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Transfer to and Discharge from Hospital Best Practice Policy

1. Purpose

The purpose of this policy is to ensure that any transfer of service users to hospital and any discharge back to the service is planned and delivered safely, effectively and in a person-centred way, with clear accountability and robust information sharing. This policy is written to support compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (as amended) (including, but not limited to, Regulation 9 (person-centred care), Regulation 10 (dignity and respect), Regulation 12 (safe care and treatment), Regulation 13 (safeguarding from abuse and improper treatment), Regulation 17 (good governance) and Regulation 20 (duty of candour)) and with the Care Quality Commission assessment approach (Single Assessment Framework quality statements). It also reflects the requirement to make statutory notifications to CQC where applicable under the Care Quality Commission (Registration) Regulations 2009 (including Regulation 18: notification of other incidents).

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. A structured handover format (e.g., SBAR) must be used to summarise the situation and ensure key information is not missed.
• Documentation: Staff must ensure that a complete, up-to-date transfer pack accompanies the service user, including: a current hospital transfer form, care plan summary, relevant risk assessments, the most recent observations (where available), allergies and adverse drug reactions, an up-to-date MAR/medicines list (including the last doses administered and times), details of any controlled drugs (if applicable), DNACPR/ReSPECT or equivalent (if applicable), advance care plan/advance decision (if applicable), and key communication needs and reasonable adjustments. The transfer pack must include a short summary of the service user’s baseline functioning and the reason for transfer, including 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: Where medication is sent with the service user, staff must ensure it is appropriately packaged, clearly labelled, and accompanied by an up-to-date MAR/medicines list showing last dose times and any recently started, stopped or changed medicines. A clear written handover must be provided to ambulance/hospital staff to reduce the risk of missed doses, duplication, or medication error.

4.1.1 Clinical escalation, baseline observations and risk assessment (including infection status)

Before arranging transfer, staff must escalate to the most appropriate senior clinician/service for advice (e.g., GP, out-of-hours service, NHS 111, community nurse, or other relevant professional) where this is clinically appropriate and does not delay urgent emergency care. Staff must record the service user’s baseline condition, current observations (where taken), presenting concern, what has changed, and the rationale for transfer.

A brief risk assessment must be completed and recorded, including (as relevant): falls risk, cognition/confusion/distress, communication needs, pressure area/wounds, oxygen/respiratory needs, nutrition and hydration risk, pain, continence/catheters/stomas, mobility/handling requirements, and allergies or known adverse drug reactions.

Staff must also document and communicate the service user’s infection prevention and control status, including (where applicable): symptoms of infection, current antibiotics, recent positive tests, and any outbreak restrictions/isolation requirements. This information must be shared with the receiving service/ambulance/hospital to reduce avoidable harm.

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.

Where there is doubt about capacity to consent to transfer/discharge, staff must complete and record a decision-specific capacity assessment. If the person lacks capacity, staff must follow a Best Interests decision-making process, including considering the person’s wishes, feelings, beliefs and values; consulting relevant others (family/friends/attorney/deputy as appropriate); and documenting the decision and rationale. Staff must check whether the person has a Health and Welfare Lasting Power of Attorney (LPA) or a court-appointed deputy and involve them lawfully. Where required, staff must consider referral for independent advocacy and ensure information is provided in a way the person can understand, including any reasonable adjustments (e.g., hearing support, interpreter, easy read).

• 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 an escort is sent) or the ambulance crew must provide a structured handover (e.g., SBAR or equivalent) and ensure hospital staff receive the transfer pack. Information must be shared in a timely way, be relevant to ongoing care, and be shared securely in line with information governance requirements. Staff must confirm the name and role of the person receiving the handover and record this in the service user’s care record.
• 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. Discharge planning will follow the current Hospital discharge and community support guidance and local system discharge pathways, including timely coordination with discharge teams and community partners.
• 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.

4.5.1 Minimum discharge information required before accepting return

The service will not accept a discharge back to the home unless a safe plan is in place and the following minimum information is received (or formally escalated to the hospital discharge team if missing): diagnosis/reason for admission, treatment provided, current clinical risks, infection status and any isolation requirements, mobility/handling guidance, nutrition/hydration needs, wound/pressure area plan, continence/catheter/stoma plan, cognitive/behavioural support plan, follow-up appointments, and a complete medicines list with clear changes and first doses due. Any shortfalls must be documented, escalated, and risk-managed before or at the point of 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.
• Medicines reconciliation on return: On the day of return, a trained staff member must complete a medicines reconciliation by comparing (1) the pre-admission MAR/medicines list, (2) the hospital discharge medicines list, and (3) medicines supplied (if any). Any discrepancy (e.g., missing medicines, unclear dose, duplication, high-risk medicines such as anticoagulants/insulin/opioids, or controlled drugs issues) must be escalated immediately to the hospital ward/pharmacy and/or GP as appropriate and recorded before administration where safety could be compromised.
• Observation and Monitoring: The service user must be monitored using an individualised post-discharge plan based on identified risks. As a minimum, staff must monitor for deterioration (e.g., infection, dehydration, delirium/confusion changes, pain, constipation, falls risk, pressure area changes, breathing difficulties, and medication side effects) and record findings at an agreed frequency. Any deterioration must trigger immediate escalation in line with the home’s escalation procedure and must be documented as part of the post-discharge review.
• 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.
• Duty of candour: Where an incident related to transfer/discharge meets the threshold for a notifiable safety incident, the Registered Manager (or delegate) must ensure the service meets the duty of candour requirements, including informing the service user/relevant person, providing an apology, offering appropriate support, and keeping a written record of communications and actions taken.
• CQC notifications: Where required, the Registered Manager must submit notifications to CQC without delay in line with the Care Quality Commission (Registration) Regulations 2009, including Regulation 18 (notification of other incidents), and maintain a record of what was notified and when.

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 at least annually and immediately following any significant transfer/discharge incident, safeguarding concern, cluster of medication discrepancies, CQC notification, or changes to legislation, CQC guidance/assessment framework, or national hospital discharge guidance. Any updates will be communicated to all staff to ensure ongoing compliance and best practice.

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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}}
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