Sample policy · Ambulance

Transfer of care and patient handover policy (ambulance)

Statutory anchor: Regulation 12 (safe care and treatment), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 17 (good governance) for the review of delayed-handover patterns. · primary source

1. Who this ambulance handover policy is for

This sample policy is for independent ambulance providers carrying out urgent transport, private ambulance work, high-dependency transfer, event medical cover or ambulance-supported inter-facility transfer. It focuses on the moment responsibility moves from the crew to a receiving clinician, ward, emergency department, event medical lead, care home, hospice or other responsible person.

Use this ambulance version when the handover record needs to cover clinical observations, treatment given within crew scope, deterioration during transfer, medicines or oxygen handed over, destination mismatch, delayed hospital handover, missing paperwork, wrong destination transfer, and escalation into incident review. For lower-acuity non-emergency patient transport, use the patient transport transfer-of-care and handover policy. For the wider sector evidence trail, use the ambulance and patient transport CQC compliance guide and the article on CQC compliance for ambulance and patient transport services.

This policy should sit alongside the service's patient-assessment, crew clinical-scope, vehicle safety, controlled-drugs, incident, safeguarding and duty-of-candour arrangements.

2. What the regulation says

Care and treatment must be provided in a safe way for service users. (Reg 12(1) (the headline duty))

assessing the risks to the health and safety of service users of receiving the care or treatment, (Reg 12(2)(a) (risk assessment))

doing all that is reasonably practicable to mitigate any such risks, (Reg 12(2)(b) (risk mitigation))

where responsibility for the care and treatment of service users is shared with, or transferred to, other persons, working with such other persons, service users and other appropriate persons to ensure that timely care planning takes place to ensure the health, safety and welfare of the service users. (Reg 12(2)(i) (shared / transferred responsibility))

Regulation 17 adds the governance duties that this policy relies on for pattern review of delayed and failed handovers:

Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part. (Reg 17(1): the umbrella duty)

assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity (including the quality of the experience of service users in receiving those services) ... assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity. (Reg 17(2)(a) and (b): quality and risk)

The full text is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/12 and https://www.legislation.gov.uk/uksi/2014/2936/regulation/17. Where this policy and the regulation diverge, the regulation wins.

3. Plain-English summary

Care and treatment must be provided in a safe way. The regulation lists the areas a provider must address, including risk assessment, risk mitigation, staff competence, safe premises, safe equipment, sufficient equipment and medicines, medicines safety, infection prevention and shared-care planning. Where responsibility for a person's care is shared with or transferred to another service, the regulation expects timely care planning between the parties so the person's health, safety and welfare are protected. Handover is the moment that transfer happens, so a clear, factual handover and a complete records transfer are how a service shows it meets Regulation 12, while review of delayed and failed handovers is part of the good-governance duty in Regulation 17.

4. Purpose

This policy sets out how the Service completes safe transfer of care at the end of each ambulance job, records handover and responds to delayed, missing or incorrect handover.

The policy applies to planned transport, high-dependency transfer, urgent transport and event-cover work where the Service hands a patient to another service, facility or responsible person.

5. Sources to verify before adoption

6. Scope

This policy applies to:

The policy applies to NHS-contracted journeys, private journeys and subcontracted journeys where the Service remains responsible for the handover process.

7. Transfer-of-care process

Crew complete transfer of care at the receiving destination before closing the job.

7.1 Before arrival

Crew check the destination before arrival.

The check covers:

If Crew identify a destination mismatch before arrival, they contact the control point before continuing unless stopping would create greater risk.

7.2 Verbal handover

Crew give a verbal handover to the receiving clinician, receiving staff member or agreed responsible person.

The handover includes:

Crew keep the handover factual and concise. They do not add information they have not received or directly observed.

7.3 Documentation handover

Crew check that required documentation has moved with the patient.

Documentation may include:

Crew record what documentation was handed over, who received it and any missing paperwork.

7.4 Handover after event cover

For event-cover work, Crew hand over to the receiving ambulance service, emergency department, event medical lead or other agreed receiving service.

The record includes:

The Service does not close the event record until the receiving route and handover have been documented.

8. Delayed handover

The Service treats delayed handover as a governance issue and a possible patient-safety issue.

Where handover is delayed for more than 30 minutes, Crew record:

The Operations Manager escalates repeated delayed handovers at the same receiving facility to the commissioner or relevant contact where the contract allows it. The Registered Manager reviews patterns as Regulation 17 governance evidence.

9. Missing paperwork and wrong destination transfer

9.1 Missing handover paperwork

If required paperwork is missing, Crew do not invent or reconstruct clinical information.

Crew:

The review checks whether the booking process, collection process or referring facility caused the gap.

9.2 Wrong destination transfer

If Crew identify a wrong destination before, during or after arrival, they escalate immediately.

Crew:

The Registered Manager reviews whether duty of candour, commissioner notification, safeguarding, complaint handling or CQC notification advice is needed.

10. Responsibilities

11. Recording requirements

The Service keeps the following records:

Records are kept in the Service governance records and are available for internal review, CQC review, commissioner review and external review where required.

12. Audit cadence

The Service uses the following Verivius default audit rhythm unless current CQC, JRCALC, NHS England, commissioner or local source material requires a different rhythm:

Audit findings are recorded as improvement actions with an owner and review date.

13. Version control and review date

The Service keeps a controlled copy of this policy. The footer or document-control table records:

14. Related records

Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.

15. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

16. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

17. Document control

Version Date Author Changes
v1 2026-06-10 Verivius (sample) Conformed to the Verivius policy standard. Added the verbatim Regulation 12 and Regulation 17 quotes, plain-English summary, sources and further reading, and document control. Original purpose, scope, transfer-of-care process, delayed-handover, missing-paperwork, responsibilities, recording, audit, version-control and related-records sections preserved and renumbered.
v1.1 2026-07-09 Verivius (sample) Clarified ambulance-specific handover intent, separated this page from the patient transport handover template, and added internal links. No regulatory claims changed.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the provider's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

An ambulance handover is the only point at which what happened in the back of the vehicle becomes part of anyone else's record. The crew hold a live account of the journey: the observation that changed, the oxygen or medicine given en route, the refusal, the difficult transfer on the tail lift, the ReSPECT form that never left the referring ward. If that account is passed by word of mouth in a busy corridor and nothing is written down, it leaves with the crew on their next job and the receiving clinician starts the person's care from a blank page, repeating what has already been done or missing what must not be. Delay sharpens it, because a patient waiting in an ambulance bay sits between two teams and is fully watched by neither, which is why arrival time, the time handover completed and the welfare given during the wait matter as much as the clinical content. Recording who received the person and which documents went with them is not administration for its own sake: it is how the next clinician knows where the person's care had got to.

  1. A completed handover is recorded against each job before the job is closed, so whoever picks the person's care up next can see what was passed on, not a verbal handover that leaves no trace once the crew move on.

    Strong evidence: The handover completion record the crew log per job (destination, receiving contact and documents handed over), which the platform captures before the job is closed under the per-job audit rhythm.

    Weak evidence: The job record closes with a handover timestamp and nothing else: no named receiving person, no ward or department, no note of what actually moved with the patient. A related tell is a run of jobs closed together at the end of a shift with identical handover wording typed from memory hours later, or a service where the only account of the handover is the crew saying they gave the patient to "the nurse on the ward".

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 17(2)(c) (and reg 12(2)(i) on transfer of responsibility)

  2. Handover delays are recorded and reviewed for pattern by receiving facility, so the time a person spends waiting on the vehicle is acted on, not tolerated shift after shift and forgotten.

    Strong evidence: The delayed-handover record (arrival time, time handover completed, reason for delay, patient condition during the wait, escalation calls and welfare needs met) and the Registered Manager's quarterly pattern review by facility as Regulation 17 governance evidence.

    Weak evidence: Delay appears only as a grumble in free-text job notes ("held at the hospital for ages"), with no arrival time recorded against the time handover completed, so nobody can tell whether the service's own 30-minute trigger was ever crossed, nothing on the patient's condition or welfare during the wait, and no escalation call logged. Or there is a delay spreadsheet with minutes in it that nobody splits by receiving facility, so the same emergency department holds crews every Friday for a year and no owner, action or approach to that facility, or to the commissioner where the contract allows it, ever comes out of it.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  3. The record names which documents actually moved with the patient and who received them, so the receiving team can see what it holds and what is still missing, not a bare 'handed over' with no detail.

    Strong evidence: The documentation-handover record listing what documentation was handed over, who received it and any missing paperwork, including resuscitation and advance care planning documents where supplied.

    Weak evidence: A tick against "paperwork handed over" with no list of what was in the bundle and no name for who took it, so nobody can later tell whether the transfer letter, the medicines list or the moving-and-handling plan actually arrived. The sharper gap is silence about resuscitation and advance care planning documents: no record that a DNACPR or ReSPECT form travelled with the person, and no record that one was expected and never came from the referring ward, so the omission cannot be traced back to where it started.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  4. A wrong destination or missing clinical paperwork is opened as an incident and escalated so the gap can be traced back to where it started, not reconstructed by the crew to fill it.

    Strong evidence: The incident record for a wrong-destination transfer or missing paperwork, plus the Registered Manager's review, taken separately, of whether the duty of candour (Regulation 20) is owed to the person and of whether a separate CQC notification is due. The duty of candour is owed to the person and is not itself a notification, so meeting one does not discharge the other. The policy bars crew from inventing or reconstructing clinical information.

    Weak evidence: The wrong destination is sorted out over the radio, the patient is redirected, and nothing reaches the incident register because it "came right in the end". Missing paperwork is quietly filled in from what the crew remember of the collection conversation, which the policy bars outright. Where a record does exist, the Registered Manager's review is a single line saying duty of candour does not apply, with no reasoning about the harm the person actually suffered measured against the threshold that applies to an independent provider, and no separate consideration of whether a CQC notification, a safeguarding referral or a commissioner notification is due. Those are separate duties and meeting one does not discharge another.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  5. The verbal handover stays factual and confined to what the crew received or directly observed, so the receiving clinician can act on it safely, not padded with second-hand detail.

    Strong evidence: The verbal-handover content (patient identity, treatment and changes during the job, and any deterioration, refusal, delay or incident), which the policy requires to be factual and limited to what was received or directly observed.

    Weak evidence: The recorded handover repeats what a relative or care-home staff member said as though the crew had seen it themselves, or carries observations the crew never took. The other tell is boilerplate: "patient stable throughout" on every job, including ones where a deterioration, a refusal or a delay is recorded elsewhere in the same job record, alongside handovers that leave out the treatment given and the changes during the job that the policy expects to be passed on.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

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Last verified 20 July 2026

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Last reviewed 10 June 2026