Safe · KLOE 3
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?
CQC wording, mental health care draft, pages 8 to 11.
Draft, not the current assessment framework
CQC's mental health care draft, published March 2026. The current quality statements remain in use.
CQC draft scope
What this proposed KLOE covers
Scope of this key line of enquiry and topic areas include:
- Care co-ordination, shared care and information sharing
- Continuity and transitions of care (including from children to adult services)
- Referrals
- Admissions and discharges
- Handover and patient flow
- Named care co-ordinators/key workers
- Proactive post discharge follow-up
- Integrated multi-disciplinary team (MDT) working
How would this apply to your service?
The draft applies one framework across mental health care, but useful evidence depends on your service and people.
Source: CQC, Mental health care assessment framework, draft, 19 March 2026, pages 8 to 11. Contains public sector information licensed under the Open Government Licence v3.0.
CQC draft rating characteristics
How the draft describes each rating
These are CQC's draft characteristics. CQC says rating characteristics guide judgements, they are not a mechanical checklist.
Outstanding
- Safety and continuity are embedded as core principles throughout the entire care journey. A fully integrated, collaborative working approach unites people and those close to them, advocates, staff teams, and partner organisations to ensure a safe, seamless experience across referrals, admissions, transitions, and discharge, including when people interact with multiple services.
- Shared systems and processes to ensure safe care are proactively governed through collective stewardship, rigorous risk identification, clearly defined accountabilities, continual monitoring, and a strong culture of shared learning and improvement.
- Plans for people’s care during transition are in place before they move between services, enabling risks to be identified and mitigated and for continuity of safeguarding. Staff have timely, comprehensive access to the information they need to understand each person’s needs and to assess, plan, and deliver safe care.
- The service continuously reviews and develops its admission and discharge processes to ensure seamless patient pathways and flow through the system. It works with partners to alleviate pressure points and to find creative solutions for optimal continuity of care and transitions at a local, neighbourhood and system level.
- Children and young people, along with their parents and carers, are empowered and supported to navigate services confidently. They experience well-co-ordinated, developmentally sensitive transitions into adult services, underpinned by clear, consistent ways of working between teams, settings, and partner agencies, which result in exceptional outcomes.
Good
- Safety and continuity are prioritised throughout the care journey through a collaborative working, joined-up approach involving people and those close to them, advocates, staff and partners. This includes referrals, admissions and discharge, and where people are moving between or accessing multiple services.
- There is a collaborative working approach with clear accountabilities to proactively manage shared systems and processes for safe care. This includes identifying risks, ongoing monitoring and shared learning and improvement to deliver optimal patient flow and timely discharge.
- Plans for people's care during transitions are established before they move between services to eliminate any avoidable risks and ensure they receive continuity of care. Staff have timely access to the information they need to understand people’s needs and appropriately assess, plan and deliver their care and treatment.
- Transition, referral and discharge arrangements are safe and consider a person’s individual needs and the needs of their families and carers, their individual’s circumstances, co-occurring conditions, ongoing care arrangements and expected outcomes.
- Children and young people, their parents and carers are involved and supported to navigate care and engage with education settings. Their transition into adult services is properly co-ordinated, with clear ways of working between teams and services.
- Staff are proactive in working with other services when there is a need for multidisciplinary involvement, and any actions are appropriately owned and followed up as needed.
- People experience continuous care delivered between services or mental health teams. Staff work cohesively, which improves their understanding of individuals care and treatment, reduces the need for people to repeat their story, and supports positive recovery outcomes.
- Named care co-ordinators or key workers provide consistency and advocacy, improving care when people experience delays accessing services.
- Good support after discharge from the service, including regular visits and appointments, helps people to recover and makes them feel re-assured.
- There are rigorous processes in place to ensure internal pathways, such as the follow up of chronic conditions, are safe. Care involving multiple teams is well-co-ordinated, with collaborative working in planning and delivery.
- Multidisciplinary teams work effectively together to support safe delivery of care and treatment.
Requires improvement
- Care journeys are fragmented, disjointed and slow because of a lack of cohesion and continuity between services and mental health teams which may result in issues with patient flow.
- Discharge planning is not always organised, leaving people uncertain about the arrangements for ongoing care.
- Safety and continuity are acknowledged but not consistently prioritised throughout the care journey. Joined-up working is not embedded or consistently applied. Working collaboratively between people, staff and partners is variable, with some gaps in communication at key transition points.
- Although there are shared systems and processes for safe care, collaborative working across care pathways may be limited, and processes are not fully embedded or used consistently.
- Plans for people's care during transitions are not always established before they move between services and continuity of care may be inconsistent.
- Staff do not always have timely access to the information they need to understand people’s needs and appropriately assess, plan and deliver their care and treatment.
- Plans for transition, referral and discharge are inconsistently completed and do not always consider people’s individual needs, circumstances, ongoing care arrangements and expected outcomes.
- Children and young people and their parents (or those with parental responsibility) and carers are not always involved and supported to navigate care and education settings, and do not always experience properly co-ordinated transitions into adult services.
- Processes to ensure internal pathways, such as the follow up of chronic conditions, are not always rigorous. Care involving multiple teams is not always well-co-ordinated, or work is not collaborative.
- Multidisciplinary teams do not always work effectively together or do not always support safe delivery of care and treatment.
Inadequate
- There is a lack of post discharge support, which has a negative impact on people’s mental health and increases the risk of a relapse.
- People’s discharge from hospital is premature, rushed, and sometimes happens while they are still unwell. This may be because of bed shortages and pressures on other services.
- Poor communication between services results in missed information, confusion about medicines and treatment plans, and undermines care co-ordination and meeting people’s needs.
- Care teams lack full access to diagnostic and functional assessments, preventing a person’s individual needs being met.
- Safety and continuity are not prioritised throughout the care journey. The approach to care is not joined up and there is little or no collaborative working between people, staff and partners. Points of transition, including referrals, admissions and discharge, are likely to be chaotic or unsafe.
- There is no effective collaborative working approach to managing shared systems and processes to ensure safe care. Accountabilities across care pathways are unclear and there is a lack of ongoing monitoring and sharing of learning and improvement.
- Poor patient flow may place people at risk of harm.
- Plans for people's care during transitions are not established before they move between services. This results in avoidable risks and means that people do not experience continuity of care.
- Staff do not have timely access to the information they need to understand people’s needs and appropriately assess, plan and deliver their care and treatment.
- Plans for transition, referral and discharge are deficient, not safe or do not consider people’s individual needs, circumstances, ongoing care arrangements and expected outcomes.
- Children and young people and their parents and carers are not involved or supported to navigate care and education settings, and experience poorly co-ordinated transitions into adult services, or achieve worse outcomes.
- Processes to ensure internal pathways, such as the follow up of chronic conditions, are not rigorous or safe. Care involving multiple teams is not co-ordinated.
- Multidisciplinary teams do not work effectively together, or they do not support the safe delivery of care and treatment.
Want to know how your service would fare?
Book a mock inspection run against the draft KLOEs, or call 020 8090 5346 to speak to one of our experts.