Transfers and Discharges

1. Introduction

In order to ensure the safe transfer or discharge (including from a respite placement) of an adult from the service, it is vital that the adult and their family are fully involved in the decision, or that it is in the adult’s best interests where they do not have mental capacity (see Best Interests).

Key staff in other agencies must also be involved in the decision making process and sharing information about the adult and their care and support needs are key to a safe move (see Information Sharing and Confidentiality).

2. Transfer to another Home within the Service

A full assessment of current needs and an up to date care and support plan must be available, including a Deprivation of Liberty assessment if needed, before an adult can be transferred to another home. These should be given / sent to the receiving member of staff in the new service.

Staff should share information verbally as well is in writing to ensure a safe and smooth transfer of care and these conversations should be recorded in the notes.

Agreement must be sought from the adult / their representative, their family and other key colleagues in partner agencies. The transfer must be in the adult’s best interests (see Best Interests).

If agreement cannot be reached with the family or the persons’s representative or if the person themselves is objecting, for an adult who lacks mental capacity an application to the Court of Protection may be required.

Any financial issues involved in an adult moving from one service to another must be agreed in advance.

Once a decision has been reached and it is agreed that the adult will be transferred to another home, see Section 3, Planned Transfers and Discharges.

2.1 Emergency transfer within the service

An emergency review should be held within seven days of the adult’s admission to the new service to review the actions taken and develop an action plan for care provision until the first review. Minutes of the meetings should be sent to the relevant senior service manager/s.

Temporary placements must be reviewed within the agreed timescale for the placement and future alternatives must be sought within the period defined.

3. Planned Transfers and Discharges

3.1 Planning for a transfer or discharge

Prior to the transfer of an adult to another service or their discharge from the service, a multi-disciplinary meeting should be held.

The meeting should include the adult / their representative, family, key worker, any other partner agency professionals involved in their care, the manager and keyworker from the new service. Where the plan is to discharge the adult from the service, staff from relevant community teams should attend. This may include the adult’s GP surgery.

The aim of the meeting is to agree a safe a transfer or discharge plan which meets the needs of the person.

The plan will cover the following:

• reasons for transfer / discharge;
• proposed date for transfer / discharge;
• in the case of discharge from a regular respite placement, proposed date of next admission;
• address and contact details of where the adult is to be transferred / discharged;
• the views and wishes of the adult concerned and their family / representative;
• summary of the adult’s care and support needs and the goals and outcomes they wish to achieve;
• who from the current services will be responsible for collating all information prior to transfer or discharge;
• who from the new service / community team will be responsible for receiving the information and act as link person during the transition;
• the transition process (including planned visits to the new service);
• what support will be in place and when, where the adult is being discharged.

The keyworker should ensure the adult is able to participate in the meeting and understands what is happening and that they receive adequate support. Agreement must be sought from the adult, their famil and the service manager / key worker. Other key professionals and those representing the adult may include a best interest assessor, an Independent Mental Capacity Advocate, a relevant person’s representative, an attorney and a social worker. The meeting should not include so many people that it becomes daunting for the adult or their family, however.

The transfer or discharge must be in the adult’s best interests, and not for the benefit of the service. The adult’s best interests are particularly important when they do not have mental capacity (see Mental Capacity).

Minutes of the transfer / discharge meeting should be recorded in the adult’s care and support plan.

Where the adult is to be transferred to a new service information relating to liaison with staff from the new home, visits to the home and support offered should be recorded in the adult’s care and support plan.

The GP should be informed of the planned transfer or discharge and a month’s supply of medication ordered for the adult.

If a psychiatrist is involved in the adult’s care, they should be informed of the adult’s transfer / discharge as they will retain their responsibilities for a six month period and will need to forward reports to a new service.

The adult may like to have a gathering, such as a meal for example with other adults and staff at the service, in order for everyone to say goodbye and acknowledge they are leaving.

On the day of transfer or discharge, the key worker should ensure – with relevant other professionals – that the adult is fit to leave and that they have all their personal belongings and valuables. An entry should be made in the service’s admissions / discharges record.

Someone close to the adult should accompany them to the new service / their home. In relation to transfers to a new service, this should include a member of staff from the current service.

3.2 Arrival at the new service

On arrival at the service, the member of staff accompanying the adult should give the following to the receiving member of staff:

• all relevant records relating to the adult;
• all medication (with an explanation of what is for);
• all money, bank books – a receipt should be obtained from the admitting member of staff;
• all the adult’s personal property, which should be recorded by the new service;
• any appointments the adult may have booked for example dentist, optician.

The member of staff should stay with the adult for a while to help them settle into their new environment. They should ensure the adult is shown around the home and introduced to everyone.

A formal handover should take place between the member of staff escorting the adult and the receiving service. Where the receiving member of staff is not the same person that has been involved in planning the transfer or discharge, all key information should have been communicated to them verbally prior to the adult’s arrival, in writing, as part of the assessment and care and support plan. This includes any possible risks to the adult, such as any needs related to physical or psychological wellbeing.

For planned transfers and discharges a current assessment of the adult’s care and support needs must be provided to the new service or organisation. This should include other assessments as appropriate, including deprivation of liberty, mental capacity, speech and language therapy (SALT) and risk assessments. See also Deprivation of Liberty Safeguards, Mental Capacity and Positive Risk Taking and Risk Assessments.

The key worker in the first service should ensure that all relevant parties are informed that the adult has moved, including:

• local services with whom they were involved / had contact;
• the adult’s relatives (if not already informed).

3.3 Discharge

Once a planned period of respite has ended, or the adult should be discharged with the agreement of the relevant key personnel (see Section 3.1, Planning for a transfer or discharge).

On the day of discharge, the key worker or delegate should ensure the adult is fit for discharge and they have all their personal belongings and valuables appropriately packed. The key worker should also confirm that all services planned to provide care and support to the adult are in place and know that the adult is being discharged that day. This should be recorded in the adult’s records, including the first date of any planned visit from each service.

The key worker should make an entry in the service admissions / discharge record.

Someone known to the adult should accompany them home, and ensure that they have everything they need until services start visiting.

The key worker should ensure that all relevant agencies and family are informed of the adult’s discharge.

4. Hospital Admissions

Where an adult from the service requires admitting to hospital for treatment, please see Transition between inpatient hospital settings and community or care home settings for adults with social care needs.

5. Discharge against Advice

5.1 Adults with capacity

If an adult insists on taking their own discharge from the service, their right to do so must be respected. The key worker or service manager should advise them about any potential risks that this may result in, and encouraged to remain for a while longer to enable staff to plan their discharge in collaboration with all relevant personnel, including their family etc. If they still insist on self-discharge, they should be asked to sign a form stating they are doing so against the advice of the service.

The manager should liaise with the GP and any other relevant staff, and the regulatory body should be informed.

5.2 Adults without capacity

If an adult who does not have mental capacity expresses a wish to leave (either verbally or through their physical actions), the service manager or delegate should be informed immediately. They should take action in line with the Mental Capacity Act 2005, and key relevant personnel should be informed such as the GP, community nurses or a social worker.

An application may need to be made in relation to depriving of them of their liberty to keep them safe (see Deprivation of Liberty Safeguards).

Where the adult is placed under a DoLS authorisation, they have the right to appeal under the Mental Capacity Act 2005. In such circumstances they should be provided with a relevant person’s representative if there are no suitable family members to assist with this appeal.