Sample policy · Reg 9A

Visiting and Accompanying Policy

Statutory anchor: Regulation 9A (visiting and accompanying in care homes, hospitals and hospices), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 10 (dignity and respect). · primary source

Download the PDF

The PDF version of this template is the same content, formatted for adaptation in your document control system. The disclaimer above is repeated on the PDF cover.

Download PDFTalk to a consultant

Verivius pack version v1, 2026-06-10

1. What the regulation says

The primary source for visiting and accompanying is Regulation 9A. CQC guidance on Regulation 9A is the primary non-statutory source named for this topic.

Unless there are exceptional circumstances, service users ... whose care or treatment involves an overnight stay or the provision of accommodation ... must be facilitated to receive visits at those premises ... who are provided with accommodation in a care home, must not be discouraged from taking visits out of that care home ... who attend a hospital or hospice for the provision of care or treatment which does not involve an overnight stay, must be enabled to be accompanied at those premises by a family member, friend or a person who is otherwise providing support to the service user. (Reg 9A(2): the visiting duty)

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/9A. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

Service users staying overnight in a care home, hospital or hospice must be able to receive visits. Care home residents must not be discouraged from taking visits out. Outpatients at hospitals and hospices must be able to be accompanied by a family member, friend or supporter. Exceptional circumstances can override this, but the bar is high, and decisions must reflect the service user's consent (or, if they lack capacity, their best interests).

3. Purpose

The purpose of this policy is to make sure that people using [Service Name] can receive visits, take visits out where applicable, and be accompanied to appointments where they want this and where Regulation 9A applies.

The starting point is that in-person visiting and accompaniment should be possible. Restrictions should be exceptional, individualised, lawful, legitimate, proportionate, least restrictive, recorded and reviewed.

4. Scope

This policy applies where [Service Name] carries on a relevant regulated activity in:

It applies to:

Regulation 9A does not apply to every regulated activity. CQC guidance identifies excluded activities including personal care, substance misuse accommodation and detox, blood and blood-derived product supply, transport services, triage, and medical advice provided remotely. Providers must check whether their service type is in scope before adopting this policy.

Before adoption, the Service must record which locations and activities are in scope, who may approve a restriction, where the restriction log is held, how often active restrictions are reviewed, and the local infection-prevention, safeguarding and complaints contacts. Remove sections that do not apply to the registered service.

5. Policy warning

The service must not apply blanket bans on visiting or accompaniment.

The service must not discourage care-home residents from visits out through unreasonable processes, excessive isolation requirements, administrative barriers or informal pressure.

Any restriction must be based on individual assessment and exceptional circumstances. It must be recorded, explained, reviewed and removed as soon as it is no longer necessary.

6. Principles

The service will:

7. Responsibilities

The provider is responsible for ensuring that visiting and accompaniment arrangements are lawful, safe and rights-respecting.

The Registered Manager is responsible for implementing this policy, approving restrictions, reviewing decisions and ensuring records are complete.

Senior staff are responsible for supporting staff, assessing risk and escalating concerns.

All staff are responsible for helping people receive visits or be accompanied, and for reporting any restriction or concern.

8. Operational procedure

  1. Record the person's preferences. On admission, assessment or first relevant appointment, ask who the person wants to visit or accompany them, how they prefer this to happen and what communication or reasonable adjustments they need.
  2. Make the arrangement easy. Agree practical details with the person and record them in the care or treatment plan. Do not add forms, fixed hours or permission steps unless they serve a clear purpose.
  3. Identify and control any risk. Assess the individual situation with the person and consider precautions that would allow the visit, visit out or accompaniment to proceed safely.
  4. Escalate a proposed restriction. Unless immediate action is needed to prevent serious harm, staff must not impose a restriction until the Registered Manager or delegated senior decision-maker has reviewed the evidence and alternatives.
  5. Record and explain the decision. Document the person's wishes, risk, rights considered, people involved, precautions tried, restriction, reason, start time and review date. Explain what remains possible and how to raise a concern or complaint.
  6. Review with the people involved. Review active restrictions at the stated time and whenever circumstances change. The reviewer must consider whether the restriction can be reduced or removed.
  7. Close the restriction. Record the date and reason it ended, tell the person and relevant others, update the care plan and complete any incident, safeguarding, complaint or improvement action that remains open.

9. Receiving visits

People staying in a care home, hospital or hospice must be supported to receive visits from people they want to see unless exceptional circumstances prevent this.

The service must consider:

The service must make visiting easy to arrange and must not create unnecessary obstacles.

10. Visits out of a care home

People living in a care home must not be discouraged from taking visits out of the care home.

The service must not impose unreasonable requirements that effectively stop or discourage visits out.

Where support is needed, the service must discuss:

This regulation does not require the provider to fund or resource every visit out, but the provider must not inhibit or discourage visits out through unreasonable rules.

11. Accompaniment to hospital or hospice appointments

Where a person attends a hospital or hospice appointment that does not require an overnight stay, the person must be enabled to be accompanied by a family member, friend, advocate or other support person if they want this.

The service must consider:

Accompaniment can help the person feel safer, communicate better and understand information.

12. Consent and wishes

The service must prioritise the wishes of the person using the service.

A person must not be required to receive a visit, take a visit out or be accompanied if they do not want this and have capacity for that decision.

Where the person lacks capacity for the relevant decision, the Mental Capacity Act 2005 must be followed and a best-interests decision made where required.

The record must show:

13. Mental capacity and lawful decision-making

Where capacity is in doubt, staff must assess capacity for the specific decision.

The service must consider whether the person can decide:

Where a person lacks capacity, decisions must be made in their best interests and be the least restrictive option.

Legal advice may be needed where there is serious dispute, restriction, court order, deprivation of liberty, safeguarding concern or family conflict. Any deprivation-of-liberty question is a separate legal matter and should be addressed through the Mental Capacity Act framework and, where needed, the Court of Protection, with legal advice.

14. Human rights and equality

The service must take a human-rights-based approach.

This includes considering:

Restrictions must be lawful, legitimate, proportionate and the least restrictive option.

15. Exceptional circumstances and restrictions

Restrictions should be exceptional.

Possible reasons may include:

Before restricting, the service must consider precautions and alternatives, such as:

16. No blanket restrictions

The service must not apply blanket restrictions, long-term bans or default exclusion rules.

Restrictions must be:

A general outbreak, staffing pressure or inconvenience does not automatically justify banning all visits or accompaniment.

17. End-of-life visiting

The service must always support in-person visiting where a person is receiving end-of-life care, unless there is a very serious and specific reason why this cannot safely happen.

End-of-life visiting must be handled with sensitivity, urgency and compassion.

The service should consider:

Restrictions at end of life must be escalated to the Registered Manager immediately.

18. Safeguarding and difficult visitor behaviour

The service must support visiting while protecting people from abuse, harassment, coercion or harm.

Where visitor behaviour creates concern, the service may need to:

Restrictions must be targeted at the risk and must not unnecessarily restrict other visitors.

19. Infection prevention precautions

Where infection prevention risk is present, the service must consider proportionate precautions before restricting visits.

Precautions may include:

Precautions must not become unnecessary barriers.

20. Communication

The service must communicate visiting and accompaniment arrangements clearly.

Information should be provided to:

Where restrictions are used, the service must explain:

Information must be accessible.

21. Records

The service must keep records of:

Records must show how the person's rights, wishes, safety and wellbeing were balanced.

Every restriction is also entered on the local restriction log so active decisions cannot disappear within individual care notes. Related incidents, safeguarding concerns and complaints are entered in the corresponding register. Any corrective work is recorded in the improvement action plan with an owner, due date and evidence required for closure.

22. Training and competence

All staff complete training at induction and annually on the starting assumption that visiting and accompaniment are possible, the scope of Regulation 9A, individual risk assessment, consent, mental capacity, human rights, equality and how to escalate a proposed restriction.

Staff who approve restrictions must be able to apply the exceptional-circumstances threshold, explain why precautions are insufficient, set a proportionate review period and recognise when legal, infection-prevention or safeguarding advice is needed. Competence is checked through scenario discussion and review of a completed decision record, not attendance alone.

Training and competence evidence is recorded in the training matrix. A staff member who cannot explain the escalation route must not approve a restriction.

23. Audit and governance

The Registered Manager reviews every active restriction at least weekly and reports the position through monthly governance. Where no restrictions have been used, the Service audits a sample of visiting and accompaniment records at least annually. After any restriction, complaint, outbreak or safeguarding concern, the audit is completed within 20 working days.

The audit must check:

Themes must be reviewed through governance. Each action has an owner, due date and closure evidence, followed by a check that the change improved practice.

24. Related policies in this pack

25. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

26. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement. For this policy in particular, seek advice where the issue involves restricting visits, a serious family dispute, a court order, end-of-life exclusion, a person's refusal, a capacity dispute, an infection outbreak, violence, harassment or discrimination.

27. Review

This policy will be reviewed annually, or sooner following a CQC finding, visiting restriction, complaint, safeguarding concern, infection outbreak, legal change, service model change or governance review.

28. Document control

Version Date Author Changes
v1.1 2026-07-19 Verivius (sample) Added the operating procedure, local adoption controls, restriction log, staff competence controls and linked companion policies.
v1 2026-06-10 Verivius (sample) Conformed new cross-cutting draft to the Verivius policy standard.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the provider's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

Visiting is not a courtesy extended to families. It is part of the person's care, and the harm from getting it wrong is quiet rather than dramatic. A restriction here rarely arrives as a decision. It arrives as a notice on the door, a phrase repeated at reception, or a habit that outlasts the outbreak that started it, and because nobody wrote it down nobody reviews it. The cost lands on the people least able to object, and it shows up as a resident who stops asking to go out because the process wears them down, or a family who were not at the bedside in the last days of someone's life. Visitors are also an informal safeguard: they notice weight loss, low mood, a sore skin area or a change in how staff speak to someone, so keeping them at a distance quietly removes a set of eyes the service benefits from. The restriction log earns its place because it is usually the only place where a manager can see that the service has drifted away from its own starting assumption that visiting and accompaniment are possible.

  1. Any visiting restriction is individual, time-limited and logged, not a blanket ban applied across the service (for example a whole-service outbreak closure).

    Strong evidence: The local restriction log (section 21) recording each restriction's rationale, alternatives considered, start time and review date so active decisions do not disappear into individual care notes, with audit confirming no blanket, long-term or default-exclusion rules (section 16).

    Weak evidence: The only trace of a restriction is a line in a daily note or the handover book saying visiting is suspended because of an outbreak, with no named person, no end date and no review point, so it applies to everyone by default. Weaker still is a restriction log that sits empty while a notice at the front door sets visiting hours, a two-visitor limit or a no-children rule that nobody has individually assessed or dated.

    What the regulator expects to see. Not a law in itself, but CQC judges you against it, so an inspector will look for it and expect a reason where you depart from it.

  2. A restriction is authorised by the Registered Manager or delegated senior after precautions were tried, not imposed by front-line staff on the day (unless immediate action is needed to prevent serious harm).

    Strong evidence: The decision record (sections 8 and 15) showing precautions considered (different room or time, personal protective equipment, supervised or shorter visits, different visitor arrangement) and the named senior approver before any restriction.

    Weak evidence: The restriction is written up by whoever was on shift, in the person's care notes, with no named approver and nothing showing what was tried first. A tick box reading 'manager informed' carries no date or time, and nothing records whether a different room, a shorter or supervised visit, personal protective equipment or a different visitor arrangement was considered and why it was insufficient.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  3. Active restrictions are reviewed and removed as soon as they are no longer necessary, not left running unreviewed.

    Strong evidence: The Registered Manager's weekly review of every active restriction (section 23) and the close-out record (section 8, step 7) capturing the date and reason a restriction ended and that the person and relevant others were told.

    Weak evidence: Entries carry a start date but the review column is blank, or the review date has passed by weeks and nobody noticed. The weekly look at active restrictions leaves no trace, reviews are recorded only as 'remains in place' with no reasoning about whether the restriction could be reduced, and there is no close-out entry, so it is impossible to say when it ended, who decided, or whether the person and their family were told it had lifted.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  4. In-person visiting at end of life is supported unless a very serious and specific reason prevents it, not curtailed for a general reason.

    Strong evidence: End-of-life visiting arrangements in the record (section 17) and immediate escalation of any end-of-life restriction to the Registered Manager, checked in audit (section 23).

    Weak evidence: End-of-life visiting is covered only by a general sentence in the visiting leaflet, with nothing in the individual's own plan about who they want present, overnight or extended visiting, or their cultural, spiritual and religious needs. A restriction applied to someone receiving end-of-life care is logged in the same routine way as any other, with no evidence it was escalated to the Registered Manager immediately or that the reason was specific to that person rather than a general precaution.

    What the regulator expects to see. Not a law in itself, but CQC judges you against it, so an inspector will look for it and expect a reason where you depart from it.

  5. Care-home residents are not discouraged from taking visits out through unreasonable rules, excessive isolation requirements or administrative barriers.

    Strong evidence: Records of visits-out discussions (section 10) covering the person's wishes, who they want to go with and support reasonably available, plus the audit check that no unreasonable requirement effectively stops or discourages visits out.

    Weak evidence: There is no record of any conversation about visits out at all, and the only paperwork is a signing-out book, so it looks as though nobody living there ever wants to go anywhere. Or a local rule requires long advance notice, a period of isolation on return, or sign-off from a professional before a resident may go out, presented as safety, with no individual assessment and nothing showing anyone asked whether the requirement is actually deterring people.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 9A (visiting and accompanying; visits out of a care home)

  6. Visiting arrangements reflect the person's own wishes, with a capacity assessment and best-interests decision where capacity is in doubt, not the family's preference imposed by default.

    Strong evidence: The consent record (section 12) capturing the person's wishes and feelings, capacity assessment where required, who was consulted and any best-interests decision, since a person with capacity must not be required to receive a visit they do not want.

    Weak evidence: The consent record is a relative's signature on an admission form listing approved visitors, and the person's own words appear nowhere. Capacity is either not assessed or recorded as a blanket 'lacks capacity' without naming the specific decision, and the best-interests record names one family member as consulted while saying nothing about the person's own wishes and feelings, or about whether they had indicated they did not want a particular visit.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Mental Capacity Act 2005 ss.1(2), 2 and 4 (with s.5); Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 11(3)

Related

Last verified 20 July 2026

Spotted something to improve?

These are sample templates, not the last word. If you would change a wording, or want to help us confirm a detail, tell us and we will look at it.

Want help adapting this to your service?

A Verivius consultant can read your adapted policy against the live regulation and your service shape. The work fits inside a Mock Inspection engagement or a shorter consulting brief. A 20-minute conversation is the fastest way to find out whether the fit is right.

Get started free

Free to start, no card. A 14-day trial when you subscribe.

Last reviewed 10 June 2026