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Requesting Medical Support: GP, Paramedic, and Specialist Services Policy

1. Purpose

The purpose of this policy is to provide clear guidance on how {{org_field_name}} identifies, escalates, requests and records medical support for individuals receiving domiciliary support in Wales. This includes routine, urgent and emergency support from GPs, GP out-of-hours services, NHS 111 Wales, paramedics, mental health services, community health teams and specialist healthcare professionals.

This policy supports compliance with the Regulation and Inspection of Social Care (Wales) Act 2016, the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, the Welsh Government statutory guidance for care home and domiciliary support services, the Social Services and Well-being (Wales) Act 2014, the Mental Capacity Act 2005, UK GDPR and the Data Protection Act 2018.

The service will ensure that medical advice and professional help are sought in a timely manner, that support is provided in line with the individual’s personal plan, provider assessment, care and support plan where applicable, risk assessments, communication needs, wishes and personal outcomes, and that all medical concerns are recorded, escalated and followed up appropriately.

Our organisation is committed to safeguarding the health and well-being of service users by ensuring that all staff are trained to recognise health concerns, escalate issues appropriately, and work collaboratively with healthcare professionals. This policy outlines the process for identifying medical needs, requesting urgent and non-urgent support, and documenting all interactions to maintain high standards of care and accountability.

2. Scope

This policy applies to:

• All staff members involved in service user care, including carers, supervisors, and managers.
• Service users and their families who require assistance in accessing medical support.
• GPs, paramedics, NHS services, and private healthcare professionals.
• Emergency and specialist medical services, including mental health support and palliative care teams.

• The Responsible Individual, Registered Manager, deputy managers, care coordinators, supervisors, care workers, agency workers and any person acting on behalf of the service.
• Individuals who receive domiciliary support, including adults and, where applicable, children.
• Representatives, advocates, attorneys, deputies, family members or other people legally authorised or consented to act on the individual’s behalf.
• Local authority and NHS commissioners, where they are involved in arranging or reviewing the individual’s care and support.
• Situations where a health concern may also require safeguarding, incident reporting, commissioner notification, CIW notification or review of the individual’s personal plan and risk assessments.

It covers:

• Identifying when medical support is required.
• Contacting and liaising with GPs for routine and urgent care.
• Requesting emergency assistance from paramedics.
• Accessing specialist healthcare services.
• Communicating with service users, families, and healthcare professionals.
• Documenting and monitoring health-related interactions.

• Using NHS 111 Wales and GP out-of-hours services when the GP surgery is closed or when urgent clinical advice is required but the situation is not immediately life-threatening.
• Using NHS 111 Wales Press 2 for urgent mental health support, where this is appropriate and does not delay calling 999 in an immediate emergency.
• Escalating concerns where staff cannot obtain timely medical advice and the individual’s condition may deteriorate.
• Recording capacity, consent, best-interest decision-making, family or representative involvement and the outcome of professional advice.
• Identifying when medical concerns may indicate abuse, neglect, self-neglect, medication error, pressure damage, infection outbreak, serious injury or another notifiable event.

3. Identifying When Medical Support is Required

3.1 Recognising Signs of Health Deterioration

All care staff are trained to identify symptoms of illness, injury, and deteriorating health in service users, including:

• Physical symptoms such as fever, pain, difficulty breathing, swelling, or loss of consciousness.
• Cognitive or neurological symptoms, including confusion, seizures, or sudden behavioural changes.
• Mental health concerns, including signs of depression, anxiety, or self-harm.
• Medication-related issues, including side effects, missed doses, or reactions.

• Possible signs of infection or sepsis, including high or low temperature, shivering, rapid breathing, new confusion, extreme pain or discomfort, mottled or pale skin, reduced urine output, marked drowsiness or sudden deterioration.
• Falls, head injuries, unexplained bruising, suspected fractures, sudden loss of mobility or new difficulty weight-bearing.
• Skin integrity concerns, including new redness, pressure damage, open wounds, swelling, discharge, odour, deterioration of an existing wound or pain around a pressure area.
• Eating, drinking or swallowing concerns, including choking, repeated coughing when eating or drinking, dehydration, sudden weight loss, vomiting, diarrhoea or inability to keep fluids down.
• Diabetes-related concerns, including symptoms of hypoglycaemia or hyperglycaemia, sudden sweating, shaking, confusion, drowsiness or collapse.
• Catheter, stoma or continence concerns, including no urine output, blood in urine, catheter blockage, pain, signs of infection or leakage that may affect dignity, comfort or skin integrity.
• Changes that may indicate abuse, neglect, self-neglect or improper treatment, including unexplained injuries, repeated missed medication, poor hygiene, untreated pain, fearfulness, withdrawal or reluctance to receive support.

If a staff member notices any change in an individual’s condition, they must:

1. Check whether the situation is immediately life-threatening. If it is, call 999 immediately.
2. Stay with the individual where it is safe and appropriate to do so, provide reassurance and follow first aid training if required.
3. Check the individual’s personal plan, risk assessments, communication needs, known health conditions and emergency contact information.
4. Seek the individual’s consent to contact medical services, unless there is an emergency, a safeguarding concern, a vital interest reason, or the individual lacks capacity for the specific decision.
5. Contact the appropriate medical service based on urgency, including the GP, GP out-of-hours, NHS 111 Wales, NHS 111 Wales Press 2 for urgent mental health support, community nursing team, specialist team or 999.
6. Inform the senior staff member, care coordinator, Registered Manager or on-call manager as soon as practicable.
7. Inform the individual’s representative, family member, attorney, deputy, advocate, commissioner or other relevant person where the individual has consented, where there is legal authority, where this is in the individual’s best interests, or where required by safeguarding or contractual arrangements.
8. Record the concern, observations, advice received, actions taken, people informed and follow-up required in the care record.
9. Review whether the personal plan, risk assessments, medication records or visit arrangements need to be updated.

3.2 Role of Care Staff and Limits of Responsibility

Care staff must remain within the limits of their role, competence and training when responding to health concerns. Staff must not diagnose medical conditions, give clinical advice, alter prescribed treatment, advise an individual to start, stop or change medication, or make decisions that are the responsibility of a registered healthcare professional.

Care staff are responsible for:

• observing and recognising changes in the individual’s presentation, health, behaviour, pain, mobility, skin integrity, eating, drinking, continence, cognition, breathing, mood or level of consciousness;
• checking the individual’s personal plan, risk assessments, communication needs and known health conditions;
• seeking advice from a senior member of staff, the Registered Manager or on-call manager where required;
• contacting the appropriate healthcare service without delay where the individual needs medical advice or treatment;
• calling 999 immediately in a life-threatening emergency;
• recording factual observations, actions taken, advice received and follow-up required.

Staff must not delay calling 999 in an emergency while waiting for permission from a manager, family member, GP, commissioner or representative.

4. Requesting Medical Support

4.1 Contacting a General Practitioner, GP Out-of-Hours or NHS 111 Wales

For non-urgent health concerns, staff should support the individual to contact their GP directly where the individual is able and wishes to do so. Where the individual needs support, staff must obtain consent before contacting the GP unless there is a lawful reason to act without consent, such as an emergency, safeguarding concern, vital interest reason or best-interest decision.

When contacting the GP, staff must provide clear, factual and relevant information, including:

• the individual’s full name, address, date of birth and NHS number if available;
• the staff member’s name, role, organisation and contact number;
• the reason for the call and the specific concern;
• when the concern started and whether it is improving, worsening or unchanged;
• relevant observations, including pain, breathing, consciousness, mobility, eating, drinking, continence, skin integrity, mood or behaviour;
• known medical conditions, allergies and current medication, where available and relevant;
• any recent falls, injuries, hospital admissions, medication changes or safeguarding concerns;
• what action has already been taken;
• whether the individual can attend the surgery or requires a home visit or telephone consultation.

For urgent concerns that are not immediately life-threatening, staff must request same-day advice from the GP surgery, GP out-of-hours service or NHS 111 Wales. Outside normal GP surgery hours, staff should use NHS 111 Wales for medical advice and access to GP out-of-hours services.

If the GP surgery, GP out-of-hours service or NHS 111 Wales advises that emergency help is required, staff must call 999 immediately. If staff cannot obtain timely medical advice and the individual’s condition is deteriorating, staff must escalate to 999.

All advice, instructions, prescriptions, referrals, appointments and follow-up actions must be recorded in the individual’s care notes and communicated to the Registered Manager or delegated senior staff member.

4.2 Requesting Emergency Assistance: 999, Ambulance or Paramedic Support

Staff must call 999 immediately where there is a life-threatening emergency, serious injury, severe deterioration or any situation where delay may place the individual at risk of serious harm.

Examples include, but are not limited to:

• chest pain, suspected heart attack or severe breathing difficulty;
• suspected stroke, including face drooping, arm weakness, speech difficulty or sudden confusion;
• loss of consciousness, collapse, seizure or unresponsiveness;
• severe bleeding, suspected fracture, head injury or serious fall;
• severe allergic reaction or suspected anaphylaxis;
• suspected sepsis or sudden severe deterioration;
• choking or severe swallowing difficulty;
• serious burns or scalds;
• suspected overdose, severe medication reaction or poisoning;
• severe pain that is sudden, unexplained or uncontrolled;
• immediate risk of suicide, serious self-harm or serious harm to others;
• any situation where the staff member believes urgent emergency medical help is required.

When calling 999, staff must provide:

• the individual’s name, address and exact location within the property;
• the nature of the emergency and current symptoms;
• whether the individual is conscious, breathing and responsive;
• known medical conditions, allergies, medication and relevant risks, where available;
• any first aid or action already taken;
• access information, including key safe details, pets, locked doors, hazards or mobility issues;
• the staff member’s name, role, organisation and contact number.

Staff must remain with the individual where safe to do so until emergency services arrive, unless instructed otherwise by emergency services or required to protect their own safety. Staff must follow the instructions given by the call handler or attending emergency personnel.

The Registered Manager, on-call manager or delegated senior person must be informed as soon as practicable. The individual’s emergency contact, representative, attorney, deputy, advocate, commissioner or family member must be informed where the individual has consented, where there is legal authority, where this is in the individual’s best interests, or where required by safeguarding, contractual or regulatory arrangements.

An incident report must be completed, and the manager must consider whether the event requires safeguarding referral, commissioner notification, CIW notification, RIDDOR reporting, medication error reporting, review of the personal plan, review of risk assessments, staff debriefing or duty of candour action.

4.3 NHS 111 Wales and Urgent Mental Health Support

Where a health concern is urgent but not immediately life-threatening, staff should support the individual to contact NHS 111 Wales, the GP surgery or GP out-of-hours service, depending on the circumstances and local arrangements.

NHS 111 Wales may be used where:

• the GP surgery is closed;
• the individual needs urgent clinical advice but does not appear to need 999;
• staff are unsure which health service is most appropriate;
• the individual requires access to GP out-of-hours services;
• advice is needed about symptoms, illness, minor injury or local urgent care services.

For urgent mental health support, staff may support the individual to contact NHS 111 Wales and select option 2, unless there is an immediate risk of serious harm, suicide, serious self-harm, violence, overdose, serious injury or life-threatening deterioration, in which case staff must call 999.

Where the individual has mental capacity, staff must respect the individual’s wishes unless there is an immediate risk, safeguarding concern or other lawful basis to share information or seek emergency support. Where the individual lacks capacity for the specific decision, staff must act in the individual’s best interests and record the reasons for the decision.

4.4 Accessing Specialist Medical Services

Some individuals may require input from specialist healthcare professionals or services. This may include, but is not limited to:

• district or community nursing services;
• tissue viability nurses;
• palliative care and end-of-life care teams;
• mental health teams or crisis services;
• learning disability teams;
• occupational therapists;
• physiotherapists;
• speech and language therapists;
• dietitians;
• continence services;
• podiatry or foot protection services;
• diabetes services;
• respiratory services;
• falls services;
• hospital discharge or virtual ward teams;
• pharmacy services;
• dental, optometry or audiology services.

Staff must follow the individual’s personal plan, provider assessment, care and support plan, risk assessments and any professional guidance already in place. Where a referral is needed, staff must check whether the referral should be made by the GP, commissioner, family member, representative, the individual themselves, or the service.

Where specialist advice is received, staff must:

• record the name, role and contact details of the professional;
• record the advice, actions required and timescales;
• inform the Registered Manager or delegated senior person;
• update the personal plan and risk assessments where required;
• share information with staff who need to know in order to provide safe care;
• inform the individual, representative, family or commissioner where appropriate and lawful;
• monitor whether the recommended actions have been completed.

Where the service cannot meet an individual’s changed health or support needs, even after reasonable adjustments, the Registered Manager must escalate this to the individual, any representative, the commissioner and other relevant professionals without delay.

4.5 Medication-Related Medical Concerns

Where a health concern may be linked to medication, staff must follow the Medication Management and Administration Policy and seek advice from the appropriate healthcare professional. This may include the GP, pharmacist, prescriber, NHS 111 Wales, community nurse or emergency services.

Medication-related concerns include, but are not limited to:

• suspected adverse reaction or allergy;
• missed, refused, delayed or incorrect medication;
• medication taken by the wrong person;
• suspected overdose;
• medication not available in the home;
• concerns about side effects;
• changes in the individual’s ability to self-administer medication safely;
• concerns about covert administration, capacity or consent;
• medication errors that may have caused harm or risk of harm.

Staff must not alter medication, give additional doses, omit prescribed medication or advise the individual to stop taking medication unless this has been instructed by an authorised healthcare professional or emergency service.

All medication-related concerns must be recorded, escalated to the Registered Manager or delegated senior person, and reviewed to determine whether safeguarding, duty of candour, commissioner notification, CIW notification or staff learning action is required.

4.6 Hospital Admission, Refusal of Treatment and Return Home

Where an individual is taken to hospital, staff must record:

• the date and time of the incident;
• the reason for admission or ambulance attendance;
• the hospital or service the individual has been taken to, if known;
• the advice given by ambulance staff or healthcare professionals;
• who was informed and when;
• any immediate impact on planned care visits;
• any safeguarding, commissioner or CIW notification consideration.

If an individual with mental capacity refuses medical treatment, ambulance transfer, GP contact or other healthcare support, staff must respect the decision unless there is a safeguarding concern, immediate risk to others or another lawful basis to act. Staff must record the information given to the individual, the decision made, who was informed and any follow-up advice.

If there is doubt about the individual’s capacity to make the specific decision, staff must escalate to the Registered Manager or on-call manager and seek appropriate professional advice. Any best-interest decision must be decision-specific, proportionate, recorded and made in accordance with the Mental Capacity Act 2005.

When an individual returns home from hospital, the service must check whether there are changes to medication, mobility, moving and handling, skin integrity, nutrition, continence, equipment, visit times, care tasks, infection prevention requirements or follow-up appointments. The personal plan and risk assessments must be reviewed and updated before or as soon as practicable after care resumes.

5. Communication and Documentation

5.1 Informing Individuals, Representatives and Families

All medical concerns and requests for medical support must be communicated to the individual in a clear, respectful, compassionate and accessible way. Staff must take account of the individual’s preferred language, communication needs, sensory needs, cognitive ability, mental capacity, wishes and feelings.

Where the individual has capacity, staff must obtain consent before sharing information with family members, representatives or others, unless there is a safeguarding concern, emergency, vital interest reason or other lawful basis for sharing information.

Where the individual lacks capacity for the specific decision, staff must act in accordance with the Mental Capacity Act 2005 and make a best-interest decision. Staff must involve any attorney, deputy, advocate, representative or family member where appropriate and lawful. Staff must not assume that “next of kin” has legal authority unless that person is also legally authorised or the individual has consented to their involvement.

The individual must be supported to understand:

• what concern has been identified;
• who has been contacted and why;
• what advice has been received;
• what will happen next;
• any choices available to them;
• how their wishes and preferences have been considered.

Where appropriate, the individual must be offered support from an advocate or representative, particularly where the decision is complex, serious, disputed or the individual has difficulty understanding, retaining, weighing or communicating information.

5.2 Welsh Language and Accessible Communication

The service must take reasonable steps to meet the language and communication needs of individuals when requesting or coordinating medical support. This includes supporting individuals whose first language is Welsh to communicate in Welsh where reasonably practicable and actively working towards offering a Welsh language service.

Where required, staff must support the individual to access communication aids, interpretation, translation, British Sign Language, easy read information, visual prompts, hearing aids, glasses, communication passports or support from a person who understands the individual’s communication needs.

Staff must record the individual’s preferred language and communication needs in the personal plan and must use this information when contacting healthcare professionals, emergency services, family members, representatives or advocates.

5.3 Accurate Record-Keeping

All records relating to medical concerns, medical advice and healthcare contact must be factual, timely, clear, legible, dated, signed or electronically attributable, and stored securely in accordance with confidentiality, UK GDPR, the Data Protection Act 2018 and organisational record-keeping procedures.

Staff must record:

• the date, time and location of the concern;
• the staff member who identified the concern;
• the individual’s symptoms, presentation and factual observations;
• what the individual said, using their own words where relevant;
• whether the individual had capacity for the specific decision, where capacity was relevant;
• whether consent was obtained, refused or not required, and the reason;
• who was contacted, including name, role, service and contact number where available;
• the time contact was attempted and the outcome;
• advice or instructions received;
• actions taken by staff;
• whether family, representative, advocate, commissioner or other professionals were informed;
• any medication advice, prescription changes or medication errors;
• whether 999, NHS 111 Wales, GP, GP out-of-hours or specialist services were contacted;
• whether the individual was taken to hospital or remained at home;
• follow-up actions, timescales and responsible person;
• whether the personal plan, provider assessment, risk assessments or medication records were reviewed;
• whether an incident report, safeguarding referral, CIW notification, commissioner notification or duty of candour action was considered or completed.

Records must be completed as soon as possible after the event and before the end of the shift wherever practicable. Where there is a delay, the reason for the delay must be recorded.

5.4 Safeguarding Escalation

A medical concern may also be a safeguarding concern. Staff must follow the Safeguarding Adults from Abuse and Improper Treatment Policy, the Wales Safeguarding Procedures and local safeguarding arrangements where there is any allegation, evidence or suspicion of abuse, neglect, self-neglect, financial abuse, psychological abuse, physical abuse, sexual abuse, discriminatory abuse, organisational abuse or improper treatment.

Examples include, but are not limited to:

• unexplained injuries, bruising, burns, fractures or repeated falls;
• delay in seeking medical treatment by a person responsible for care;
• medication being withheld, misused, stolen or administered incorrectly;
• pressure damage, poor hygiene, malnutrition or dehydration linked to neglect;
• an individual being prevented from accessing medical advice or treatment;
• domestic abuse, coercive control or fear of a family member or carer;
• mental health crisis with risk of serious self-neglect or harm;
• concerns about staff conduct, professional misconduct or wilful neglect.

Where safeguarding is suspected, staff must take immediate action to protect the individual, report the concern to the Registered Manager or on-call manager, and ensure appropriate referral to the local authority safeguarding team, police or emergency services where required. Staff must not wait for proof before reporting a safeguarding concern.

5.5 CIW, Commissioner and Other Notifications

The Registered Manager and Responsible Individual must consider whether any medical incident, emergency attendance, hospital admission, safeguarding concern, medication incident, infection concern, serious injury or death requires notification to CIW, the service commissioner, local authority safeguarding team, health board, police, RIDDOR or another relevant body.

CIW notification must be considered where the event involves, or may involve:

• abuse or allegation of abuse involving the service provider, staff member or volunteer;
• allegation of misconduct by a member of staff;
• serious accident or injury to an individual;
• category 3 or 4 pressure damage or unstageable pressure damage;
• outbreak of infectious disease;
• incident reported to the police;
• any event that prevents, or could prevent, the provider from continuing to provide the service safely;
• death of an individual where notification is required by the Regulations or CIW process;
• any other event required under the Regulated Services Regulations or CIW notification process.

Notifications must be made without delay, in writing, and in the manner required by CIW, unless a different timescale is specified. The service must retain evidence of the notification, including the date, time, person completing the notification, summary of the event and any reference number.

Where the individual receives commissioned care, the commissioner must be informed in line with contractual requirements and where the event may affect the individual’s care package, risk level, personal outcomes, visit arrangements or the service’s ability to meet assessed needs.

5.6 Duty of Candour and Being Open When Things Go Wrong

The service must act in an open and transparent way with individuals and, where appropriate, their representatives when something goes wrong with care or support, including where a medical concern, delay, omission, medication error, failure to escalate, communication failure or other incident has caused harm or may have caused harm.

Where duty of candour applies, the Registered Manager or delegated senior person must ensure that:

• the individual is told what happened in a sensitive, honest and accessible way;
• any representative is informed where appropriate and lawful;
• an apology is offered where appropriate;
• immediate actions to protect the individual are explained;
• the incident is investigated or reviewed proportionately;
• learning and improvement actions are recorded;
• records clearly show what was communicated, when and by whom.

Staff must be supported to report errors, near misses and concerns honestly. No staff member must obstruct another staff member from being open and honest about an incident or concern.

6. Staff Training and Responsibilities

All staff must:

• complete induction appropriate to their role before working unsupervised;
• complete training relevant to recognising deterioration, responding to medical emergencies, first aid, safeguarding, medication, infection prevention and control, mental capacity, confidentiality, record-keeping and lone working;
• understand how to contact the GP, GP out-of-hours, NHS 111 Wales, NHS 111 Wales Press 2, 999, community nursing services and specialist teams;
• understand the limits of their role and must not diagnose, give clinical advice beyond their competence, or alter prescribed treatment;
• know how to access and follow the individual’s personal plan, risk assessments, medication records, communication needs and emergency contact information;
• understand when a health concern may also be a safeguarding concern, incident, medication error, notifiable event or duty of candour matter;
• seek guidance from senior staff if unsure, but must not delay calling 999 in an emergency;
• record all health concerns, advice received, actions taken and follow-up required;
• participate in supervision, competency checks, refresher training and learning from incidents.

The Registered Manager is responsible for ensuring that staff have the necessary training, competence, supervision and access to guidance to implement this policy safely. The Responsible Individual must maintain oversight of whether the policy is being followed and whether learning from incidents is used to improve the quality and safety of the service.

6.1 Management Review and Learning

The Registered Manager or delegated senior person must review medical incidents, emergency calls, hospital admissions, medication-related medical concerns, safeguarding concerns and repeated health deterioration to identify whether further action is required.

The review must consider:

• whether staff acted promptly and in line with this policy;
• whether the personal plan and risk assessments remain accurate;
• whether additional equipment, training, supervision or staffing changes are needed;
• whether the commissioner, GP, community nurse or specialist service should be contacted;
• whether the individual’s needs have changed and whether the service can continue to meet those needs safely;
• whether CIW, safeguarding, RIDDOR, commissioner or other notifications were required and completed;
• whether duty of candour applies;
• whether learning should be shared with staff through supervision, team meetings or policy updates.

Where themes or repeated concerns are identified, these must be included in quality assurance monitoring and used to improve the service.

7. Related Policies

This policy should be read in conjunction with:

• Medication Management and Administration Policy (DCW21).
• Safeguarding Adults from Abuse and Improper Treatment Policy (DCW13).
• Mental Capacity and Deprivation of Liberty Safeguards Policy (DCW39).
• Risk Management and Assessment Policy (DCW18).
• Confidentiality and Data Protection Policy (DCW34).

• Incident Reporting and Accident Policy.
• Duty of Candour Policy.
• Consent to Care and Treatment Policy.
• Mental Capacity Act Policy.
• Infection Prevention and Control Policy.
• Pressure Damage and Skin Integrity Policy.
• Falls Prevention and Management Policy.
• End of Life and Palliative Care Policy.
• Lone Working Policy.
• Staff Training and Development Policy.
• Whistleblowing Policy.
• Complaints Policy.
• Hospital Admission and Discharge Policy, where available.
• Welsh Language and Communication Policy, where available.
• Record Keeping Policy.

8. Policy Review

This policy will be reviewed at least annually, or sooner if there are changes to legislation, Welsh Government statutory guidance, CIW requirements, NHS Wales pathways, local safeguarding procedures, contractual requirements, best practice guidance, serious incidents, complaints, audit findings or operational learning.

The Registered Manager is responsible for implementing this policy, ensuring staff understand and follow it, and ensuring that records, audits, incidents and notifications demonstrate compliance. The Responsible Individual is responsible for maintaining oversight of the effectiveness of this policy and ensuring that any required improvements are completed.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
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