Sample policy · Patient transport

Transfer of care and patient handover policy (patient transport)

Statutory anchor: Regulation 12 (safe care and treatment), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936), in particular Regulation 12(2)(i) on shared or transferred responsibility. This policy also engages Regulation 17 (good governance). The operational handover standard also draws on Joint Royal Colleges Ambulance Liaison Committee (JRCALC) clinical practice guidelines and NHS England ambulance handover guidance as primary professional sources. · primary source

1. What the regulation says

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

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))

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))

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

2. 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. Regulation 12 is central to CQC's safety expectations.

3. Purpose

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

For PTS work, transfer of care is a high-volume risk surface. Every journey ends with a receiving person, receiving facility or agreed home handover.

4. Sources to verify before adoption

5. 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.

6. Transfer-of-care process

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

6.1 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.

6.2 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.

6.3 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.

6.4 Handover at home

For hospital-to-home transport, Crew confirm that the patient has reached the agreed safe handover point.

The handover check may include:

Crew do not leave a patient where the booking required a receiving person and that person is absent. They contact the control point and follow the escalation route.

7. 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.

8. Missing paperwork and wrong destination transfer

8.1 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.

8.2 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.

9. Responsibilities

10. Recording requirements

Each handover record must include the patient, date and time, sending and receiving services, named people handing over and accepting care, current condition, risks and essential information transferred, documents or medicines transferred, delay or refusal, escalation and final outcome. The Service also 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.

11. Training and competency

Before completing handovers without direct supervision, Crew receive training and practical sign-off in:

The Clinical Lead samples at least one documented handover for each new crew member during induction and after any material handover incident. Gaps are entered in the training matrix and linked to supervision or an improvement action.

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 policies and 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) Initial sample template, conformed to the Verivius policy standard.
v1.1 2026-07-19 Verivius (sample) Added handover evidence fields, competency sampling and linked companion policies.

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.

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Last reviewed 19 July 2026