Safe systems, pathways and transitions
Are there systems to enable collaborative working across care pathways and services, to ensure that safety and continuity of care are prioritised?
In brief
Safe systems, pathways and transitions is key line of enquiry 3 under the Safe key question in the Care Quality Commission (CQC) draft adult social care assessment framework (v9, 19 March 2026), currently published for consultation. It covers care co-ordination and information sharing, continuity and transitions of care (including from children to adult services), referrals, delegation (for example, clinical/healthcare activities). CQC describes performance against it at four rating levels: Outstanding, Good, Requires improvement and Inadequate. Each statement and rating characteristic quoted here is reproduced verbatim from CQC's draft; plain-English summaries are HLTH's own.
- Key question
- Safe
- Line of enquiry
- KLOE 3 of 7 under Safe
- Rating levels
- Outstanding, Good, Requires improvement, Inadequate
- Source
- Adult social care assessment framework, v9 (19 March 2026)
- Status
- Draft, published by CQC for consultation
- Reference
- pp. 8–10 of the CQC draft
Scope and topic areas
What this line of enquiry covers
Scope of this key line of enquiry and topic areas include:
- Care co-ordination and information sharing
- Continuity and transitions of care (including from children to adult services)
- Referrals
- Delegation (for example, clinical/healthcare activities)
Rating characteristics
How CQC describes each rating
The four characteristic sets for this KLOE, best to worst. Every point is CQC's wording, reproduced exactly.
Outstanding
In plain terms: Care is exceptional and consistently better than the Good standard.
- There is a strong culture of collaborative working, which supports the delivery of joined-up care. The service has introduced innovative and efficient ways to deliver care and support that is more joined-up for people, actively working with other services.
- Care journeys are proactively planned and co-ordinated across services from the earliest stage. People receive enhanced care at each step of the care journey and their outcomes demonstrate this.
- Safety policies and processes are co-developed and reviewed with partners and communities.
- Transitions, referrals and discharges are co-designed with people and those close to them. Arrangements reflect individual circumstances, goals and preferences. Equity and inclusion are actively prioritised to remove barriers and support continuity.
- Multi-disciplinary teams work cohesively across boundaries with shared accountability. Where appropriate, partners hold joint ownership of safety and manage shared risks comprehensively.
Good
In plain terms: The service meets the expected standard.
- Safety and continuity are maintained across people’s care journeys through collaborative working with people, staff and partners. This includes where people are moving between or accessing multiple services.
- Shared systems and processes for safe care are managed collaboratively, including proactive risk identification, monitoring and learning.
- Plans and information for care during transitions are established and shared before people move between services.
- Plans consider people’s individual needs, circumstances, ongoing care arrangements and expected outcomes. People experience a smooth process and there is continuity of care.
- Staff can access the information they need to assess and understand people’s needs, and to plan and deliver care.
- Staff work together proactively with teams in other services, commissioners and people using the service to deliver co-ordinated, timely, consistent and person-centred care, support and treatment. Actions are appropriately owned and followed up.
- The service has appropriate systems and processes to manage its responsibilities in relation to delegated healthcare activities safely, in line with good practice.
- When people have needs that are outside of the service’s remit, staff adapt support and escalate issues to relevant agencies.
Requires improvement
In plain terms: The service is not yet Good and has areas that must improve.
- Safety and continuity are not consistently prioritised when people move between services. Planning and co-ordination are inconsistent, and information sharing may be unreliable.
- Care plans are not routinely updated before transitions, causing or increasing the risk of harm.
- Referrals are not timely enough to maintain or improve people’s health and wellbeing. Care, support and treatment is not consistently carried out as directed by healthcare professionals.
- Systems and processes for managing delegated healthcare activities are not consistently followed.
- Some staff do not know how and when to share information externally.
- Some people do not know which service to contact about the care and support they receive.
- When people develop care, support and treatment needs that are outside of the service’s remit, this is not consistently recognised or escalated appropriately to ensure these needs are met.
Inadequate
In plain terms: Performance is well below the expected standard; enforcement may follow.
- Safety and continuity are not considered priorities for people’s care journeys. There is no joined-up approach between staff and partners involved in people’s care.
- Planning and co-ordination is insufficient or absent when people move between different services.
- The service does not take responsibility for coordinating care and support, leaving it to other agencies to manage. People may be harmed as a result.
- Information sharing and communication with other services is consistently poor. Information is not shared with other services, including when people move between services, or is insufficient when it is shared.
- The service does not engage with other services or make timely referrals for appropriate care, support and treatment, meaning people’s health and wellbeing can deteriorate. Staff lack knowledge about how and when they should refer concerns.
- The service does not have effective systems or processes to manage delegated healthcare activities.
- People do not know which service is responsible for their care and support, or who to contact about it.
- When people develop care, support and treatment needs that are outside of the service’s remit, this is not recognised or escalated.
Reading these against your own evidence is where most providers get stuck. We can walk it through with you.