Nettlestead - In-Home Visit Declaration
Prior to conducting any visit inside the home, please complete this declaration. Once completed, you do not need to resubmit it for subsequent visits.

Once you click 'Submit' your response will automatically be sent to the home.
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Email *
Your Name *
The name of the person completing the declaration.
Your Mobile Phone Number *
Please make sure you have this phone with you for any visits.
Resident's Name *
Please give the name of the resident you will be visiting.
Coronavirus Vaccine *
Have you received a first dose of any of the approved Coronavirus Vaccines?
Vaccination Date
If yes, what date did you receive it.
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Guidelines for In-Home Visits
Garden Visits and Pod Visits may still be booked as well as In-Home Visits, but only one type of visit will happen at any one time to ensure there is sufficient staff cover.

Named visitors can only be changed in exceptional circumstances, so please make sure you consider these carefully before submitting the form.

Visits will be conducted in line with current government guidelines in regard to who and how many people may visit, and which may be varied by us to take into account circumstances specific to the home. These will be confirmed to you when you book.

To book, please phone the home who will confirm your agreed visit time by email. Please do not consider any visit as booked until you have received this confirmation email.

Prior to your visit, please ensure that you are symptom free.

You will need to complete a Lateral Flow Test to confirm you are Covid-19 negative prior to entering the home.

You will be supplied with appropriate PPE and given guidance in how to wear it. If you and the resident have received their first Covid-19 vaccines more than two-weeks prior to the visit, face visors may be used instead of face masks.

The only physical contact should be hand holding and, subject to this, you should maintain a social distance throughout the visit.

You should arrive in good time for the visit, as stated in the confirmation email. The duration of the visit will be specified in the email. If you arrive late, the visit must end forty minutes after the scheduled start time to give time to prepare for the next visit.

Once you have arrived, please phone the home on 020 8460 2279 to let them know you are ready.

A member of staff will come out to conduct your Lateral Flow Test and assist you with PPE. Please wait in your car for approximately 30 minutes whilst the results are determined, after which a carer will come to fetch you for the visit. If you have not arrived by car we will find somewhere else for you to wait.

The carer will then guide you to wherever the visit is scheduled to take place, and then assist the resident to join you.

Please make sure you do not touch anything on site, such as gate latches or door handles. If you inadvertently do, please tell the carer so any touched areas can be cleaned.

The carer may either remain close to the resident if required or retire to a discreet distance according to your preference. Please follow any instructions the carer may give.

If the resident requires assistance for whatever reason, the carer will deal with this and may ask you to leave so they can focus on whatever situation has arisen.

You will not be able to leave the visiting area for any reason, including using the toilet.

The carer will give you two-minutes notice of the meeting ending. Once it ends, the carer will escort you out of the home whilst another carer looks after the resident. Again, please be careful not to touch anything on your way.

If you bring any gifts, please hand them to the carer to wipe down and pass to the resident on your behalf.

Covid Testing Information
Apologies for asking such personal information, but we are required to test each visitor for Covid-19 and submit the following details when registering them.
Date of Birth *
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First Line of Your Address *
Post Code *
Guidelines Declaration *
I declare that I have read and understood the guidelines above, and also confirm that the Covid Testing Information may be shared with the testing authority.
Disclaimer *
Despite the use of PPE and other protective measures, I recognise that visiting any care home may lead to an increased risk of contracting Covid-19 or other infectious diseases. I confirm that the choice to visit the home is solely mine and I take full responsibility for any consequences that may follow this decision and, by ticking the 'I Agree' box below, hereby absolve Nightingales from all and any responsibility in this regard.
Data Protection Declaration *
In accordance with The Data Protection Act 2018 (DPA 2018), by ticking the 'I Agree' box and submitting this form, I give permission for all or part of this data to be held on both computerised and manual records, which I may request access to.
Date Form Submitted *
Version
vNS.4.2.D - 11.05.2021
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