Last reviewed 28 July 2020
Those with cognitive impairment or dementia living in care homes with limited understanding of the pandemic situation have been significantly adversely affected by absence of face-to-face visits from loved ones over the past four months.
In this feature Deborah Bellamy reflects on some of the issues faced and how new visiting guidance for care homes is likely to help as we move forward.
The Covid-19 pandemic presented challenges for care homes distinct from other health and care settings, having to contend with the need to safeguard service users from specific outbreak risks to balancing individuals’ needs and ensuring the health and safety and wellbeing of care workers, service users and visitors.
With around 70% of care home service users having some form of dementia, and many in the last stage of their life, the UK dementia organisation, Dementia Voice, has welcomed the decision from the Government to begin to reopen care homes to visitors. They have called for family carers to be treated the same as Key Workers, a view supported by the Relatives & Residents Association (RRA) and the National Care Forum.
The Government has acknowledged lockdown has been difficult for many service users and that families and visits are important for those in care settings. As the rate of infection is decreasing across the country, restrictions are being lifted. However, a number of changes still need to be adhered to and it remains likely the frequency of visits will be limited and/or controlled for the foreseeable future.
Directors of public health and care providers are being urged to follow the new Public Health England (PHE) guidance and ensure robust practices and policies are in place for visiting arrangements and decisions made based on risk assessments to minimise risk.
What have some of the issues been with regard to dementia sufferers?
Care home staff have done their utmost to maintain contact via Skype, video calls, drive-throughs and garden visits/through the window, but it has undoubtedly been a difficult time.
For those with cognitive impairment or dementia, family members or carers are an integral part of their care system, used to providing elements of essential care. They also play a key role in advocacy and timely detection of changes in health of service users. It is likely without visitors and excursions many service users’ health and wellbeing will have significantly deteriorated. Limited opportunity for physical activity may have resulted in loss of muscle mass and strength with potential for increased falls as a consequence.
Levels of anxiety and distress resulting from the absence of face-to-face visits are likely to have increased and optimum nutrition and hydration decreased.
With spatial distancing and reductions in group activities, service users may have felt lonely or bored and limited opportunities for cognitive stimulation may have led to increased cognitive decline for those with dementia.
Increased episodes of aggressive or agitated behaviour or social withdrawal and apathy may have seen a subsequent increase in prescribing and use of psychotropic drugs, affecting mood, mental activity, behaviour, or perception, particularly if there have been reduced staff numbers or they have been unable to manage.
Visiting policy and restrictions
As community transmission rates fall, care homes can develop policies for limited visits, but the main priority must continue to be prevention of infection so visiting policies should be restricted with alternatives sought where possible.
Decisions about conditions, times and frequency of visits will be made by care home providers and whilst visit capacity will increase, it must be based on local ‘dynamic risk assessments’ founded on principles outlined in PHE guidance, subject to individual care home situations and those living and working within it.
The guidance, Update on policies for visiting arrangements in care homes, can be accessed on the GOV.UK website.
Advice for families pre-visiting
For those who have been longing for face-to-face visits, they should be prepared in advance of the contact as some service users may struggle initially to remember or recognise their family members.
Advice and support prior to visiting on how to prepare after this time lapse may include tips on how to communicate when wearing face coverings, such as:
speaking loudly and clearly
maintaining eye contact
not wearing a hat, new glasses/sunglasses, or anything else that might conceal their faces
wearing clothing or their hair in a way that the service users is more likely recognise.
Staff can also support the visiting process by helping prepare the service user by showing them a memory book, video clips and photographs of the person due to visit in advance and talking to them about their relationship, or reading letters that have been sent during lockdown.
All visits will need to be pre-booked in advance, via telephone or email, and thorough cleaning of the area undertaken after every visit to ensure the safety of service users, staff and visitors. To help minimise risk, numbers should be limited to a single constant visitor, per service user, wherever possible to reduce overall numbers of visitors.
What needs to happen before visitors are allowed in to care homes?
Prior to a visit, the care home should undertake a person-centred assessment of the circumstances of each service user, including their vulnerability to Covid-19 and wellbeing.
Each home will be responsible for undertaking risk assessment which should incorporate arrangement or development of safe spaces, reviewing social distancing measures and ensuring full infection control procedures can be followed.
Before visits are allowed in a local authority area, the director of public health will assess the suitability of visiting guidance for that area considering specific local relevant infection and growth rates, taking into consideration wider environment risk.
The care home manager will make local decisions on visiting their care home, liaising closely with the local director of public health.
What if visiting needs to stop again?
If any service users or staff contract coronavirus, visiting will cease until at least 28 days after the last case. Exceptions may be made for those visiting someone nearing the end of their life.
Visitors will be denied access if they display any coronavirus symptoms or are self-isolating under the track and trace scheme. Some homes are installing thermal-imaging machines to measure the body temperature of visitors, prior to access.
In circumstances where an individual or group of care homes needs to restrict visiting, either temporarily or permanently, the director of public health should communicate this in writing to commissioners of all the relevant care homes, or direct to the registered manager.
Care homes will need to ensure effective communication channels with the local outbreak board, and family members in a timely way so it is good practice to check for up- to- date email addresses.
Regular testing is critical, even where residents and staff are asymptomatic, and pivotal in identifying and isolating cases of the virus, preventing wider outbreaks.
Testing is available to all care home staff and service users in England who primarily care for those over 65 and those with dementia. This is being rolled out to all other adult care homes in August.
While this will also help to protect visitors, as yet there are no plans to include family carers in testing programmes. Dementia Voice, and other organisations are keen for this to be bought in comparable to key workers.
Care home residents in Scotland have been able to have visitors from 3 July, if they have not had a coronavirus case or been free of the virus for 28 days, following a “cautious” phased approach, visits are initially restricted to outside with a single visitor required to wear a face covering, this can be accessed on the GOV.SCOT website.
The Welsh Government provided advice on how to safely facilitate outdoor visits under current regulations, which 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. Guidance can be accessed on the GOV.WALES website.
In Northern Ireland during the pandemic, normal care home visiting arrangements were suspended with key exceptions. The guidance, COVID-19: Regional principles for visiting in care settings in Northern Ireland was issued in June 2020, acknowledging rights of next of kin, partners, children, parents and carers to visit their loved ones in health and social care facilities and independent care sector facilities in Northern Ireland, whilst being mindful of the associated risks. Guidance may be accessed on the Department of Health website.
Guidance for visits out of a care home, for example to a family home, are being considered and updated guidance anticipated soon.