GO Online: Inspection toolkit

Safe systems, pathways and transitions

Safe care is reliant on organisations working well together to support people moving between services and ensuring there is a continuity of care when this happens. The CQC inspection will look at the systems, processes, and relationships you have in place to ensure this is as seamless and safe as possible.

The following film provides a summary of this area of inspection. It can help you and your teams learn about what will be inspected and what is important to demonstrate to deliver good or outstanding care.

Safe systems, pathways and transitions

• We can evidence how we have safely managed people’s transition between care services.
• We ensure we can meet the needs of people being discharged/transferred to our service before this happens.
• We involve the people we support in discussions around their care pathways and transitions, including how to keep them safe throughout these processes.
• We risk assess and develop appropriate mitigations to ensure people are kept safe as they move between services (e.g., hospital passports, assessment, use of partnership working such as trusted assessor etc.).
• We ensure emergency admissions out of our service to a hospital have all the relevant information and support to ensure a rapid, accurate assessment through to discharge.
• We ensure that people’s safety is a key issue in our engagement with our partnership working with other health and care services and professionals.
• Our policies and processes are aligned with our key partners supporting people’s care journey. This helps us to share learning and drive improvement between our services.
• Our effective and open relationships with other services and professionals ensure that there is a safe continuity of care when people move between services (e.g., evidence of our involvement in multi-disciplinary team meetings etc.).
• We work with partners to ensure effective monitoring of care continues as people move between services, enabling any changes and deterioration to be identified and acted upon
• We work with partners to ensure effective monitoring of care continues as people move between services, enabling any changes and deterioration to be identified and acted upon
• We ensure partners and professionals communicate with us via secure email systems (e.g., we use NHS.net and comply with the Data Security Protection Toolkit to share information back and forth with a hospital discharge team).
• We identify gaps in communication in these processes and implement new strategies.
• We work closely with partners and professionals to ensure that their own systems and processes ensure information is protected.
• We ensure handovers between both our own staff team members and other services and professionals we engage with do not omit important information.
• We learn from experience if an admission has not gone well e.g., we are unable to meet someone’s needs following admission – what could we have done differently to avoid this happening again.
• We have clear records related to correspondence and referrals to other professionals and services, including associated transfer and transition documentation.
• Where we feel that there has been an unsafe discharge/transfer, we escalate these matters to safeguarding teams and appropriate bodies.
• We involve relevant staff and external healthcare experts in reviews of incidents and significant events (e.g., admission to hospital) to learn from what contributed to the event and how these can be mitigated.

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