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 transfer is recorded in the patient transport or clinical record at the point responsibility changes. The handover record should include:

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
v1.2 2026-07-21 Verivius (sample) Expanded the handover record to evidence transfer timings, accepted responsibility, clinical risks, exceptions and outcome.
v1.1 2026-07-19 Verivius (sample) Added handover evidence fields, competency sampling and linked companion policies.
v1 2026-06-10 Verivius (sample) Initial sample template, conformed to the Verivius policy standard.

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.

Patient transport is the one stretch of a care pathway where the person is held by a crew who did not assess them and will not treat them, travelling between two organisations that each quietly assume the other holds the full picture. The risk lives in that gap: a pressure area that developed over a two-hour journey, oxygen handed over at a flow the ward was not expecting, a discharge letter that never left the sending ward, a frail person set down in a cold house because the relative who was meant to be there was stuck at work. None of it reaches the people taking over unless the handover record names who accepted care and captures what was still unresolved at the moment responsibility changed hands. For the person, a good handover is the difference between arriving as someone known, with their medicines, their mobility plan and their story intact, and arriving as a stranger the receiving team has to piece together from scratch. Inspectors follow the same trail, but the reason to keep it is that whoever picks the person's care up next, a ward nurse or a daughter standing in a hallway, needs it straight away.

  1. A transfer of care is actually completed and recorded at the receiving end before the job is closed, with the person accepting care named. What goes wrong is a job closed on arrival with no recorded acceptance of care and no unresolved risks captured, so whoever takes over care does not know what is still outstanding.

    Strong evidence: Handover completion record naming the people handing over and accepting care, current condition, risks and essential information transferred, and documents or medicines transferred (Section 10), with the per-job audit that handover completion is recorded before the job closes (Section 12).

    Weak evidence: The job is closed on the tablet the moment the trolley clears the vehicle, and the record says "handed over to ward staff" with no name, no role and no time, or a receiving signature box carrying the same illegible mark on every job. Weaker still is a handover record with no field for unresolved risks, so a pressure area that developed on a two-hour journey, a refused medicine or a deterioration during the journey has nowhere to land.

    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 12(2)(i) and reg 17(2)(c)

  2. At a home handover, crew stay with the patient and escalate when the booking required a receiving person and that person is absent, rather than leaving the patient alone. The real-world failure on discharge-to-home work is a record reading home safe while nobody was actually there to receive them.

    Strong evidence: Handover-at-home check confirming a required escort, family member, carer or receiving support is present, with escalation to the control point or referring facility where that person is absent (Section 6.4).

    Weak evidence: Home discharge records that end at "patient home safe" with no note of who was actually there to receive them, or free text such as "left with neighbour" or "daughter due shortly" with no escalation call logged to the control point. If the booking record carries an escort or receiving-person requirement but the handover record has no matching field to confirm it was met, nothing shows that anyone reconciled the two before the crew drove away.

    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 12(2)(a) and (b)

  3. Missing paperwork is recorded and escalated rather than reconstructed. What puts the patient at risk is crew inventing or filling in clinical information they did not receive, instead of telling the receiving person what is missing and raising an incident where the gap created risk.

    Strong evidence: Missing paperwork record noting what was missing, advice received and whether the patient was accepted by the receiving facility, plus an incident record where the gap created risk, delay or complaint (Sections 8.1 and 10).

    Weak evidence: Paperwork ticked complete on every job across months of discharge work, with not one missing-paperwork record on file, which reads as a recording failure rather than a clean run. Or a single line saying "medicines list not received, ward advised" with no record of who was told, what advice came back, or whether the receiving facility still accepted the patient, and no incident raised when the gap delayed treatment. The worst version is a transfer summary reconstructed by crew from memory or from what the porter said at the door, which puts information nobody received or observed into the receiving record.

    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)

  4. For a wrong-destination transfer, the review reaches and records a decision on duty of candour, safeguarding, complaint handling and CQC notification as four separate questions, not a single tick. Openness to the patient is owed even where the Regulation 20 duty of candour threshold (a defined, high bar) is not met. Where a safeguarding referral to the local authority or a statutory notification to CQC under the Care Quality Commission (Registration) Regulations 2009 is needed, each is its own decision, and neither of them is the duty of candour, which is owed to the person.

    Strong evidence: Wrong destination transfer incident record and the Registered Manager review of whether duty of candour, commissioner notification, safeguarding, complaint handling or CQC notification advice is needed (Sections 8.2 and 10).

    Weak evidence: One incident record with a single tick against "duty of candour: not applicable", or a manager comment reading "no harm, no further action", closed the same day. Reviews that treat openness to the patient and a CQC notification as one question, or that log a safeguarding referral and treat that as having covered the notification decision, show the four decisions were never separately reached. Nothing is recorded about what the patient and the people close to them were told at the time about being taken to the wrong place, who told them, and what was put right.

    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, regs 20, 13 and 16, with Care Quality Commission (Registration) Regulations 2009, reg 18

  5. Delayed handovers are captured with the patient's condition and welfare during the wait, and repeat delays at the same receiving facility are escalated and reviewed as Regulation 17 governance evidence, not just logged and forgotten.

    Strong evidence: Delayed handover record (arrival time, time handover completed, reason for delay, patient condition during the wait, escalation calls, welfare needs met) and the Registered Manager pattern review by receiving facility (Section 7). The 30-minute trigger is a Verivius operational default, not a statutory timescale.

    Weak evidence: Delayed handover entries that capture arrival and departure times only, so an eighty-minute corridor wait reads exactly like a ten-minute one and nothing shows whether the person was offered a drink, repositioned, helped to the toilet or observed for deterioration. And a delay log nobody reviews by receiving facility, so the same ward appears dozens of times with no escalation, no commissioner conversation and no improvement action. The 30-minute recording trigger in this policy is a Verivius operational default, not a statutory timescale.

    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.

  6. New crew are signed off as competent to hand over before doing so unsupervised, with a real handover sampled rather than a training tick.

    Strong evidence: Training and practical sign-off in the structured verbal handover method, with the Clinical Lead sampling at least one documented handover per new crew member during induction and after any material handover incident, gaps linked to supervision or an improvement action (Section 11).

    Weak evidence: An induction checklist with "handover training" ticked and dated, signed by the trainee, with no named assessor and no observed handover behind it. Sign-off completed in a classroom the day before a crew member's first solo job tells you a course was attended, not that anyone watched them hand a real patient over. If a crew member has been involved in a handover incident and the file shows no fresh sampling afterwards, the sign-off is a date rather than a judgement about competence. The sample-one-documented-handover mechanic is a Verivius default; the duty it evidences is that staff are competent and properly supported for the work they are given.

    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.

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Last verified 20 July 2026

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Last reviewed 21 July 2026