{{org_field_logo}}

{{org_field_name}}

Registration Number: {{org_field_registration_no}}

---

Transfer to and Discharge from Hospital Best Practice Policy

1. Purpose

The purpose of this policy is to ensure that the transfer of service users to and their discharge from hospital is conducted in a safe, efficient, and person-centred manner. This policy aligns with the Care Quality Commission (CQC) Regulations, including Regulation 9 (Person-centred care), Regulation 10 (Dignity and respect), Regulation 12 (Safe care and treatment), and the Care Act 2014, ensuring continuity of care while upholding the dignity and rights of individuals.

2. Scope

This policy applies to all staff members involved in the transfer or discharge of service users from {{org_field_name}} to any hospital. It includes planned and emergency transfers, short-term admissions, and discharges from hospitals back to the care home or other settings.

3. Policy Statement

{{org_field_name}} is committed to ensuring that transfers to and discharges from hospital are well-coordinated, person-centred, and managed with the utmost respect for the service user’s dignity, preferences, and safety.

4. Best Practice Procedures

4.1 Pre-Transfer Preparation (To Hospital)

• Assessment of Need: A thorough assessment of the service user’s condition will determine the need for hospital transfer. This decision will be made in consultation with healthcare professionals, the service user (where possible), and their family or advocate. This ensures that hospital transfers are appropriate and necessary.
• Documentation: Staff will ensure that all necessary documentation accompanies the service user, including the hospital transfer form, medication chart, care plan, Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) form (if applicable), and any advance care plans. The care home will also include a summary of the service user’s baseline health condition and any recent changes.
• Personal Belongings: Personal belongings required for the hospital stay, such as clothing, hearing aids, glasses, dentures, mobility aids, and toiletries, will be packed and documented. Staff will also ensure that items are clearly labelled with the service user’s name.
• Medication Preparation: Any required medication for the journey and initial hospital stay will be prepared and handed over to the ambulance crew or hospital staff, with a clear record of administration times.

4.2 Communication and Consent

• Informed Consent: The service user and their family or advocate will be informed about the reasons for the transfer and the expected process, ensuring that consent is obtained where the service user has capacity. If the service user lacks capacity, decisions will be made in line with the Mental Capacity Act 2005.
• Service User Profile: The care home will prepare a “Transfer Sheet” providing all relevant information to ensure continuity of care. This includes sharing the service user’s current health status, any ongoing treatment, and risk factors.

4.3 Safe Transfer Process (To Hospital)

• Transport Arrangements: The service user will be transferred using a suitable mode of transport, ensuring safety and comfort throughout the journey. This may include ambulance services, non-emergency patient transport, or private transport, depending on the urgency and the service user’s condition.
• Staff Accompaniment: A designated staff member will accompany the service user where necessary, particularly if they are vulnerable, have communication difficulties, or experience anxiety. The accompanying staff member will remain with the service user until hospital staff formally take over responsibility.
• Handover: Upon arrival at the hospital, the staff member (if escort is sent) or the ambulance crew will provide a detailed handover to the hospital staff, ensuring they are aware of the service user’s condition, care needs, medication requirements, and communication preferences.
• Record Keeping: All actions taken during the transfer, including departure and arrival times, individuals involved, and handover details, will be documented in the service user’s care record.

4.4 Hospital Admission and Monitoring

• Ongoing Communication: Upon admission, the care home will maintain contact with the hospital, ensuring regular updates on the service user’s condition. The care home will record all updates in the service user’s file and communicate any significant changes to the family or advocate.
• Emotional Support: Service users will be visited (subject to hospital policies) or contacted to provide reassurance and maintain social connections. This includes ensuring the service user has access to a mobile phone or other communication device if desired.

4.5 Discharge Planning (From Hospital)

• Early Planning: Discharge planning will commence as soon as the service user is admitted to hospital, ensuring a smooth transition back to the care home. The hospital discharge team, care home staff, service user, and their family or advocate will collaborate to develop a discharge plan.
• Pre-Discharge Assessment: Prior to discharge, the hospital will conduct a comprehensive assessment to determine whether the service user’s condition has changed and if additional support is required upon returning to the care home.
• Equipment and Medication: Any equipment required for ongoing care, such as mobility aids, continence products, or specialist mattresses, will be ordered in advance. New medications will be cross-checked against existing prescriptions to avoid errors.
• Transport and Accompaniment: The discharge team at the hospital will arrange appropriate transport for the service user’s return.

4.6 Safe Return to the Care Home

• Arrival and Welcome: Upon return to the care home, the service user will be welcomed and reassessed to ensure their care plan reflects their current needs. The staff will provide reassurance and ensure the service user is settled comfortably in their room.
• Handover and Documentation: The discharge summary will be reviewed, and the service user’s care plan will be updated accordingly. This includes medication, mobility requirements, dietary needs, and any new or modified treatments.
• Observation and Monitoring: The service user will be closely monitored for the first 72 hours post-discharge, with regular checks to identify any signs of deterioration. This includes monitoring for dehydration, infection, or medication side effects.
• Family Communication: The family or advocate will be informed of the service user’s safe return and any changes to their care plan.

4.7 Incident Reporting and Learning

• Any issues encountered during the transfer or discharge process, such as delays, medication discrepancies, or safeguarding concerns, will be documented and reported to the Registered Manager. This includes incidents that occurred during the hospital stay.
• Lessons learned from incidents will inform improvements to the policy and procedures, ensuring continuous development of best practices.

5. Related Policies

• CH07: Person-Centred Care Policy
• CH08: Dignity and Respect Policy
• CH11: Safe Care and Treatment Policy
• CH42: Communication and Engagement with Service Users and Families Policy
• CH154-New Service User Onboarding Policy

6. Policy Review

This policy will be reviewed annually or sooner if there are changes in legislation, best practice guidance, or operational requirements. Any updates will be communicated to all staff to ensure ongoing compliance and best practice.

---

Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.