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Registration Number: {{org_field_registration_no}}

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Transfer to and Discharge from Hospital Best Practice Policy

1. Purpose

The purpose of this policy is to ensure that hospital transfers and discharges are managed safely, efficiently, and with dignity at {{org_field_name}}. Our goal is to minimise disruption, reduce risks, and ensure continuity of care while maintaining compliance with CIW regulations, NHS Wales guidance, and best practices in adult social care.

This policy outlines clear procedures for planning, executing, and reviewing hospital admissions and discharges, ensuring that residents receive timely, person-centred care and that all relevant information is shared effectively between healthcare providers.

2. Scope

This policy applies to:

• All residents at {{org_field_name}} who may require hospital transfer or discharge.
• All care staff, nurses, and senior management responsible for overseeing hospital admissions and discharges.
• Family members and legal representatives, ensuring they are informed and involved where appropriate.
• External healthcare professionals, including hospital staff, paramedics, and community nurses.

The policy covers:

• Decision-making for hospital transfers.
• Pre-transfer preparation and information sharing.
• Managing hospital stays and communication.
• Safe and structured discharge planning.
• Post-discharge follow-up and continuity of care.

3. Legal and Regulatory Compliance

This policy aligns with:

• The Regulation and Inspection of Social Care (Wales) Act 2016, ensuring safe and coordinated care transitions.
• The Social Services and Well-being (Wales) Act 2014, promoting person-centred, multi-agency collaboration.
• The Mental Capacity Act 2005, ensuring residents’ rights and best interests are upheld when making decisions about hospital transfers.
• NHS Wales Discharge Planning Guidance, ensuring a structured approach to safe hospital discharge.
• CIW Guidance on Safe Care and Treatment, requiring continuity of care and robust communication.
• The Health and Safety at Work Act 1974, ensuring the well-being of residents and staff during transfers.

4. Decision-Making for Hospital Transfers

4.1 Criteria for Hospital Admission

Residents may require hospital admission due to:

• Acute medical conditions or injuries requiring hospital-level intervention.
• Worsening of long-term conditions beyond the scope of in-house care.
• Severe infections requiring IV treatment or isolation.
• Falls with potential fractures or head injuries.
• Severe dehydration or malnutrition requiring urgent intervention.

4.2 Emergency vs Planned Transfers

• Emergency Transfers: Immediate transfer via 999 ambulance, with a staff member providing a handover report to paramedics.
• Planned Transfers: Coordinated in advance with GPs, hospitals, and next of kin, ensuring appropriate transport and documentation.

4.3 Mental Capacity and Best Interests

• If a resident lacks capacity to consent, the best interest decision-making process must be followed, with input from family, advocates, or legal representatives.
• If a Do Not Attempt Resuscitation (DNAR) order is in place, staff must ensure that this is communicated to the ambulance service.

5. Pre-Transfer Preparation and Information Sharing

5.1 Essential Documentation

Before transfer, staff must prepare:

• Handover form detailing the resident’s current condition, medications, and allergies.
• Care plan summary with pre-existing medical conditions and history.
• DNAR orders and advance care plans (if applicable).
• Personal identification (NHS number, date of birth, next of kin contact).

5.2 Medication and Personal Items

• All current medications should be listed and, if appropriate, sent with the resident.
• Hearing aids, glasses, dentures, and mobility aids must be provided to ensure comfort.
• A staff escort may be provided if the resident requires additional support or advocacy.

6. Managing Hospital Stays and Communication

6.1 Maintaining Contact with the Hospital

• The Registered Manager or senior care staff will remain in contact with the hospital team.
• Regular updates will be obtained from hospital staff, and care home staff will be available for consultation regarding the resident’s needs.
• Family members and legal representatives will be kept informed throughout the hospital stay.

6.2 Advocacy and Safeguarding

• If the resident lacks capacity, a representative or advocate (e.g., IMCA) must be assigned to ensure their rights are upheld.
• If there are safeguarding concerns, hospital staff must be notified, and a multi-agency safeguarding referral may be required.

7. Safe and Structured Discharge Planning

7.1 Criteria for Hospital Discharge

A resident may be discharged when:

• Their condition is stable and manageable within the care home setting.
• A care plan update has been completed by the hospital.
• The appropriate equipment, medication, and community support are in place.
• The discharge has been coordinated with the GP and care home team.

7.2 Multi-Disciplinary Discharge Planning

• The hospital discharge team must liaise with {{org_field_name}}’s Registered Manager to ensure a smooth transition.
• A home visit assessment may be required if mobility or equipment needs have changed.
• Care staff, therapists, and nurses must be involved in post-discharge planning.

7.3 Medication and Treatment upon Return

• Updated prescriptions and MAR (Medication Administration Record) charts must be provided by the hospital.
• Any new dietary or therapy requirements must be communicated to kitchen staff and activity coordinators.

8. Post-Discharge Follow-Up and Continuity of Care

8.1 Immediate Post-Discharge Actions

• The resident must be monitored closely for the first 48 hours following discharge.
• A post-discharge review meeting will be held with care staff, nurses, and the resident’s GP.

8.2 Family and Resident Support

• Families must be informed and involved in any changes to the resident’s care plan.
• Additional support sessions, counselling, or therapy will be provided if needed.

8.3 Incident Reporting and Learning Reviews

• If any issues arise during transfer or discharge, a formal review must be conducted.
• Lessons learned must be documented and shared with staff to prevent recurrence.

9. Staff Training and Responsibilities

9.1 Training Requirements

All staff must be trained in:

• Hospital transfer protocols and best practices.
• Emergency and non-emergency response procedures.
• Dementia-friendly hospital transfers and communication.
• Safe handling and mobility support.

9.2 Staff Roles

• Care staff prepare residents and provide emotional reassurance.
• Nurses/senior staff manage medical handovers and ensure documentation accuracy.
• The Registered Manager oversees compliance with hospital transfer procedures.

10. Related Policies

This policy should be read in conjunction with:

• Safe Care and Treatment Policy (CHW11)
• Medication Management and Administration Policy (CHW21)
• Risk Management and Assessment Policy (CHW18)
• Safeguarding Adults Policy (CHW13)
• End of Life and Palliative Care Policy (CHW38)

11. Policy Review

This policy will be reviewed annually or sooner if legislative changes or operational needs require amendments.

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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}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.