Audit template
Hospital Transitions
Examines admission and discharge handovers, hospital passports and follow-up actions. This template runs quarterly in MyCareCompliance and carries 8 mapped checks across 8 CQC quality statements.
Last reviewed: September 2026. This guidance reflects CQC information available at the date above — always refer to cqc.org.uk for current regulatory requirements.
What the audit covers
Every question in the Hospital Transitions is mapped to a CQC quality statement and the underlying regulation, so a failed check tells you exactly which part of the single assessment framework is at risk. This is an optional template you can switch on when it applies to your service.
- Runs quarterly — optional template
- Part of the Service users & care quality audit category
- Maps to 3 regulations: Regulation 12 — Safe care and treatment, Regulation 9 — Person-centred care, Regulation 17 — Good governance
- Failed checks become tracked improvement actions with an owner, due date and evidence
The 8 checks
Medicines optimisation
Safe — 1 check- Regulation 12 — Safe care and treatmentHospital Transitions
Is a full medicines reconciliation completed immediately following hospital discharge to ensure safe administration of new or altered prescriptions?
What we look for: Review the MAR charts and discharge notes for recently discharged people. Check that new medications are accurately transcribed, stopped meds are removed, and staff are clear on changes. A fail is an active MAR that contradicts the hospital discharge prescription.
Evidence: Hospital discharge summaries (TTOs), New MAR charts, Pharmacy correspondence, Medicine risk assessments
Safe environments
Safe — 1 check- Regulation 12 — Safe care and treatmentHospital Transitions
Are required changes to equipment and the home environment arranged and verified before care is restarted?
What we look for: Check files for people returning home with new mobility needs. Verify that required equipment (e.g., hospital beds, hoists) is installed, staff are trained to use it, and environmental risk assessments are updated. Restarting care without safe manual handling equipment is a clear fail.
Evidence: OT assessments, Manual handling risk assessments, Environmental risk checklists, Communication logs with equipment stores
Safe systems, pathways and transitions
Safe — 1 check- Regulation 12 — Safe care and treatmentHospital Transitions
Are 'Hospital Grab Bags' or emergency information packs available and up to date in the person's home to support safe emergency admission?
What we look for: Sample 3-5 files of people with fluctuating health or recent admissions. Check if a hospital transfer document exists and includes baseline observations, current medicines, and communication needs. A fail is an outdated or missing pack that delays vital information sharing with paramedics.
Evidence: Hospital passports, PRSB 'About Me' documents, Medication administration records (MAR), ReSPECT/DNACPR forms
Assessing needs
Effective — 1 check- Regulation 9 — Person-centred careHospital Transitions
Does the service conduct and document a comprehensive re-assessment of needs prior to restarting care following a hospital discharge?
What we look for: Sample records of recently discharged people. Check that a manager or senior reviewed the hospital discharge summary and confirmed the agency can still safely meet the person's needs. A fail is restarting care without verifying if mobility, dietary, or clinical needs have changed.
Evidence: Discharge summaries, Pre-restart assessments, Communication with hospital discharge teams, Updated dependency tools
How staff, teams and services work together
Effective — 1 check- Regulation 17 — Good governanceHospital Transitions
Are care workers thoroughly briefed on the person's updated needs, risks, and required care plan changes before their first post-discharge visit?
What we look for: Check how information is cascaded to frontline staff. Look for read-receipts on digital care systems or signed handover sheets demonstrating that the allocated care workers know about the changes in the person's condition or equipment. A fail is a care worker arriving unaware of a recent hospital admission.
Evidence: Staff communication logs, Huddle notes, Care worker system alerts, Supervision notes
Care provision, integration and continuity
Responsive — 1 check- Regulation 9 — Person-centred careHospital Transitions
Is there a robust system for tracking hospital admissions, pausing care, and maintaining appropriate contact during the hospital stay?
What we look for: Review the agency's hospital tracking logs. Check that care packages are correctly paused on the rostering system to prevent staff arriving at empty homes. Good practice includes scheduled welfare checks with the hospital ward and family to anticipate discharge.
Evidence: Call log records, Communication notes, Hospital tracker spreadhseet, Roster system printouts
Person-centred care
Responsive — 1 check- Regulation 9 — Person-centred careHospital Transitions
Are care plans and individual risk assessments updated promptly to reflect changes in care needs following hospital discharge?
What we look for: Compare pre-admission and post-discharge care plans. Look for evidence that changes in routine, dietary needs (e.g., new IDDSI levels), or pressure area care have been formally updated and signed off. A fail is staff working from a pre-admission care plan that does not reflect current needs.
Evidence: Updated Care Plans, Moving and Handling assessments, Nutrition/Hydration risk tools (e.g. MUST), Skin integrity charts
Learning, improvement and innovation
Well-led — 1 check- Regulation 17 — Good governanceHospital Transitions
Does management audit hospital readmission rates and delayed discharges to identify trends and improve transition processes?
What we look for: Review the service's overarching governance records. Check if the manager analyses reasons for 30-day readmissions or failed discharges to identify lessons learned (e.g., missed medication reconciliations or premature discharges). Good practice shows proactive engagement with local health systems to resolve recurring issues.
Evidence: Quality assurance reports, Audit logs, Incident reports, Meeting minutes from management reviews
See it running for your service
Book a free demonstration and we will run the Hospital Transitions against scenarios from a service like yours, or start your 7-day trial and try it yourself.
See it with your own service
Book a free demonstration and we will walk through the platform using scenarios from a service like yours.