Frequently asked questions for adult care home and domiciliary support services

Can care home providers use a trusted assessors’ assessment to determine whether the service can meet an individual’s care and support needs?

Yes. However, while a trusted assessor may be able assess whether a person’s needs can be met by a particular type of service e.g. care home or domiciliary support, they will not be able to determine if a specific provider can meet that person’s needs. This is because only the provider will have an accurate understanding of the skills, competence and sufficiency of their staff and the potential risk and impact on the other people using the service. 

The provider must decide on the most appropriate way to make an informed decision as to whether they can meet an individual’s care and support needs. The provider can draw on trusted assessors’ assessments in order to make this determination.

The RISCA statutory guidance (External link) sets out what providers should take into account when making this determination. This includes any health or social care assessments or care and support plans in place for the person, any risks to the person and their wishes and feelings. Where there is no care and support plan in place for the person, the provider is required to undertake an assessment.

Importantly, Regulation 14 (External link) sets out that the determination must include consultation with the individual and consideration of compatibility, and the potential risk and impact on the other people using the service.   

Please note Regulation 14 is not about assessment by the provider. Regulation 18 requires the provider to carry out an assessment within seven days of the commencement of the provision of care and support. These two requirements should not be confused.
 

Can a nurse working in a care home verify death?

Yes. Verification of an expected death is the process of identifying a person has died. Verification of an expected death can be undertaken by a registered nurse who has been deemed as competent to undertake the extended role of verification of death. There must be clear policies and local agreements in place about the circumstances in which this can be done. Certification of death requires a registered medical practitioner.  Nurses should refer to the Royal College of Nursing (RCN) guidance, Confirmation or verification of death by registered nurses (External link).

Can nurses in care homes sign the All-Wales ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) form (section 5)?

Personalised future care planning is and has always been a vital factor in ensuring people receive high quality and dignified care, particularly for people who have serious and life-limiting conditions and older people who may be frail. 

People’s wishes and best interests must be taken into account in a personalised way through bespoke future care planning discussions. Decisions must only be made on an individual basis and never be made for groups of people. The Mental Capacity Act requires these decisions to be taken in collaboration with the person involved. It sets out how discussions should take place if a person has capacity and what to do when a person lacks capacity. Consideration must always be given to involving family members or an advocate. 

As part of future care planning processes, there may also be consideration of a ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) discussion and form. As has always been the case, personalised and compassionate communication must be central to this process. It is essential all those involved with DNACPR conversations and decision making, never discriminate against specific groups with protected characteristics and people are at the centre of individualised, high quality, safe DNACPR decision making.

Providers/Responsible Individuals decide whether registered nurses employed can sign section 5 of the DNACPR form. In making this decision they must familiarise themselves with the Clinical Policy for DNACPR for adults in Wales (External link) and The All Wales Competency Framework for DNACPR (July 2023)(External link). The competency framework sets out that health care professionals fully registered with either the General Medical Council (GMC), Nursing and Midwifery Council (NMC) or Health and Care Professions Council (HCPC) with a good understanding of the person’s current clinical condition, and who may anticipate a possible deterioration in the coming days, weeks or months, can lead and facilitate a DNACPR conversation, and are able to sign section 5 of the new revised DNACPR form.

The policy recommends the form still needs to be countersigned (Section 6) by a senior responsible clinician, though makes it clear the DNACPR is valid as soon as section 5 of the form is signed. To avoid any challenge about potential conflict of interest, it is CIW’s view where a nurse in a care home signs section 5 of the DNACPR form, section 6 should be completed by a senior clinician as soon as practicable. 

Where providers agree for staff working in care homes to take on this task, they must ensure the appropriate training, education and governance is in in place as set out in the competency framework. The policy outlines suitable training for health care professionals involved in supporting patients with DNACPR discussions and decisions. Care home providers must be able to evidence the training completed by staff undertaking this task and how competency has been tested and signed off.
 

Can care homes administer intravenous antibiotics?

Administering intravenous (IV) antibiotics is a highly skilled clinical task which requires:

• appropriate clinical governance, oversight and supervision; 
• skilled, qualified, competent and experienced nurses; and 
• the appropriate environment.

Where intravenous antibiotics are administered in care homes, robust clinical governance arrangements must be in place to support nurses administering and monitoring intravenous antibiotics. 

Staff undertaking delegated healthcare activities should be aware of, and adhere to, any code of practice and guidance issued in relation to undertaking delegated activities, for example the all-Wales guidelines for delegation 2020 (External link). Registered nurses should consider professional responsibilities and accountabilities in line with their Code of Practice when delegating an activity or having an activity delegated to them. Providers must ensure nurses have the training and skills appropriate to carry out any procedure. 

They also have responsibility to ensure staff do not undertake tasks beyond their skill, expertise and qualification. Staff must receive supervision in their role to help them reflect on their practice and make sure their professional competence is maintained. Registered nursing staff must have the opportunity to receive clinical supervision. Please refer to RISCA statutory guidance, regulation 36 (External link). 

Where community nursing services are administering IV antibiotics, responsibility for oversight remains with their employer (health board or primary care contractor) and should also reflect requirements of the NMC Code of Practice and guidance around delegation. In appropriate circumstances, administration of IV antibiotics in a care home may be considered a safe alternative to receiving this in a hospital environment; however, care home providers must satisfy themselves they can continue to meet the needs of the person and to provide a service in line with their Statement of Purpose. 

It is important people’s views and wishes are sought in relation to receiving treatment in the care home and not in hospital. 
 

Can NHS healthcare staff work alongside care home staff to support a person following their discharge from hospital? 

There is nothing in the regulations which prevents this from happening and people living in care homes (without nursing) currently receive nursing care via district nurses. Providers will need to ensure their insurance will allow this and have clear governance and accountability arrangements in place with the health board. 

Supporting people to remain in their care home if that is their wish, in their best interests and if they can be safely treated/supported, should always be considered as the preferred option. The requirement for enhanced support from additional services, NHS or third sector (e.g. hospices) should not be a barrier. However, consideration of training/education and/or special equipment that may be required to safely manage a person’s increased health needs must always be considered, alongside appropriate delegation of activities.

If you have a query which is not answered here, please email ciw@gov.wales