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Introduction

This guidance has been developed following the changes to the Health Protection (Coronavirus Restrictions) (Wales) Regulations 2020 that came into force on 1 June 2020 and 22 June 2020.

This guidance provides suggestions of actions care and support providers can take and points for them to consider when supporting people who are using their service to reconnect safely with families, friends and professionals, whilst restrictions are in place.

Who is the guidance for

This guidance is intended for providers who provide care and support to people living / staying in care homes (adults and children), supported living and extra care settings. The guidance sets out an ethical framework as well as questions and points for consideration by care and support providers, to assist them when organising and providing care and support. 

When we refer to a ‘person’ or ‘people’, we mean an adult (s) or child (ren) living or staying in a care home, and an adult (s) living in supported living or extra care setting.  

When we refer to a ‘visitor’ or ‘visitors’ we mean family members, friends and professionals visiting a person at a care home, supported living or extra care setting.

Background

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

The restrictions and requirements set out in the Welsh legislation are different in some respects 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 / service is located.

On 23 March, Welsh Government wrote to all care home providers in relation to restricting visits to care home accommodation. This was in response to the increasing pace of the transmission of coronavirus throughout the community. The purpose was to protect people living at, working at and visiting care homes.

On 1 June, changes to the coronavirus regulations came into force:  

From 1 June people from one household have been permitted to meet outdoors with people from one other household at a time. Carers are considered for these purposes to be members of a household – so if for example one person in each household had a carer, both of those carers could also be part of an external gathering between the two households. It is important however, that advice on social distancing (staying at least two metres apart) and personal hygiene, is followed.  

Following the changes to the regulations, Welsh Government wrote to all care home providers on 5 June giving updated advice on how care homes can safely facilitate outdoor visits under the current regulations. It was updated, on 16 June to reflect the Chief Medical Officer’s advice that face coverings are not required to be worn by visitors, when visits are outdoors and social distancing is maintained. Some visitors may choose to wear face coverings, and advice from the Chief Medical Officer to those in vulnerable groups has been to wear masks. However, this is not a requirement.

This guidance builds on the advice set out in that letter regarding facilitating safe visits.  

Ethical principles

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 our families, carers and communities, and have a wider impact on the organisation and delivery of our health and social care services.

We recommend that care and support 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. An ethical framework helps to ensure that ample 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. 

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

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.

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 and support providers can take to support people to reconnect with families, friends and professionals

It is 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. In addition to these ways of supporting people to maintain contact, we would encourage care and support providers to make every effort to facilitate outdoor visits where it is safe to do so, given the significant well-being benefits to people, their families and friends. However, it is important to minimise the risk of infection to protect people, visitors and staff.

Balancing the rights and responsibilities in relation to people, visitors and staff is not easy or straightforward. To assist care and support providers to think about how they can support people to reconnect safely with their families, friends and professionals we have set out in the enclosed appendices some  points / questions 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.

Appendix 1

Questions that all care and support providers should consider when supporting people to reconnect with families, friends and professionals

  • Does anyone living or working at the service / setting currently have COVID-19?

(If ‘yes’ visitors are not allowed to visit until the situation is resolved. Requirements for self-isolation must be adhered to. People who are required to self-isolate, including those identified as a contact of a positive case under the Test, Trace and Protect Strategy, those who are self-isolating outside of the test, trace and protect requirements e.g. quarantine following foreign travel or those with other infections must stay at home)

  • Are people and visitors 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 / setting? 
  • What does the service need to do to adhere to latest official guidance, statutory duties, and relevant regulations?
  • How can the service ensure that people are provided with the opportunity to understand situations, contribute to decisions that affect them, and offer their views and challenge i.e. use of advocates, clear appeal and complaint processes?
  • How can the service support people to reconnect in a safe way, including risk assessment / risk management, which includes consideration of potential risks in relation to confidentiality?
  • How does the service respect individuals’ personal choices as much as possible, whilst considering and communicating implications for the present and future?
  • Does the service assess people for COVID-19 risk factors e.g. underlying conditions and keep a record of whether they are in the shielding category?
  • Where an individual may lack the relevant decision-making capacity (as defined in the Mental Capacity Act 2005). How does the service ensure that in making a best interest decision under the Act, that the decision-maker is considering 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?  
  • What does the service need to do to ensure all people using the service, who wish to reconnect with family, friends and or professionals, are supported to do so?
  • What can the service do to help support people to maintain social distancing and infection prevention and control?
  • What can the service do to prepare people and visitors for visits?
  • Do staffing levels support safe visiting arrangements?
  • Are there adequate processes in place to maintain infection prevention and control during visits?
  • How can the service keep people and visitors as informed as possible of what is happening or what is expected to happen in any given circumstance?
  • Does the service base decisions on the evidence and information that is available at the time, and is conscious of known risks and benefits that might be experienced?
  • Does the service consider alternative options and ways of thinking, being conscious of diverse views from cultures and communities?
  • Does the service provide an environment in which staff can work effectively and collaboratively, and which protects their health and well-being?
  • Does the service act on and deliver the outcomes required by their responsibilities and duties to people, their families and carers, and staff? 
  • Is the service able to respond and adapt to changes as and when they occur e.g. in the event of new information arising or changed levels of demand? 

Appendix 2

Questions and points for care home providers to consider (in addition to the questions detailed in Appendix 1) to support people in care homes to reconnect with families, friends and professionals

  • Does the service have a clear and accessible policy in place that is communicated with relevant individuals, regarding visiting during COVID-19 restrictions? Does the policy include the procedures for infection prevention and control, including Personal Protective Equipment (PPE)?
  • Are visitors contacted prior to visits to inform them of the current restrictions and requirements in place and their responsibilities?
  • Are staff aware of the restrictions and requirements in relation to visitors?
  • Prior to and during visits, are visitors informed of any requirements in relation to infection prevention and control, including where required the supply, wearing and disposal of PPE?  
  • Are people and visitors informed of the social distancing requirements?
  • Are all breaches in relation to requirements / procedures recorded, including the type of breach, date and time? 
  • Are visitors made aware of the arrangements for cancelling their visit and what will happen if they arrive late for their pre-booked visit?
  • Are people and visitors aware of the exceptional circumstances that may warrant consideration of a change of arrangements for visits?
  • Does the service have the most up to-date information about restrictions and requirements and ensures relevant policies are up-dated and communicated with all relevant people and visitors?
  • Is follow up communication provided by the service to ensure people and visitors are aware of any changes and the implications, understand their responsibilities and the action that will be taken if they do not adhere to the service’s relevant policies? 
  • Does the service provide timely updates about any changes to arrangements, restrictions, requirements, or a confirmed or suspected case of COVID-19 at the service?
  • Are the methods of communication used appropriate for people and visitors? 
  • Are people, and where required, their representatives, consulted regarding identifying priority of visitors i.e. who should visit (priority visits are those that support people’s health and well-being)?
  • Are people, and where required their representatives, involved in developing and reviewing personal plans and risk assessments?
  • Do personal plans and risk management processes reflect the arrangements for supporting well-being and social connections?
  • Is a risk assessment completed for all types of visits?
  • Is consideration given as to how the external area of the home is organised to assist in facilitating safe visits i.e. zoned areas with clear two-meter social distancing, coverings such as gazebos and garden umbrellas (these should not be enclosed) to protect people from weather conditions. 
  • Is signage for navigating any visit visible, do visitors know where to park and the route to the outside visiting / meeting space?
  • Are visits by appointment only?
  • In order to facilitate visits is consideration given to the duration of the visit? (We suggest 30 minutes as a guide)
  • Are the number of visitors limited to no more than two people from the same household? 
  • Are the number of households from which visitors are drawn minimised?

(As a guide, it is suggested that visits be limited to visitors from one or two households per week. If multiple visits from the same household occur within a week, it should be the same two visitors, not different people from the same household). However, this should take into account the individual’s circumstances – individuals may have multiple adult children each living in separate households) 

  •  Are visits from young children and toddlers generally discouraged due to the difficulty of maintaining social distancing and the risk that presents?

There may be exceptional and or compassionate circumstances where a visit from a child is permitted. Visits from children are carefully managed and are at the Care Home Manager’s discretion.

  • Are visitors 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 not shared between people and their visitors.  

Prior to and on arrival, visitors are asked:

  • to confirm they do not have any COVID-19 symptoms. 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. People who are required to self-isolate, including those identified as a contact of a positive case under the Test, Trace and Protect Strategy, those who are self-isolating outside of the test, trace and protect requirements e.g. quarantine following foreign travel or those with other infections must stay at home and are not permitted to visit a care home
  • to provide their contact details, for the purpose of informing them of any changes to visiting arrangements / requirements
  • to adhere to the service’s policy and procedures including infection prevention and control
  • to adhere to social distancing requirements and other restrictions
  • to use a tissue or their sleeve for any sneeze or cough, not their hand

Consideration is given to the types of visit that could be offered, 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
     
  • Do visitors have a clear and signposted route to the outdoor visiting / meeting area, ideally directly into the visiting / meeting area. Where visitors may need to walk through the home to access the outdoor meeting area, are they guided through, and do not touch anything and do not visit any internal areas?
  • 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. 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.  
  • Are all chairs and equipment used during visits, easy to clean and impervious to fluids and cleaned after each visit in preparation for the next?
  • Are visitors advised and supported to perform hand hygiene on arrival at the home, 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 i.e. in the garden / meeting area.
  • Are additional waste points provided and strategically placed to avoid litter?
  • Where a service has an outbreak of coronavirus all routine visits to the care home are postponed. 

Appendix 3

Questions and points for providers to consider (in addition to the questions / points detailed in Appendices 1 and 2) to support children and young people  living in care homes to reconnect with families, friends and professionals

  • It may not always be practicable or appropriate to facilitate outdoor meetings with children and their families, friends and professionals in the external areas of the home. Outdoor meetings within the home’s external areas should be based on a risk assessment that includes consideration of the restrictions in place. Relevant professionals should be involved in the risk management process.  
  • Any decisions made should be in the child’s best interests.  Decisions on prioritising visits should be based on individual circumstances and children should be included in these decisions. This should include their right to access advocacy.
  • In addition to considering how to facilitate outdoor meetings in the outdoor areas of 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.

Appendix 4

Questions and points for providers to consider (in addition to the questions detailed in Appendix 1) to support adults in supported living services to  reconnect with families, friends and professionals  

Provision of care and support in supported living is largely delivered to help people to be able to live as independently as possible, with their own tenancy. 

Supported living as a term covers a wide range of environments and support levels. Some may be group living environments with communal areas and others wholly individualised. Some may be providing intimate and personal care or an emergency service. Others will involve significant support around daily living, food preparation, personal safety and access to the community. Therefore, care and support providers should consider how this guidance could be used to support the people receiving their service.

Questions and points for providers to consider:

  • Does the service have a clear and accessible policy in place, which is communicated with relevant individuals, regarding the arrangements for the service to support people to reconnect with visitors during COVID-19 restrictions? Does the policy includes the procedures for risk assessment / management and infection prevention and control, including Personal Protective Equipment (PPE)?
  • Are there adequate processes in place to maintain infection prevention and control during outdoor visits and meetings?
  • In addition to considering how to facilitate outdoor meetings in the outdoor areas of the home. Providers should also consider how they could facilitate outdoor meetings elsewhere, between people and their families, friends and professionals, which is in accordance with current requirements and where social distancing and personal hygiene is maintained.

Appendix 5

Questions and points for providers to consider (in addition to the questions detailed in Appendix 1) to support adults in extra care accommodation to safely reconnect with families, friends and professionals

Extra care accommodation is where occupants have a tenancy to occupy self-contained dwellings and where they may have agreements that cover the provision of care, support, domestic, social, community or other services.  

Questions and points for providers to consider:

  • Does the service have a clear and accessible policy in place that is communicated with relevant individuals, regarding the arrangements for the service to support people to reconnect with visitors during COVID-19 restrictions? Does the policy includes the procedures for risk assessment / management and infection prevention and control, including Personal Protective Equipment (PPE)?
  • Are there adequate processes in place to maintain infection prevention and control during outdoor visits / meetings?
  • Has the provider consulted with people , and where appropriate their representatives, on how they can assist in facilitating outdoor meetings between people and their families, friends and professionals, which is in accordance with current requirements and where social distancing and personal hygiene is maintained? 

Appendix 6

Questions and points for providers to consider (in addition to the relevant actions as detailed in Appendices 1 and 2) when supporting people in care homes who have exceptional circumstances including receiving end of life care or compassionate circumstances, to receive visitors in the internal area of the home

  • Request for a visit that will need to take place within the home for a specific purpose felt to be absolutely essential is made to the care service manager for a decision. The visit, if agreed, has restrictions in place regarding the number of visitors, the duration and location of the visit.
  • Are clear notices in place at all entry points into the premises for any visitors setting out the expectations to gain admission?
  • Are visitors asked to wash their hands with soap and water for a 20-second   duration on arrival into the home, often during their stay, and upon leaving?
  • Infection prevention and control guidance on the use of PPE 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, in addition if there is a high risk of splash / respiratory secretions being coughed uncontrollably from the resident.
    • If the visitor is in a “shielded category”, they should be advised of their increased risk – PPE would be the same, if they still choose to visit.
  • Visitors should not be allowed to visit during the undertaking of an aerosol generating procedure (AGP) or for an hour after an AGP is performed on their relative.   
  • The visit takes place in the individual’s room and social distancing is maintained. 
  • 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 door(s) are kept closed where possible and safe to do so. Entry and exit from the room is minimised. Visitors should remain in the room of the individual they are visiting.
  • Visitors do not have access to other people living in the home and contact with staff is limited (any contact with staff occurs at a two metre distance).
  • Are additional waste points provided and strategically placed for disposable face coverings and additional items to avoid litter?
  • Are arrangements in place to ensure the room is cleaned immediately following the visit and there are robust infection prevention and control procedures in place?

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