Carehome Visits

Louise7

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Mar 25, 2016
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But the term 'risk' is not useful in a situation where Covid-19 is practically becoming endemic in any event. I think we need to start using terms like 'accepted risk' instead.

I agree with you @Palerider There are homes - like my Mum's - who have been allowing relatives inside the home, there are homes that have designated relatives as 'essential care providers/key workers' and provided them with tests, and there are others that have done very little to accommodate visits. I've posted on another thread that more should be done to establish what the 'barriers' are in those homes that are not allowing visits - if some homes are managing to come up with workable solutions within the 'guidance' then why aren't others doing so? In terms of risk assessment, you need to have a decent understanding of how to identify & mitigate potential risks, and determine acceptable risks, when preparing a risk assessment so perhaps this experience is lacking in some areas?

Edit: This Guardian article highlights some of the disparities, with some care homes wanting to arrange visits but their Director of Public Health is advising them not to, and it also mentions a care home which is allowing touching & kissing (through PPE): https://www.theguardian.com/society...ness-on-death-certificates-but-it-is-a-killer
 
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Palerider

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Aug 9, 2015
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I agree with you @Palerider There are homes - like my Mum's - who have been allowing relatives inside the home, there are homes that have designated relatives as 'essential care providers/key workers' and provided them with tests, and there are others that have done very little to accommodate visits. I've posted on another thread that more should be done to establish what the 'barriers' are in those homes that are not allowing visits - if some homes are managing to come up with workable solutions within the 'guidance' then why aren't others doing so? In terms of risk assessment, you need to have a decent understanding of how to identify & mitigate potential risks, and determine acceptable risks, when preparing a risk assessment so perhaps this experience is lacking in some areas?

Edit: This Guardian article highlights some of the disparities, with some care homes wanting to arrange visits but their Director of Public Health is advising them not to, and it also mentions a care home which is allowing touching & kissing (through PPE): https://www.theguardian.com/society...ness-on-death-certificates-but-it-is-a-killer

I quite agree with the Guardian article. The local Directors of Public Health are significnat key players in this. I won't post the letter I recieved from our local DPH but I will say my response was a sharp one!
 

anxious annie

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Jan 2, 2019
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I can't understand @Palerider , @Louise7 why local PHDs can't share good practice! It should be about enabling visits in the safest way possible, not taking the easy option and just banning them. I know physical layouts of the home mean all cannot manage the same, but they must do something, after all they are in the "caring" business and are witnessing first hand what isolation is doing to residents. These homes who are saying no visits must try harder.
 

Palerider

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Aug 9, 2015
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I can't understand @Palerider , @Louise7 why local PHDs can't share good practice! It should be about enabling visits in the safest way possible, not taking the easy option and just banning them. I know physical layouts of the home mean all cannot manage the same, but they must do something, after all they are in the "caring" business and are witnessing first hand what isolation is doing to residents. These homes who are saying no visits must try harder.

Penultimately the lowest grade of evidence is being used -that of expert opinion which in todays world has little strength in terms of evidence (because essentially there is none) on that basis I can understand where Dr Mike Yeadon is coming from in his comments on the matter.
 

MartinWL

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Jun 12, 2020
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@Palerider It is a very crude measure, but the only one available, to say that if 1 person in 500 is infected in s particular county, that's twice the risk of infection by visitors as in another county where 1 in 1000 people in the community is infected. The justification for curtailment of visits is based on the likelihood of a visitor being infectious so if the level doubles do does the risk. Of course you may say that this is a crude and inaccurate way to measure risk, and it is, but the tools are not available to card home managers to assess the risk individually of each visitor so they rely on published statistics which themselves are only estimated.

Imagine a care home has 25 staff and 25 residents with 25 weekly visitors. The staff come in 4 times a week. All the staff and visitors mix in the community and in the community 1 person in 500 has the virus. The risk of a visit by an infected person in a week is

25 X 4 = 100 staff days
25 X 1 = 25 visitor days
Total 125 visits.

Risk of a visit by an infected person is 125 ÷ 500 = 0.25 or 1 in 400
If visitors are banned that result is reduced to 0.2 or 1 in 500

That is of course a great over-simplification, as staff spend more time in the building and the risk isn't directly proportional to the number of days worked but it explains why care homes cut out the risk that they can most easily control.
 

MartinWL

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Jun 12, 2020
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I agree @MartinWL that doctors etc need to visit ( tho Drs to my mums home are extremely reluctant, resulting in a medical complaint for my mum worsening and letter of neglect written, but that is another story). They will bring an element of risk as you say, and the managers need to keep risk to a minimum ( it can never be risk free) BUT I strongly disagree when you say visiting can be done without!
I didn't say it was my view that visits *should* be done without, just that they *can* be done without. If the care home manager is 100% focused on prevention of covid-19 you can see why other negative health consequences get forgotten. Many things *can* be done but *should not* be done.
 

Palerider

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Aug 9, 2015
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@Palerider It is a very crude measure, but the only one available, to say that if 1 person in 500 is infected in s particular county, that's twice the risk of infection by visitors as in another county where 1 in 1000 people in the community is infected. The justification for curtailment of visits is based on the likelihood of a visitor being infectious so if the level doubles do does the risk. Of course you may say that this is a crude and inaccurate way to measure risk, and it is, but the tools are not available to card home managers to assess the risk individually of each visitor so they rely on published statistics which themselves are only estimated.

Imagine a care home has 25 staff and 25 residents with 25 weekly visitors. The staff come in 4 times a week. All the staff and visitors mix in the community and in the community 1 person in 500 has the virus. The risk of a visit by an infected person in a week is

25 X 4 = 100 staff days
25 X 1 = 25 visitor days
Total 125 visits.

Risk of a visit by an infected person is 125 ÷ 500 = 0.25 or 1 in 400
If visitors are banned that result is reduced to 0.2 or 1 in 500

That is of course a great over-simplification, as staff spend more time in the building and the risk isn't directly proportional to the number of days worked but it explains why care homes cut out the risk that they can most easily control.

I see your reasoning, but risk in this scenario doesn't quite work that way because there are other factors to take into account -it gets complicated by the R0, what infection control measures are in place as well as what we already know about SARS-COV2. Risk will vary dependent on a number of factors not just the ratio of visits to staff encounters. To date there is no evidence that stopping visits has any effect on infection rates in care homes. The other side to this is that its easier to manage care homoes without having to address the added 'burden' of arranging visits -which to me seems more feasable an explanantion -essentially lack of resources to cope.

But I want to present this article for you and anyone else to read on Covid-19 because it helps to clarify our understanding and sends out some key points at the end of the article:

 

anxious annie

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Jan 2, 2019
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Visits can not be done without as the whole point is to avert death @MartinWL , whether this be death from covid infection, or death prematurely from dementia due to isolation. Data suggests a much higher percentage of deaths from dementia during the pandemic compared to previous years. Care home managers must look and balance the risk of both, not just be 100% Focused on prevention of covid 19 on the death certificate.
As regards the risk of staff v the risk of family, the former are spending a much greater time with the resident during their "visit" and interacting with more residents, giving personal care etc so must pose a greater risk in this way.
 

Lone Wolf

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Sep 20, 2020
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I totally agree anxious annie. And if I understand David Spiegelhalter's analysis, as referenced by Palerider, the covid death rate risk for the care home demography is not greatly higher than the death risk from normal other causes. And that data was based on statistics only to the end of June, the period when most of the covid deaths occurred, and again arguably in uneccesarily vastly higher numbers in care homes if it had not been for the policy of discharging elderley covid hospital patients directly into care homes.

And a factor which is never taken into account is the devastating impact on the relatives who have always been very closely involved with the care of their loved ones in care homes. This is not about occasional visits to see grandma, grandpa, aunty etc. For many, the one compromise of having to succomb to placing your loved one into a care home was the ability to still be closely involved in your loved one's care, which has now been impossible for 8 months, with no end in sight.

For example, I have been told that my loved one now regularly has distressed moods, with crying and shouting. If I could still visit, and be with her for hours at a time, and having been together for 35 years 24/7, I would better than anyone be able to consider whether their was an underlying cause, or simply due to progression of her Alzheimer's. Care home staff, who chop and change anyway, do not have the time to be one on one with residents for hours at a time. It is well reported that pain and discomfit in care home residents is often put down to dementia, when there is an unrecognised underlying pain, discomfit or emotional cause.
 

MartinWL

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Jun 12, 2020
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Visits can not be done without as the whole point is to avert death @MartinWL , whether this be death from covid infection, or death prematurely from dementia due to isolation. Data suggests a much higher percentage of deaths from dementia during the pandemic compared to previous years. Care home managers must look and balance the risk of both, not just be 100% Focused on prevention of covid 19 on the death certificate.
As regards the risk of staff v the risk of family, the former are spending a much greater time with the resident during their "visit" and interacting with more residents, giving personal care etc so must pose a greater risk in this way.
I think there is confusion here between what can be done without and what should be done without. In a nice warm care home clothing can be done without but that doesn't mean I am advocating that the residents should always be naked.

Actually I agree that a range of harms and adverse effects should be considered. However care homes are effectively being tasked with prevention of covid-19 as a priority. They are not considering other risks of harm. What I have tried to point out is that by cancelling visits care homes have reduced the risk of infection bring brought in to the home. I have not said that they have reduced the total risk from all causes. Nobody can really say whether the damage done by the lack of visits outweighs the potential damage from covid being brought in because neither side of that equation can be accurately measured.

There is much harm being done by banning visits but we should realise the valid reasons why that has happened in an attempt to prevent covid-19 from getting in. Squaring those conflicting factors is very difficult. I personally would allow visits but I can understand the pressure on managers not to.
 

Louise7

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Mar 25, 2016
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@Palerider For info, the BGS also published a 'Good practice guide to managing the covid pandemic in care homes' in March (updated in June) which stated the following:

“Current government guidance suggests that family members and friends should be advised not to visit care homes. There are, though, some residents, particularly those with mental health disorders such as dementia, learning disability or autism, or those approaching the end of life, where there may be a strong welfare case for allowing families to visit in order to reduce distress for the resident and/or family. We recommend working with residents, and their relatives, to establish, on a case-by-case basis, the risk-benefit ratio of visiting. For most residents, it is likely to be beneficial for families to stay away but, for some, visits may be required. This should be a shared individualised decision between the resident, care home staff and family”.

 

Palerider

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Aug 9, 2015
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North West
@Palerider For info, the BGS also published a 'Good practice guide to managing the covid pandemic in care homes' in March (updated in June) which stated the following:

“Current government guidance suggests that family members and friends should be advised not to visit care homes. There are, though, some residents, particularly those with mental health disorders such as dementia, learning disability or autism, or those approaching the end of life, where there may be a strong welfare case for allowing families to visit in order to reduce distress for the resident and/or family. We recommend working with residents, and their relatives, to establish, on a case-by-case basis, the risk-benefit ratio of visiting. For most residents, it is likely to be beneficial for families to stay away but, for some, visits may be required. This should be a shared individualised decision between the resident, care home staff and family”.


Yes I saw that, but clearly they have changed their view ;). Just to say that post has now been moved to the campaigns section on TP
 

anxious annie

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Jan 2, 2019
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Managers must stand up to this "pressure" @MartinWL , in my opinion. They are in the prime position to see the deterioration in mental health( and the knock on effect on physical health) in their residents. If they "care" they ought to be challenging the PHD and Government to give family members tests so they feel safe letting us in and not just letting campaigning families fight for this right for their loved ones to have indoor visits ( not behind a prison screen). If they don't "care", should they really be taking their wage and turning their back on this issue by taking the easy option and banning visits.
Many residents, like my mum, are self funders and paying for the privilege of having no meaningful contact with their family. If the care home my mum was in lost all its self funders the home would end up closing, perhaps the manager, and others like her, ought to think about this too!
In my opinion, protecting mental health, and physical health ( catching covid), should both be considered when drawing up guidance. At the moment it is all about protecting physical health , and not balancing this with protecting mental health. Both need to be considered, not one or the other.
At risk of sounding like a parrot, this can and should be achieved by testing family members, and if you are not in the position of having seen your loved one visibly distressed and feeling abandoned, it is perhaps hard to understand what those of us with loved ones in care are going through.
 

Lone Wolf

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Sep 20, 2020
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I totally agree with you anxious annie. And the guidelines and lockdown regulations actually allow for this flexibility. Following is my research on the legal position.

The government guidelines have been advising this principle for some time. The current (November 5th) guidelines call for individual risk assessments and individual visiting arrangements that take into account the needs of their residents, including residents’ needs which "make visits particularly important (for example, people with dementia, a learning disability or autistic people may be permitted visitors when restricting visitors could cause some of the residents to be distressed)."

And the guidelines call for care homes to "work collaboratively with residents, families and local social care and health professionals to strike a good balance between the benefits of visiting for residents’ health and wellbeing and quality of life"

The current lockdown is legislated by The Health Protection (Coronavirus, Restrictions) (England) (No. 4) Regulations 2020.

Care home visiting is explicitly provided for in the current lockdown regulations, where Exception 7 to Regulation 11 (which restricts gatherings) allows for visiting a person staying in a hospice or care home, where the visitor must be a close family member or friend.

And Regulation 6, which restricts movement, has Exception 4 which allows travelling to visit a person staying in a hospice or care home, where the visitor must be a close family member or friend.

The key question is why are so many care homes continuely failing to do individualised risk assessments and visiting arrangements?
 

anxious annie

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Jan 2, 2019
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I agree, they ought to be doing these individualised risk assessments, but are taking the easy option, and doing nothing @Lone Wolf . Between the care home owners/managers, local PHD and Government , all not really doing anything to proactively support visits, and insist they go ahead, it is the residents who sadly suffer, along with their families.
Today I read in the news that mass testing of students (fast tests with results within the hour), will take place between 30th November and 6th December to get the students home for Christmas. The aim is to stop them spreading infection, and I can understand this, but what I can't understand is why family members can't also be tested with these fast tests so we can visit safely ( and stop spreading infection, assuming we are infected in the first place!)
I hope that we hear shortly about testing for family ( only hope that "shortly" , wouldn't be what Helen W thinks this word means!!)
 

Palerider

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Aug 9, 2015
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North West
Johns Campaign have made a new post today on visiting in care homes:

I agree with their view on the DPH being in part responsible for blanket banning as well as the issue of managers not taking to task the decisions being made.

But these subtle changes to the guidance effectively are a means of avoiding any serious legal challenge. I wonder what would happen if care homes nationally were forced to facilitate visiting? I suspect there would be a plea for extra funding and staff.
 

anxious annie

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Jan 2, 2019
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Care homes would need to be given the rapid tests for family, and staff would have to "administer", but apart from that , allowing family in would result in staff having support, as family members take on tasks that they would otherwise spend time doing and so extra staff not required.
 

Palerider

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Aug 9, 2015
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North West
Care homes would need to be given the rapid tests for family, and staff would have to "administer", but apart from that , allowing family in would result in staff having support, as family members take on tasks that they would otherwise spend time doing and so extra staff not required.
I agree, but if there is an insistence that care home visits are monitored then that would change the game -a reflection on what has been said generally on the crisis in social care before Covid-19 came along. There is also some resource required to manage visiting and we have to be aware of that pitfall -its not just a case of testing and opening the doors.

I can't help feeling that as we chip away at this what will be found at the end of it are the things we knew already and some of those things have been raised on here a few times as well as elsewhere. Meanwhile I am desperate to see my mum and today I recieved the first newsletter from the care home since this whole saga began 😲. I can't say there was anything in it of any use!
 

anxious annie

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Jan 2, 2019
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If @Palerider , family were tested, I would assume this meant "as safe as possible, there will always be a risk", but allowed to hug and be close to our loved one , so no need to be "guarded" by staff. I think the fact that visits should be monitored at all times just increases lack of trust. We have to trust staff to be wearing masks etc ( and I know for a fact that this isn't always happening) , so why should we trust staff without being allowed to check they follow procedure, but they have to check up on us? These guidelines do not help to build good relationships.
I hope you get to see your mum soon. I was asking about a newsletter, but perhaps that's not worth chasing up!
 

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