household with someone who is self-isolating
  • to adhere to the service’s policy and procedures including infection prevention and control and testing if undertaking an indoor visit or visit within a visiting pod
  • to adhere to social distancing requirements and other restrictions 
• physical interaction should be avoided where possible, as this will breach social distancing requirements, for example avoid hugs and kisses. However, where visits are to non-COVID positive residents, hand holding without gloves may be allowed as long as visitors perform hand hygiene before and after any contact with the resident or their environment and adhere to the instructions given. Any broken skin must be covered with a waterproof dressing or plaster before contact. A face covering or mask must be worn where social distancing cannot be strictly maintained.

Points for consideration (in addition to the points detailed in the other appendices) to support children and young people living in care homes to reconnect with families, friends and professionals: 

• Welsh Government has published operational guidance for providers of children’s social care services during COVID-19, which is routinely updated. The guidance includes how local authorities should maintain contact with children and young people living / staying in care homes      
• it may not always be practicable or appropriate to facilitate meetings with children and their families, friends and professionals in the internal or external areas of the home. Visits should be based on a dynamic risk assessment that includes consideration of the restrictions in place. Relevant professionals should be involved in the risk management process
• as with adult care home services, indoor and inside visits to care homes for children should have  designated and deputy visitors. Where parents are separated the designated and deputy visitor roles may be allocated to each parent
• any decisions made should be in the child’s best interests. Decisions on whom should visit and prioritising of visits should be based on individual circumstances and children should be included in these decisions, including the designated and deputy visitor roles. This should include their right to access advocacy
• in addition to considering how to facilitate indoor, inside and outdoor meetings in/at the home, providers should also consider how they could facilitate outdoor meetings elsewhere, between children and their families, friends and professionals. Which are in accordance with current requirements and where social distancing and personal hygiene is maintained

Points for consideration (in addition to the points detailed in the other appendices) to support people receiving indoor visits for exceptional circumstances, whilst visits are restricted to exceptional circumstances  visits only:

• requests for a visit that will need to take place within the home for a specific purpose felt to be essential should be made to the care home manager for a decision. The visit, if agreed, has restrictions in place regarding the number of visitors, the duration and location of the visit
• infection prevention and control guidance on the use of face coverings, hand hygiene and appropriate PPE (if required) should be followed for the visitors 
• if the resident’s COVID-19 status is probable or confirmed, a fluid resistant surgical mask, gloves and apron should be provided for the visitors and eye protection e.g. visor
• if the visitor is in the extremely clinically vulnerable category, they should be advised of their increased risk –  PPE would be the same, if they still choose to visit
• visitors should not visit during the undertaking of an aerosol generating procedure (AGP) or for an hour after an AGP is performed on their relative. The care home should inform visitors of this as relevant

Visitor leaflet (a word version of this document is available on the CIW website 

Staying in touch with your relative / friend is important and we want to help you do this as safely as possible. All of the people living in the care home are at a higher risk from COVID-19 because of their age and/or health. This leaflet will help you know what to expect when you visit and how to do this safely.

Wales is operating alert levels and the arrangements for visitors will differ depending on the alert level.

To reduce the risk of COVID-19 in the care home, we are limiting the number of visitors, and in accordance with current guidance, we are operating a designated visitor system. 

Welsh Government guidance advises that there should be (two) named (designated) visitors for indoor/inside visits for each resident. With a nominated deputy who can take their place if a designated visitor is ill or not able to visit.

The number of visitors may change, depending on the local and national alert level. Arrangements for visits may also change for some reasons for example, if there is an outbreak of COVID-19 in the care home.

We will let you know how many people can visit at one time, the duration of the visit, where the visit will take place, whether you will need to have a COVID test and what else to expect ahead of the visit. Please consider this when planning your visit.  

In some circumstances, even if you have arranged a visit in advance it might have to change. For example, if there is an outbreak of COVID-19 at the care home, or if we are advised that the infection rate in the community is too high. 

The rules for visiting people where there are exceptional circumstances (such as end of life) will be different. Please contact us if you need to talk about this.
 
Thank you in advance for helping keep the residents safe and for your patience and support.   

Before your visit 

• please contact us to arrange a date and time for your visit which works for you, the person you are visiting and our staff. Unfortunately, visitors who have not arranged their visit in advance will not be able to enter the care home
• if you are extremely clinically vulnerable (previously shielding) please let us know
• we will let you know how many people can visit at one time, the duration of the visit, where the visit will take place and whether you will need to have a COVID test and what else to expect ahead of the visit. Please take this into consideration when planning your visit
• we know that lots of people will be eager to visit their loved ones as soon as possible, but unfortunately we can only support a limited number of visitors at any one time’
• while we know this is a challenging time but to protect people living and working at the care home visitors with any of the following MUST postpone their visit:  
  • you have any symptoms consistent with COVID-19
  • you have tested positive for COVID-19 within the last 10 days
  • anyone in your household or anyone you have been in close contact with has symptoms of COVID-19 
  • you have been advised to self-isolate by a contact tracer from NHS Test, Trace and Protect 
  • you have returned from overseas travel in the last 10 days from a non-exempt country and are required to be in quarantine
• symptoms of COVID-19 include: 
  • a high fever 
  • a new, continuous cough 
  • a loss of taste or smell 
• please be prepared to wear protective equipment. This may include a face covering and gloves
• we understand that you may wish to bring a gift with you. Please let us know to see if we are able to accommodate this request
• if you have any concerns or your circumstances change between booking your visit and the day of your visit you must  get in touch with us
• please do not visit if you have any transmissible infections/illnesses e.g. flu, norovirus 

During your visit  

• care homes have all made their own arrangements to make visits as safe as possible. This means visits will be a bit different to before COVID-19
• you will be asked to sign in and provide your contact details. This is to check that you are feeling well enough to visit, and so that the care home and Test, Trace and Protect can get in touch if needed
• as part of keeping people in the care home safe you will be asked to be tested for COVID-19  (called a lateral flow test). This is an extra way to reduce the risk of COVID-19 spread as it checks whether someone is infectious at the time of the test. The test takes time (approximately 30 minutes) to be processed, and you will be asked to wait outside the care home while the results comes back
• unfortunately, if the test is positive you won’t be able to visit your relative. Following a positive test you will need to go straight home and contact the test and trace service to arrange follow up testing. Therefore we would recommend that you have a contingency plan in place, should you need to return home immediately following a positive result
• if the test comes back negative, please remember that you still have to follow all of the our procedures to keep you and your relative/friend safe
• we will explain our procedure for visitors. This will vary depending on the Alert Level in place at the time of your visit. This will include:   
  • where the visit will take place. This might be outdoors or in a “pod” so please make sure you wear appropriate clothing
  • social distancing such as staying 2 metres / 6 feet apart from others, and although it may be difficult, avoiding physical contact such as hugging  
  • thoroughly washing or sanitising your hands on arrival and at appropriate times throughout your visit 
  • appropriate use of face coverings and any personal protective equipment as directed by the care home staff
  • going to the bathroom. Ideally you should not use the toilets at the care home, but if required staff will advise which toilet is allocated as a visitor toilet
• designated visitor areas will be cleaned before and after your visit. To help us maintain this cleaning regime, please follow any one-way markings that may be present. Please keep to the designated visiting area and avoid contact with other residents.
• we know that trying to talk to your loved one while wearing a face covering can be challenging. To make talking easier, you could try:  
  • maintaining eye contact and speaking clearly and loudly
  • wearing clothes that your loved one would recognise   
  • taking off hats so more of your face can be seen   
  • using message boards or other technology provided by the care home  

After your visit  

• we will support you in seeking alternative ways to keep in touch with your loved one, for example, by arranging a future visit, or through video and telephone calls
• if you become unwell with any of the symptoms of COVID-19 at any point before or after any visit please stay at home and organise a test. Please let us know as soon as possible that you have developed symptoms and when you receive the result of your test. 

Definitions of key terms  

When we refer to:

A ‘person’ or ‘resident’- we mean an adult or child living or staying in a care home. 

A ‘visitor’ or ‘visitors’- we mean family members, friends and professionals visiting a person at a care home. Where volunteers and family carers usually support residents the provider or manager should carefully consider whether their support is more aligned to that of a staff member or a regular visitor and apply the appropriate oversight and IPC procedures.  If the support is more aligned to that of a staff member then they should be tested in line with care home staff, and would not be counted as a 'designated visitor'.

A ‘designated visitor’- we mean a family member or friend who will be the primary visitor when local COVID-19 circumstances allow. This means the same visitor(s) visiting each time to limit the number of different people entering the care home and reducing the consequent risk of infection. A deputy may be identified to undertake visits if the designated visitor is unable to visit, for example if they are unwell or away.  If babies and very young children (under two years old) are visiting with a designated visitor, they do not need to be counted in visitor numbers. 

‘Exceptional circumstances’ - we mean circumstances such as end of life visits, visits by professionals that are needed to ensure residents health/safety/well-being, visits by designated visitors that are needed to ensure a resident’s well-being (for example, a resident who may be particularly distressed or a resident who is cared for in bed and is unable to connect with family/friends using other methods). These are a small number of examples and not an exhaustive list. Each situation must be considered on an individual basis and no ‘blanket’ approaches taken.  The arrangement for designated visitors does not apply to visits arranged for exceptional circumstances.  

Visits in exceptional circumstances may be supported regardless of alert level. 

A ‘dynamic risk assessment’ - we mean a process of continually observing and analysing risks and hazards in a changing, or high-risk environment. This allows for risks to be identified quickly and action taken to mitigate against risks.

The ‘level of COVID-19 at a local or national level’- we mean the incidence of infection, the number of new infections that are occurring and the number of people tested who are testing positive and any outbreaks or hot spots that may increase risk of introducing COVID-19 into care homes.

‘IMT’ - we mean an Incident Management Team, which will have been put in place by the local authority / local health board to manage the incident of COVID-19 infection.

‘Temporary/semi-permanent visiting structures/pods’- we mean fully enclosed structures that are located in the grounds of the care home, which are used to support visits (visits undertaken in these structures require visitor testing in alert levels 2, 3 and 4). 

'Indoor visit’ - we mean visiting people inside the care home premises by crossing the threshold of the care home (indoor visits require visitor testing in alert levels 2, 3 and 4).

‘Outdoor visit’ - we mean visiting people in the grounds of the care home. This includes for example visits under a canopy that is open on at least one side and does not need to be accessed by a doorway (outdoor visits are not subject to visitor testing).