Visiting in Care Settings task group report – 23 October 2020

Introduction

This report provides North Yorkshire County Council (NYCC) with recommendations from a task group established to consider possible future arrangements for visits in care settings.

These recommendations are presented as a reflection of discussions by the members of the group only. They should be considered by NYCC in context of other parallel work on visiting by NYCC and emerging nationally.

Background

The NYCC Health and Adult Services Leadership Team (HASLT) is considering the management of visits to people who live in care settings in light of increasing cases of Covid-19 in North Yorkshire and nationally. 

In mid-September the Corporate Director, Health and Adult Services (HAS) wrote to service providers to advise of some restrictions to visiting in Scarborough, Selby and Harrogate where there was the sharpest rise, with a commitment to review weekly.

North Yorkshire residents living in care homes and family members have shared their feedback on the impact of visiting restrictions, as well as recent national attention and an impending judicial review on the Government guidance.

On 17 September HASLT requested that HAS colleagues work together to explore the idea of forming a reference group to consider how to support Covid-secure visiting and contact for people who live in care settings. Primarily this would consider the issues involved in visits in a way that minimises risk of virus transmission but also reflects the very real mental health and connectedness issues that people have reported.

On 25 September, the Corporate Director wrote again to all care providers to advise that all regular visiting for people in care settings be stopped until 31 October. This did not include visits for people at the end of life or essential professional visits. A commitment was made to review this situation by 31 October 2020. A letter was sent to residents and families to the effect on 6 October.

Decisions about visiting after 31 October will be informed by recommendations by the task group in the context of current and anticipated transmission rates; advice from the Government and analysis by the NYCC Public Health team amongst others.  

What has been done already?

 Care Home Designated Visitor Guidance (pdf / 658 KB) was produced by the HAS Practice Team and Public Health, with assistance from the Participation and Engagement Team and input from a range of colleagues. This includes City of York Council and the Independent Care Group.  These guidelines reflect the Government guidelines for visiting care homes. A version of the guidance for  residents, family and friends (pdf / 348 KB), including an easy read version, was also produced. 

Feedback from other areas

The issue of restrictions on visiting for people in care homes has been raised throughout the 2020 pandemic since the initial lockdown in March 2020. Feedback was received via correspondence from members of the public including residents and family members. This peaked in May 2020 and picked up again in mid-September after the announcement of the advice about visiting restrictions. To date the Social Care complaints team has received 37 pieces of correspondence about care homes in 2020, with almost a third (13) received since mid-September. The Corporate Director of HAS also received direct correspondence from members of the public and MPs who had received representations about visiting.    

The Participation and Engagement Team have also shared feedback from members of disability forums supported by the County Council. The chair of the Harrogate District Disability Forum had direct contact with the Corporate Director, on the subject of visits and in particular the system whereby only one designated visitor is permitted per resident, as per the Government advice (note this advice was updated to allow two visitors in a Government update on 15 October).   

Representations have also been made by care providers through the daily calls with HAS colleagues and via the online care provider forums.

On 6 October, a page was created on the NYCC website about the establishment of the task group and containing letters about advised restrictions to care settings sent to providers and residents and families. The page invites members of the public to HASCovidComms@northyorks.gov.uk with views or suggestions regarding visits.

Reference group membership

Given the tight timeframes to provide advice by the end of October, potential members of the task group were identified through existing networks (for example the Harrogate District Disability Forum), from previous engagement and known interest in the topic. Some members were approached personally by the Corporate Director to participate. Final membership included:

  • people with lived experience of living in different care settings (including older people and working age disabled people)
  • people with children and people with older relatives in care settings
  • representatives from care providers, including Independent Care Group
  • representatives for people with dementia and their families
  • NYCC representation from Quality and Monitoring, Housing Market Development and Public Health

Meetings

There have been three meetings of the task group.

  • Monday 5 October 2020
  • Wednesday 14 October 2020
  • Thursday 22 October 2020

Members were sent an agenda and information by email about the nature and aim of the meetings several days prior. All meetings were held online via GoTo Meeting.

5 October

14 October

22 October

  1. Welcomes and introductions
  2. Current situation and why we are here
  3. Care Home visits: your experiences during Covid-19
  4. What works, and what else could be done?
  5. Next steps
  6. Future meetings
  1. Welcomes and introductions
  2. What we talked about last time
  3. Recent Updates
    - Website / Press release

- Letter to Residents / families

  1. Care Home visits: any further experiences to share?
  2. Solutions to support in person visits
  3. Next steps
  4. Future meetings
  1. Welcomes and introductions
  2. Recent Updates –
    - updated guidance
    - Nursing Times actions
  3. Draft Task Group Report on Care Setting Visiting 
     - Review of recommendations           
  4. Recommendations          - priority actions        
  5. Next steps
  6. Future meetings

Conversations

Over the three meetings, members discussed a number of topics relating to the current advice to halt to visits and how North Yorkshire can collectively plan for Covid-secure visits in the coming months with winter approaching. 

The participants were able to share their own personal experiences of the impact of restricted visiting since the start of the pandemic. People living in care settings, and parents and children of people in care settings shared stories. Some people on the group had not had any family visitors in over six months. It seemed that sharing these experiences and being heard was an important part of the task group’s role and helped quickly engender a strong sense of community in the group.

Care providers spoke about the difficulty of explaining the restrictions to residents and families. They highlighted the need for clearer, easy to share information that made it easier to explain the basis for decisions around the restrictions. Providers also talked about the creative ways they had tried to support visits since the start of the pandemic.

Despite peoples different backgrounds, roles and situations there was agreement on a number of issues including:

  • The negative impact of a general blanket restriction on visiting and a stated desire for this to be lifted as soon as practicable
  • The need for a visiting strategy and guidelines to support flexible approaches based on risk assessments for individual people and specific settings.
  • The need for clarity about going out into the community, including the rights of people in care settings to visit the community and the potential for people to meet with loved ones away from the care setting      
  • The need for greater investment in technology to support contact between people in care settings and the rest of the world, including loved ones. This covered access to technology, but also the role of care providers to support access to and use of technology, and their current capacity to do so.
  • Concern about how any approaches can be implemented to support visits for people who do not have mental capacity to make decisions about visiting o who might not understand how to meet loved ones in a Covid-safe way. The group explored the idea of best interest decisions. This includes being able to identify in whose best interests any decisions might be made about visits. It was noted that in some cases, no visit might be less distressing than a short rushed visit or interactions where use of PPE or other Covid-safe measures might cause emotional distress.    

It was notable that some members of the forum currently living in care settings all had a relatively risk-averse view of visits and trips into the community. Whilst wanting to be able to see family and friends, they recognised the inherent risk of on-site, in person visits and noted that not having visitors was a sacrifice they were prepared to make to protect themselves and others from Covid-19.

This led to a discussion on balancing the rights and responsibilities of residents around visits, and how care providers can support both safely.     

Recommendations by task group members

View a summary of the main suggestions and recommendations made during discussion with the group in first two meetings. The recommendations were written in Easy Read, and then reviewed by participants at the third meeting. Plans to rank the recommendations in order of importance or urgent need were not able to happen due to reduced attendance at the third meeting.

A longer version of the recommendations is provided below with additional content and notations from discussions.

Task Group recommendations: full length and discussion

1

Visitors are a key part of the care and support people receive, especially for mental and physical wellbeing, and should be subject to the same Covid-safe practice required of staff in the care setting.

It was understood that this would require weekly testing and that there are currently capacity issues on testing that need resolution to make this work. This was seen as more aspirational in the long term.  

2

Allow more than one designated visitor per resident.

Changes to Government advice on 15 October this rise from one designated visitor to two. This was broadly supported by the group on 22 October although they was a view that the need for ‘designated’ visitors would not exist if processes around covid-safe visits are clearly set out and followed.  

3

Clear, tailored communication for different audiences.

Should include clearly defined, easy to understand responsibilities and roles about who is making decisions about any restrictions to visiting. There was a view that it was not clear who was ultimately responsible for decisions around restrictions. 

4

Make rules and processes easy to understand

An easy to use flow chart or decision tree (similar to the one for PPE) that would help support providers, family and residents to understand the rules and processes for Covid-safe visits depending the type of setting and if the person has capacity.

It was recognised that the addition of the Tier 1, 2 and 3 system complicates decision making especially when the resident and loved ones live in areas under different tiers.  

5

Develop care setting and individual ‘Keeping in Touch’ plans

This plan would detail the process and means by which all types of visits would be undertaken including the risks and mitigations for each individual in the care setting.

This would cover (as appropriate):               

  • face to face visits (indoor and outdoor)
  • window visits
  • virtual visits using technology
  • visits arrange by going out into the community
  • visits to specific locations such as a family home

Members felt that ‘Keeping in Touch Plan’ was a more personal, relatable and positive way to talk about the issues around visiting and also less clinical.

The plans would be about finding the balance between meeting care needs, and emotional needs and wellbeing for residents with a focus on choice and control. 

The last dot point around people being able to go out and for the day to another person’s home was added at the end of the last meeting and there was not time to explore this further.

6

Make available additional resources to employ care staff to support with visiting both virtual and face-to-face visits. 

This recognises that staff are often rushed trying to fit the management of visits in with their caring tasks and other tasks. It also recognises that some staff are less skilled at supporting people to use technology and may need some training.  

7

Clear guidance for residents, families and providers about supporting people to meet loved ones safely in their local community.

There have been a number of representations about this issue, with some care providers not supporting this option. As for (5) above it was requested that this section include the possibility of a visit inside the home of a friend or family member.   

8

Recognise and support the importance of technology

This is about providing support for residents and organisations with training, advice and support to use technology to keep in touch. Some residents were very familiar with using technology to stay in touch and felt it was an adequate substitute. They were happy to be Technology Champions to help others get online.

It was raised that there is not equal access to such technology, and that NYCC should consider if people have access to the internet, hardware such as iPads and the accessibility of software platforms like Zoom.

It was recognised that there are other benefits of technology to reduce isolation for example participation in physical and mental health activities, virtual appointments with professionals and social events.

9

Support for people who lack mental capacity to make decisions on visits.

Clear guidance for how providers should be supporting people who lack capacity to have meaningful and supported contacts and activities. This includes considered thinking about best-interest decision making and the role and professional status of independent advocacy services.  

10

Designated visitors being given the same training around PPE 

This included the need for donning and doffing to be done correctly (an online video was suggested). Families and providers both said guidance is needed on who provides the adequate PPE. If the onus is on the provider, they will need to plan for this when ordering PPE stock

 

11

Create standards and advice for care settings about best practice in setting up and management of indoor visiting spaces

For example the use of a conservatory that is accessed by two separate doors or signage that is accessible and not reliant on words.

12

Consider setting up Covid-safe spaces in the community for people to meet loved ones – for example in unused office spaces or library meeting rooms.

13

Support providers to access the skills and resources to build outdoor spaces –

For example, pods and shelters fit for use in the winter both in care home gardens and in general community areas for outside visiting. This might include approaching local businesses or even the military.

14

Create a safe space for providers to talk about risks and mitigations such as a peer support network or WhatsApp group.  

This would be a place to raise questions and share good practice about how people and settings are supporting visiting.

15

Extra support and guidance for people in care settings wanting to go out into the community and who need to use public transport.

This includes working with transport providers to provide information about how they are meeting standards such as cleanliness of buses and taxis, planning around supporting people with mobility and accessibility issues and appropriate use of PPE.

16

Recognise the importance for some families to spend religious festivals and special occasions away from the care setting in the family home.

Although not part of the original recommendations after the second meeting, planning for Christmas was raised by a number of correspondents during October. The issue was brought to the final meeting and the group agreed on the need to provide clear advice so people know what is required to spend time in the family and how to prepare.  This should obviously be applied to all religious festivals.