The arrival of COVID-19 resulted in many rapid changes across health and social care services, with one of them being the suspension of visits to care homes to protect residents, their loves ones and staff.
However, despite care home visits being permitted from July 2020, the sad reality for many is that visits have continued to be restricted, resulting in detrimental effects on people’s health, welfare and wellbeing.
On 8 October 2020, we wrote to the Secretary of State for Health and Social Care Matt Hancock to express our concerns in partnership with the Association of Directors of Adult Social Services (ADASS) and the Care and Support Alliance.
In reply, the Department of Health and Social Care has invited Healthwatch England, ADASS and the Care and Support Alliance to sit on a working group for the recently announced care home visiting pilot and to continue to share recommendations for future updates to the visiting guidance.
What did we say?
The wellbeing of people in residential homes
The absence of visits for older and disabled people in residential homes is having a profoundly detrimental effect on their health, welfare and wellbeing. Prolonged isolation is detrimental to all of us. For those who lack capacity or who are at the end of their lives, it is particularly devastating.
Despite care home visits being permitted from July, we are hearing that the reality for many residents and their families is that visits have continued to be severely restricted.
In some cases, residents have had no visits since March. We are also concerned as to the default position advocated by the guidance that there should be a limit of one constant visitor, which is depriving residents of contact with their wider family and social circle. The guidance also fails to make provisions for people living in residential care settings to go out and visit their friends and family away from their homes.
This restriction in visits to and from friends and family is leading to increased isolation and loneliness, and we are now receiving reports of significant and widespread physical and mental deterioration of residential care residents and grief for families. In such cases, not only do many residents grow confused and distressed, but there is an increasing risk that the practical and emotional issues often picked up by relatives will be missed. Indeed, homes that become, in effect, closed institutions are very high risk for abuse and neglect. Even the best run that risk if there is a sudden drop in staffing. Family and other close visitors are among the best advocates on behalf of their loved ones.
The recently published Adult Social Care Winter Plan rightly states that people’s needs should be considered regarding the allowance of visits. Ensuring that this point is at the heart of updated visiting guidance would be a vitally important step for the physical and mental wellbeing of residential care residents and would provide greater clarity to providers in developing visiting plans.
Deprivation of liberties and human rights
Human rights are complex. On the one hand, there are those who want, more than anything else, to be protected from a virus that is highly dangerous to people with underlying health conditions. On the other, there are many, particularly those who may be in the last years of their lives, who do not feel their lives are worth living without contact with the people they love.
For most, there is probably a decision to be made about a balance of risks to themselves and to others. Those who are able to do so have a right to choose what risks they are willing to take for the benefit of seeing their family. Obviously, the accommodation of such choices has to have regard to the protection of others from harm. Those unable to make decisions for themselves are entitled to have choices made which are in their best interests and looked at holistically, not just with regard to protection from infection. However, a lack of clarity in the current guidance regarding involving residents and their families in decision-making around visits has led to many visiting policies which remove the rights of people to make decisions on their own lives. Taking away the rights of people to make their own choices or take part in conversations around joint decision-making runs contrary to Article 8 of the Human Rights Act 1998 and Section 4 of the Mental Capacity Act 2005. There may also be a further breach to Article 8 and an unlawful deprivation of liberties if all visits moving forward are to be supervised, as stated in the Adult Social Care Winter Plan.
Although it is permissible to restrict human rights in certain situations, actions must be proportionate and in accordance with law. Restricting the right to a family and private life in order to protect the right to life of others should only be done where providers have found no practicable alternative after considering all other options available to them, and residents and their families have been involved in the decision-making.
The current guidance states that all visiting decisions are ultimately operational and for the provider to make. A certain level of variance in policies is therefore to be expected. However, with recommendations made both centrally through the Department’s guidance and locally through Directors of Public Health, we have had reports of a lack of consistency and clarity for both providers, residents, and their families.
Although there are examples of innovation from providers in finding ways to make safe visits possible, we are also hearing increasing reports of residential care providers introducing blanket ‘no visiting’ policies. Such policies not only run counter to anything personal in relation to care but are directly leading to and exacerbating the wellbeing issues highlighted above.
Any update to the visiting guidance should more simply set out the expectations on providers, local authorities, residents and their families in developing local visiting policies. Providers should be supported to seek the views and wishes of each resident in relation to visiting, and be supported in attempts to provide safe, zoned visiting areas. Where this is not possible, expectations should be made clear that current and prospective residents (or their representatives or advocates if they lack capacity) will be clearly informed, so that they can weigh up the risks and consider these along with visiting alternatives with the provider and with social workers.
Residential Care and Beyond
The current guidance only mentions wider residential care as a footnote. New guidance should more explicitly cover the arrangements of those across all residential care settings and should do so in the context of safely enabling care users to live the fullest lives they can. Some of the issues we have raised are rightly addressed in guidance for the supported living sector, such as shared decision-making on visits. These points should be replicated in guidance to the residential sector.
We hope that the Department will take on board our suggestions. As organisations representing service users, carers and local leaders, we stand ready to provide any support required as part of updating the visiting guidance. The pandemic has been affecting the visiting rights of residential care residents since March and can now be expected to continue for many months to come. Reconsideration of the guidance is, we suggest, now urgent.
Read our letter to Government in full
What was the response?
It's important to note that the guidance for care home visitation was updated between us sending the letter to the Department of Health and Social Care and their response.
In the Governments response to our letter, Healthwatch England, ADASS and the Care and Support Alliance have been invited to sit on a working group for the recently announced care home visiting pilot and to continue to share recommendations for future updates to guidance.