People and communities have the best possible outcomes because their needs are assessed. Their care, support and treatment reflects these needs and any protected equality characteristics. Services work in harmony, with people at the centre of their care. Leaders instil a culture of improvement, where understanding current outcomes and exploring best practice is part of everyday work.

Everyone is supported to see what works well and not so well based on indicators of quality. Continuous improvement is always guided by this insight.

How staff, teams and services work together

• We ensure individual needs are carefully considered in the planning of transition, referral, and discharge. These processes involve all relevant staff, teams, and services to ensure people’s needs are met.
• We can evidence how we safely and effectively share information to remove duplication of effort around care needs and assessment.
• We ensure our own internal systems enable staff across different parts of our service to have access to the latest information safely and securely.
• We ensure staff are clear about their roles and responsibilities in relation to information sharing, including during handovers and other interactions with internal and external colleagues.
• We ensure our staff establish direct and meaningful relationships where relevant with healthcare professionals and other services.
• We embed clear and effective systems in our service that enable us to track engagement with healthcare organisations and ensure a timely response.
• We document our engagement with healthcare services and professionals and how this is contributing to the quality of care that’s provided by our service.
• Our care plans include details of recent and upcoming health-related appointments (e.g., hospital, GP, dentist, optician) and update them with key information following visits.
• We know the impact that healthcare appointments, treatment and periods in hospital can have on the wellbeing of people. We adapt our support to respond to additional care, comfort and communication that may be needed.
• Whether internal or with partner organisations, our handover meetings ensure staff have accurate and up-to-date information about people’s needs. Where handover meetings aren’t possible, we ensure documentation is available to inform the next care worker.
• We prepare and maintain health passports and work closely with other organisations on people’s transition plans.
• When people with social care needs are admitted to hospital, we ensure their existing care plans are shared with the admitting team. This is in accordance with NICE Quality Standards.
• Our systems and processes enable us to share information securely about people’s care, treatment, and support.
• We use technology to help strengthen record keeping, providing opportunities to instantly update and reduce risks from bad handwriting etc.

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