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, primary care and community services draft V6.0, pages 8 to 10.

Draft, not the current assessment framework

CQC's primary care and community services draft V6.0, 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:

The draft applies one framework across primary care and community services, but useful evidence depends on your service and people.

Source: CQC, Primary care and community services assessment framework, draft V6.0, 19 March 2026, pages 8 to 10. Contains public sector information licensed under the Open Government Licence v3.0.

CQC draft rating characteristics

These are CQC's draft characteristics. CQC says rating characteristics guide judgements, they are not a mechanical checklist.

There is joint ownership of safety and continuity across people’s care journeys. When people are moving between or using different services, there is a clear plan to manage and mitigate any risks.
There is a collaborative approach between services to comprehensively identify and manage shared risks at different stages of the care journey. Mitigations are monitored for their effectiveness. This has led to better standards of treatment and care at each step of the person’s care journey.
Care plans for transition between services, referral and discharge are co-produced with people and those close to them to reflect their individual needs and personal preferences in managing their risk. Plans are continuously reviewed to ensure they are up-to-date and include appropriate support for people and carers.

Safety and continuity are prioritised throughout the care journey through a collaborative, joined-up approach involving people, staff, and partners. This includes referrals, admissions and discharge, and where people are moving between or using different services.
There is a collaborative and proactive approach to managing shared systems and processes to enable safe care. This includes having clear accountabilities, identifying risks, ongoing monitoring and shared learning and improvement.
Care plans for transition between services are established in advance, to eliminate any avoidable risks and ensure people receive continuity of care. Care plans for children and young people moving into adult services are well planned and co-ordinated.
Plans for transition between services, referral and discharge are safe and consider people’s individual needs, circumstances, ongoing care arrangements and expected outcomes.
There are rigorous processes in place to ensure internal pathways are safe, such as the follow-up of chronic conditions. Multidisciplinary teams work together effectively to support the safe delivery of care and treatment. Care involving multiple teams is well-co-ordinated, with collaborative planning and delivery.
Staff have timely access to the information they need to understand people’s needs and appropriately assess, plan and deliver their care and treatment. This includes information from other services.

Safety and continuity are acknowledged but not consistently prioritised throughout the care journey. Joined-up working is not embedded or applied consistently. Collaboration between people, staff, and partners is variable, with some gaps in communication at key transition points.
There are shared systems and processes to enable safe care, but collaboration across care pathways may be limited and processes are not fully embedded or used consistently.
Care plans for transition between services are not always established in advance and continuity of care may be inconsistent.
Internal pathways, such as the follow-up of chronic conditions, are inconsistent and some people may not receive the follow-up care they need.
Staff do not always have timely access to the information they need to understand people’s needs.
Plans for transition between services, referral and discharge are inconsistently completed and do not always consider people’s individual needs, circumstances, ongoing care arrangements and expected outcomes.

Safety and continuity are not prioritised throughout the care journey. The approach to care is not joined up and there is little collaboration between people, staff and partners. Points of transition between services, including referrals, admissions and discharge, are likely to be chaotic or unsafe.
There is no effective collaborative approach to managing shared systems and processes to enable safe care. Accountabilities across care pathways are unclear and there is a lack of ongoing monitoring and sharing of learning and improvement.
Care plans for people’s care during transition between services are not established in advance. This results in avoidable risks and means that people do not experience continuity of care.
There are no processes in place to ensure internal pathways, such as the follow-up of chronic conditions, are safe.
Staff do not have timely access to the information they need to understand people’s needs.
Plans for transition between services, referral and discharge are either incomplete, not safe or do not consider people’s individual needs, circumstances, ongoing care arrangements and expected outcomes.

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