Policy Statement

Having reviewed the latest public health evidence from clinical advisers in UKHSA and the SAGE Social Care Working Group, and with on-going robust infection prevention and control measures in place, the Dept of Health & Social Care have, from 31^st January 2022 eased the restrictions with regards to visiting care homes which was implemented in the response to the Omicron variant.

This Policy follows the guidance updated on 4^th April 2022 and aims to ensure the continuation of safe visiting during the COVID-19 pandemic and the easement on visiting those who are vulnerable as a result of the sustained transmission of the Corona virus.  

The Trust welcomes that the default position set out in the guidance is that visits should be supported and enabled wherever it is safe to do so.

Amica Care Trust’s Care Homes and services have a duty of care to protect its residents and staff from intruders and anyone who threatens their safety and security.

This policy is to be used in conjunction with the visiting and visitor’s policy and the COVID 19 Testing policy.

This policy is also intended to assist decision making during the COVID-19 outbreak, which is anticipated to last for a sustained period, compared to the usual period for other infectious outbreaks. As we see the majority of our community experiencing the removal of lockdown rules in England, it is important to recognise that for those in our care settings, there is still the need to balance the continued management of COVID-19 risk, with a cautious approach to enabling the opportunity to receive visitors,

Scope

Closure of the home to visitors

In certain circumstances the management of the home may decide to close to all visitors as they have always done so in the interest of safeguarding residents; this could be due to an infectious outbreak such as:

• Diarrhoea & or vomiting (Gastroenteritis)
• Norovirus
• Clostridium Difficile (C-Diff)
• Respiratory outbreak such as flu or chest infections
• During any pandemic in recent times such as COVID-19
• Discretion of management during any disaster or major event

During these times the home will operate a traffic light system Red, Amber or Green

• Green – open for visitors
• Amber – suspected cases – managers discretion – option to close the home 
• Red – confirmed cases of either staff / residents / Major incident affecting the home – home closed

As a result of the global pandemic all the Trust services have previously been closed to all visitors as residents are classified as extremely vulnerable and have been shielding on the advice of the Government. 

In order to ensure the residents safety, it has previously been necessary to limit visiting to open spaces such garden visits at these times when the homes were unable to accommodate indoor visits, these visits have been important for the emotional wellbeing of the residents in our care.

Human rights recognise that all people living in care settings have the right to freedom of movement and association, including the right for residents to see their families.

This policy and guidance seeks to balance the rights of an individual with the rights of the others within the care setting (residents and staff) and the duties and responsibilities of Amica Care Trust.

All visitors also have an important role to play – helping to keep their loved ones, other residents and staff safe by carefully following the policies described in the guidance, and the practical arrangements that care homes put in place, such as internal risk assessment and infection prevention and control protocols.

In the face of new variants of the virus such as the Omicron variant, we need to remain alert to ensure we protect those most at risk in care homes.

From 31^st January there is no limit to the number of visitors a resident is able to receive, and the duration of the visits are not limited.

Following the opening of the restrictions a resident and relative survey was undertaken to ensure all parties continue to feel safe and this policy follows the majority wishes of our residents and visitors.

• visitors should make arrangements with care homes in advance of the visit, so that the home can manage the number of people attending at any one time to ensure safe visiting practices can be maintained taking into account the size and layout of the care home.
• be free of any COVID-19 symptoms on the day of their visit
• must be well on the day of their visit’s visitors should not enter the care home if they are feeling unwell, even if they have tested negative for COVID-19, are fully vaccinated and have received their booster. Transmissible viruses such as flu, respiratory syncytial virus (RSV) and norovirus can be just as dangerous to care home residents as COVID-19. If visitors have any symptoms that suggest other transmissible viruses and infections, such as cough, high temperature, diarrhoea or vomiting, they should avoid the care home until at least 5 days after they feel better.
• essential Care Givers who are providing personal care should wear appropriate PPE and have a negative COVID-19 lateral flow test result from a lateral flow device before entering a care home, unless medically exempt. If these visitors attend once or twice a week, they should only test on that day (testing can be completed at home or on site). If they visit more than twice a week, they should test a maximum of twice weekly, 3 to 4 days apart. Essential Care Givers should show proof of their negative test result prior to entry. This may be an email or text from reporting the result, a date stamped photo of the test cartridge, or any other proof. If they are not able to produce a negative test, they may be asked to reschedule.
• visitors and residents are advised physical contact is now enabled. Physical contact like hand holding is acceptable if hand washing protocols are followed.
• visitors (who are not legally required to self-isolate) are advised against visiting the care home (for 10 days) if they have been identified as a close contact of someone with COVID-19, unless absolutely necessary, even if they have been fully vaccinated.
• vaccination is one of our best defences to combat infection. It significantly reduces the transmission of the virus, particularly following 2 doses and evidence suggests that having the booster (and second booster if eligible) will also give protection from the Omicron variant. It is strongly recommended that all visitors and residents take the opportunity to be vaccinated before conducting visits.

Each care home is unique in its physical environment and facilities, and the needs and wishes of their residents. As such, care home managers are best placed to develop their own policies to ensure that the visits described in the guidance are provided in the best way for individual residents, their loved ones, and care home staff.

Care home managers should feel empowered to exercise their judgement when developing practical arrangements or advice to put this guidance into practice so that visiting can take place smoothly and comfortably for everyone in the care home.

All visits have and will continue to have to follow safe visiting practices. Which are in line with Government guidelines and the wishes of our residents.

• A note to ensure visitors are wearing a face covering / face mask. Transparent face masks can be worn by visitors that meet technical specifications. (https://www.gov.uk/government/publications/technical-specifications-for-personal-protective-equipment-ppe/transparent-face-mask-technical-specification)  These must be purchased directly from the manufacturer and used subject to risk assessment. If you do purchase and want to wear a clear mask, then please let the manager know giving all the details of the mask before you visit to ensure a risk assessment is in place.

Types of visiting

Visits can take place in a room most practical and comfortable for the resident, such as their own room. IPC measures must still be adhered to by the visitors and good ventilation in the rooms is recommended.

During the pandemic, the Trust’s services have engaged in a variety of visiting options which and some will continue to be available during an outbreak such as:   

• Window visits:  ground floor window access for both residents and their visitors and the relevant social distancing and PPE measures have been observed.
• Garden visits: Relevant PPE measures and social distancing have been used, and these visits have been pre-booked to ensure distancing is observed.
• Designated areas within a care setting where settings allow for this: depending on the physical layout of the care setting, we have enabled visits to an identified location inside our services reserved for this purpose, these areas have been made to the best of our abilities COVID-19 secure
• Essential Care Givers - Care home residents in England will be able to receive visits inside the care home even during periods of an outbreak if agreed by the Essential Care Giver and management. To reduce the risk of infection home managers will continue to regularly update their risk assessments which will allow them to assess and ascertain safe visiting in line with guidance.

It will continue with its policy of:

• “indoor” visits to dedicated areas if able to do so.
• The homes will continue to enable visiting needed in exceptional circumstances such as when a person is receiving end of life care and the continuation of visits by Essential Care givers during an outbreak.
• The home will ensure that all visits are conducted in a risk-managed way that considers the needs of our service users and the practicalities arising from the physical features and layout of the home
• It will continue to assess the rights and needs of individual residents, particularly those with specific vulnerabilities as outlined in their care plans and will consider the importance of visits in promoting their health and wellbeing
• It will continue to make appropriate best interest decisions with the help of all involved in their care in respect of residents who lack mental capacity and who might be subject to deprivation of liberty authorisations
• It will follow all government and local guidance in respect of the arrangements needed to ensure safe visiting of residents under the new testing procedures
   

Additional measures

Each service will risk assess their environment to be able to accommodate visiting in areas of the home, each service will also take the following measures.

• Where an area is available, staff will facilitate the visit. This will be to ensure the area has been disinfected before and after the visit, (visiting spaces must be used by only one resident and visiting party at a time. Between visits there must be appropriate cleaning and an appropriate time interval) but also to support PPE requirements, and residents’ needs.
• Although every effort is made to provide privacy for visiting due to the risk of some residents’ staff need to support them. For example, if a resident poses high risk of falls, staff need to be close by to reduce the risk and support mobility.  Should a fall occur, to ensure compliance with social distancing, family members would be unable to support.   
• Staff will ensure the visitor/s have washed their hands / used the alcohol hand gel when they arrive and leave the area.
• Social distancing (between visitors and residents, staff, and visitors from other households) must be always maintained – during the visit, and around the care home building and grounds
• Visitors’ temperatures are taken, and questions asked about their general health on admission through the E-reception ipad.
• The visitor should have access to a face covering and will not be permitted to visit without this, please ask the team if you do not have one.
• Where a visitor appears unwell / has a temperature the home / service will request the visitor leave and re book their visit.

If at any time visitors break the visiting protocol, they may be asked to leave, and a meeting arranged with the management of the home.

The health and wellbeing risks arising from the needs of our residents will be taken into consideration. Each resident will have a care plan detailing visiting information / requirements and a risk assessment.

Implementation

The Trust recognises that its visiting policy and arrangements will be very much subject to local circumstances and will have to be adjusted to meet any changes in these. These changes include:

• the circumstances of the care home in terms of, for example, its location, resident needs, current staffing situation and its experiences with the COVID-19 outbreak
• the local circumstances of the COVID-19 epidemic, including past and current incidence and transmission risks

Any arrangements made by the home will apply only when safe to do so, with the approval of the local Public Health authority and on the basis its “dynamic risk assessment”.

The home recognises that decisions to allow visiting and under what circumstances will be made in line with local intelligence from testing on the community and of residents and staff, transmission risks in the local community and other information provided by the home, for example, through its Capacity Tracker updating.

Visiting Schedules

The home will ensure that the visiting arrangements are planned, including times, frequency, and duration, as agreed following consultation with residents and their families and with professionals involved in a person’s welfare.

• visitors should make arrangements with the home in advance of the visit, so that we can manage the number of people attending at any one time to ensure safe visiting practices can be maintained taking into account the size and layout of the care home. This also follows the majority wishes resulting from our survey undertaken with residents and their loved ones.

Communicating with Families and Visitors

The Trusts homes will follow Government guidance in respect of enabling visits to be conducted safety and successfully, including supporting visitors on how to prepare for a visit, including where testing is being carried out.

The Trusts homes accepts that the arrangements for each set of visits will vary and need to be highly individualised.

Visitors’ Risk Assessments

When visiting our care homes we will still ask you to:

• check with us before visiting that everything is in order and that you do not have any symptoms for COVID-19 via the E-Reception pad.
• check if you might have had any contact with anyone who might have been in contact with an infected person or someone carrying the virus in the last 14 days and take a decision about visiting based on your assessment of any risks
• be extra careful about being in physical contact with the person you are visiting and other people whom you might meet by:
• avoiding touching their eyes, nose, and mouth with unwashed hands
• keeping to designated areas of the building which we will inform you about
• carry out stringent hand hygiene practice by always washing hands carefully before and after any contacts made - using the soap and hand sanitiser gels and paper towels provided
• help staff to carry out the procedures that have been put in place to keep everyone safe from the virus and its spread
• report and discuss with us any concerns you have about the health of the person whose welfare is your concern

We are confident that with these precautions in place we will be able to keep our residents safe as possible.

The home will update this visiting policy in the light of further developments and the easing of restrictions as the risk decrease. It will, however, return to a tightening- up if there are further cases of COVID-19 in the home or evidence of increased risk from community transmission that has been identified by local Public Health.
 

Ability to suspend visiting

In the event of any suspected or actual outbreak of COVID-19, or a suspected or known case of COVID-19 within the home / service, visitor restrictions may need to be immediately implemented which suspend some of these enabling approaches and will include exclusion of any non–essential visitors. (This includes any contractors visiting the home).

This will be implemented in a transparent manner with open and clear communication to residents and relevant family members; this could mean that a visitor will be turned away if a suspected case has come to light during the time, it has taken them to travel to the home.

The Trust will work within the guidance set out by the Government which states:

There will be no limit on the number of visitors a resident can have, and the duration of the visit is not limited.

There is no requirement for the resident to test and isolate after visits out, providing these visits are not deemed to be “high risk”.

The visits can now take place in a room most practical and comfortable for the resident such as their own room.

The isolation period is reduced from 14 days to a maximum period of 10 days.

In the event of an outbreak of Coronavirus, the decision on visiting will be based on the advice from the director of public health, as well as any additional advice or guidance from the local infection-control lead from the CCG, and the local PHE HPT.

Role of providers and directors of public health (DPH) in providing a dynamic risk assessment

The priority is making sure those in care homes receive the care and support they need. This includes making sure that residents are not put at avoidable risk of contracting COVID-19, which can have such a devastating impact if it spreads through a care home, infecting vulnerable residents and potentially care staff.

Therefore, the provider will continue to assess and balance the risk of local prevalence and the ability of the care home to manage the visit safely. This dynamic risk assessment must formally take into account the advice of the local DPH. The DPH may choose to provide this through a dedicated care home outbreak management team or group, often in partnership with local social care commissioners. 

The role of the DPH includes formally leading efforts to suppress and manage outbreaks, and the local outbreak plan (overseen by the DPH) includes care homes. DPH also have powers to issue directions to homes to close to visiting, or to take further specific steps.

Care homes must also take into account the significant vulnerability of residents in most care homes, as well as compliance with obligations under the Equality Act 2010 and the Human Rights Act 1998, as applicable.

The care home’s visiting policy is made available and communicated to residents and families, together with any necessary variations to arrangements due to external events.

In the event of an outbreak in a care home, the home will rapidly move to stop visiting (except in exceptional circumstances such as end of life ) to protect vulnerable residents, staff and visitors. Visiting by the Essential Care giver will continue to be encouraged with a risk assessment in place.

There may be local policy and outbreak management arrangements, which will be important to follow. These restrictions may continue until such time as it is understood that the outbreak has been brought under control and the care home has recovered – at this point visiting will be restarted but with the usual infection prevention and control measures and any enhancements required due to any risks identified following the recent outbreak.

In making their judgement the director of public health should consider as a minimum:

• local testing data, including test and trace data, to form a view on the accuracy of local outbreak information including data on uptake, results and frequency of testing in the local area, as well as to form a view of community prevalence
• any national oversight taking place in an area due to transmission risks

In addition, in making their decision about visiting policy, providers and the director of public health should, where possible, consider:

• any testing that takes place outside of the care home, for example community or home testing.  Staff must inform the care home so that the result is factored into the decision-making process to help inform the visiting policy
• results from 2 tests per week of staff. This data will enable the risk assessment to be well informed. Evidence of outbreaks and recovery from outbreaks should also be considered (a recovered outbreak is defined as 14 days or more since the last suspected or confirmed case reported) but subject to a risk assessment by the health protection team (HPT), in some circumstances some outbreaks may be considered over when there have been 2 rounds of whole home polymerase chain reaction (PCR) testing, taken 4 to 7 days apart, which are both negative. This means that effectively some outbreaks could be declared over after 7 to 8 days subject to other considerations. An outbreak of a variant of concern could still see more prolonged and significant restrictions. This might include delaying the whole home outbreak recovery testing until 28 days from the last positive test.
• local intelligence on risk factors relevant to transmission in the care home, for example a nearby concentration of locations where there is a higher potential risk of transmission (for example, food processing plants)
• readiness of the care home to respond quickly when there is a confirmed or suspected COVID-19 case within the care home, to immediately return to essential visits only (for example, end of life and Essential Care Givers), with no exceptions. This assessment of readiness may be based on Care Quality Commission reports, experience of a care home’s responsiveness throughout the pandemic and other local qualitative information

In order to enable visits to happen safely it is vital that the DPH has a live view of the local conditions. The Capacity Tracker is a timely and rich source of information which will help inform the DPH’s advice on visits. Completing the Capacity Tracker daily will help provide assurance and early warning if there were to be an outbreak, as well as helping to provide confidence on regular reporting and that any new cases would be rapidly reported to the local PHE Health Protection Team.

Rights and responsibilities

This policy includes the rights and responsibilities for both Amica Care Trust and visitors which put the welfare and wellbeing of residents/ people receiving care at the heart of the approach when developing this visiting policy.

Rights
Amica Care Trust has the right to	Visitors have the right to
Mitigate risk of infection by refusing entry to their home to anyone, or requesting that a person leave the premises, for any justifiable reason consistent with this policy / protocol.	Access care homes in accordance with the entry requirements set out in the visiting policy of the care setting.
Consider increased visitor restrictions when an outbreak (including non-COVID-19) occurs within the home or declared outbreak / clusters have occurred within the home's local area or if there are other extraordinary circumstances that require it, and usage of such circumstances will be closely monitored.	Be notified by timely and regular updates and information about what is happening in the home, in relation to visiting and local COVID-19 prevalence and transmission risk.
	Be provided and supported with additional ways to connect such as video conference or telephone calls in addition to a limited number of in-person visits.

 

Responsibilities
Amica Care Trust has the responsibility to	Visitors have the responsibility to
Provide a clear policy and information on how they will facilitate visitors, using a dynamic risk-based approach, and make this publicly available as needed.	Follow the home's visiting policy and Visitor Code, including booking in advance.
Provide clear information about how the visit will work and the infection and prevention control measures that must be followed.	Not to visit when unwell or displaying any signs of a cold/flu, respiratory or COVID-19 symptoms.
Appropriately support staff to facilitate visits including written processes and procedures.	Respond truthfully to COVID-19 screening questions asked by the home's staff and to sign the checklist / visitor.
Treat all visitors with respect and courtesy, and to provide clear instructions about the visiting policy.	Treat all staff with respect and courtesy, and to follow their instructions on the visitor policy.
Proactive communication with residents and families where an outbreak occurs, and the impact on the visiting policy.	Follow visiting requirements including, infection and prevention control measures such as washing hands, use of visiting windows, remaining designated areas and social distancing requirements – as directed by the care home staff – and that failure to do so may affect the future ability to visit.

 

Visiting outside the care home

Spending time out of the care home has always been an important part of life for many people living in residential care, and residents leave their care home for a range of reasons. These might include to attend work or education, attend medical appointments and to spend time with friends and family.

For some residents, regular visits out may have been assessed as being a necessary part of their care plan, such as accessing care and support at day services, participating in community groups and volunteering. This might include regular planned overnight visits to the family home.

We recognise how important this is for residents’ health and wellbeing, their ability to remain at the heart of family and social networks, and, in some cases, to deliver the objectives of their care plan. 

However, spending time with others outside the care home will increase the risk of exposure to COVID-19 for the resident and potentially to other residents and staff on their return. This is the case even when we see community infection rates dropping and vaccine coverage increasing. 

There are certain types of activity where the risks are inherently high and only in these circumstances will the resident need to self isolate on their return to the care home. This is to ensure that, in the event they have unknowingly become infected while out of the home, they minimise the chances of passing that infection on to other residents and staff. These activities are:

• overnight stays in hospital in these instances isolation for 10 days is required.
• visits assessed to be high-risk following an individual risk assessment will again require 10 days isolation on return

During this period of isolation within the care home, residents may continue to undertake visits out of the care home, if:

• a risk assessment has been completed showing they can avoid other residents
• they are not visiting another social care setting
• consideration is given to the vulnerability of those they will be visiting

Residents who are able to take lateral flow tests should be able to end isolation as follows. Residents who are:

• vaccinated (with their primary dose and any eligible booster dose) should take a lateral flow test on day 4, 5 and 6, following their return to the care home (day 0), and, if negative, can end isolation
• unvaccinated should take a lateral flow test on day 6, 7 and 8, and, if negative, can end isolation

Residents who are unable to test should isolate for 10 days.

All precautions relating to COVID-19 (including social distancing and those set out below) should be followed while out of the care home. Where residents are visiting a location with an existing testing regime – for example a workplace, day care centre or education setting – they should participate in the relevant testing regime for that organisation where possible.

Our Care homes will always support visits out and all residents (regardless of vaccination status) do not need to self-isolate following a normal visit out, but a risk assessment will need to be carried out.

 

Supporting visiting – guidance

Providers are best placed to define their overall policy for how outward visits are supported in the care home, in a way that takes into account the assessed needs of their residents and what is possible within the facilities and resources of the care home.

The make-up of the care home community should be a key determinant of local arrangements for supporting outward visits. This is because residents are likely to have a range of needs, long-term conditions and other clinical vulnerabilities and levels of mobility.

Providers should consider both the benefits and potential risks involved in a visit out of the care home, in order to recommend measures to mitigate risks before, during and after the visit. Consideration should be given to the risk to other residents (who may be particularly vulnerable) and staff.

Individual risk assessments

No visit out of a care home during a pandemic is without risk, but there are steps we can take to reduce those risks. Care homes will discuss and agree arrangements with residents, visitors, or their essential care provider in advance.

Decisions about an individual resident’s visits out of a care home should be taken with the resident’s assessed needs and circumstances considered. The care home will balance the benefits of visits out of the care home against a consideration of the risks to others in the home, where necessary.

It is important that the resident and their family are involved in discussions throughout this process. If undertaking a visit out is not possible because of the risk to the individual and other residents and staff, care home managers will communicate the reasons for this decision clearly to the resident and their family.

Individual risk assessments should take into account:

• the vaccination status of residents, visitors and staff, including the extent of 2nd vaccinations and boosters.
• any testing of those accompanying the resident or who they intend to meet on their visit out
• levels of infection in the community
• variants of concern in the community
• where the resident is going on a visit and what activities they will take part in while on the visit
• the mode of transport that residents intend to use

 

Where a care home is situated in a local community with high, or rapidly rising, levels of infection, and/or where there is evidence of variants of concern or variants under investigation, care home managers should seek additional local advice from their local authority DPH.

Regard will also be given to the ethical framework for adult social care, and the wellbeing duty in section 1 of the Care Act 2014, and all decisions should be taken in light of general legal obligations, such as those under the Equality Act 2010 and Human Rights Act 1998, as applicable.

Other steps to mitigate the risks around a visit out

To support safe visits out of care homes and to minimise the risk of transmission of infection to care home residents and other people they live with in the care home, the following measures are advised and should be considered for all visits out of care homes:

residents may be (but are not required to be) accompanied by:

• a member of care home staff
• one or more of their visitors, and/or
• their essential care giver (where applicable)

• residents may meet other people but should maintain social distance from anyone who is not one of their named visitors, essential care providers, or care staff and, wherever possible, should avoid close physical contact with those who are supporting their visit to minimise the risk of infection
• where visits out are accompanied by a visitor, the visitor should follow the relevant testing regime as referenced in the guidance on care home visiting and receive negative test results in the same way as if they were visiting in. Testing arrangements are outlined in more detail in the guidance on care home visiting
• where possible, anyone else who the resident meets as part of an indoor visit should undertake a lateral flow device test and receive a negative result on the day of the visit. This can be confirmed by the named visitor. All tests should be reported to the unique organisation number (UON) of the care home
• residents should avoid crowded places and ensure places to be visited are comfortable, but well ventilated.
• residents should avoid using public transport where possible, especially at peak times; travelling in a family car or private taxi is an acceptable alternative. If comfortable, the vehicle windows should be opened to aid ventilation

Others involved in the visit should take steps leading up to the visit to minimise the risk to the care home resident and others in the care home, recognising that introducing COVID-19 to a care home puts all those who live and work there at risk. This includes following good infection control practice including social distancing, hand hygiene, wearing face coverings and avoiding crowded places.

Vaccination is one of our best defences to combat infection risk. It significantly reduces the transmission of the virus, particularly following 2 doses and the booster.

It is strongly recommended that all visitors and residents take the opportunity to be vaccinated before conducting visits.

In the event of an outbreak in the care home

In the event of an outbreak, all movements out of a setting should be minimised as far as possible.

In the event of an outbreak, other methods of maintaining contact between residents and their loved ones (who are not essential care givers) will be supported. This could include:

• visits in well-ventilated spaces with substantial screens, from behind windows
• telephone calls
• video calls
• newsletters
• emails, letters, cards or photographs
• Outbreak restrictions will be in place for different lengths of time, depending on the characteristics of the outbreak and the results of outbreak testing.
• If the first and second rounds of outbreak PCR testing do not detect any further cases in residents or staff, then outbreak control restrictions may be lifted following a risk assessment by the HPT. This may mean that outbreak measures may only be in place for about 7 days (depending on PCR turnaround times), if there is no evidence of further transmission within the care home.
• Otherwise, outbreak recovery testing should be undertaken when there have been 14 days with no new cases. If no new cases are found, outbreak restrictions can then be lifted.
• If the outbreak involves a particular variant which requires additional mitigations (this does not include Alpha, Delta or Omicron), outbreak recovery testing should take place once there have been 28 days with no new cases, rather than 14 days.

The Trust will have the right to change and adapt this policy in line with Government guidance at any time.

Visitors have the right to express their concerns through the Amica Care Trust complaints and concerns policy.

The Trust will not accept liability for any illnesses the visitor may contract following a visit to its services including COVID-19 as a global pandemic.

Amica Care Trust services will request that visitors complete the questionnaire and give consent provided by the services and this is a true and honest reflection.