Case study
One plan. Two care agencies.
What happens when a person changes care agency soon after discharge, and the plan does not follow them.
Illustrative case. Ada is not a real person. It shows how Handling Plan is designed to be used; it is not a measured outcome.
Read the illustration as text
- Before discharge, a therapist on the ward assesses Ada and writes her moving and handling plan.
- The plan goes to Care Agency A. Ada is hoisted for all transfers.
- Three weeks later, Ada chooses to move to Care Agency B.
- Agency B needs a plan before it starts. The copy stayed with Agency A and is not on the community record.
- The community practitioner opens Ada's existing plan, confirms nothing has changed, and updates it.
- The updated plan goes to Agency B's inbox, ready to print. Agency A's copy is marked no longer in use.
Why plans do not follow the person
This is a gap between systems, not a failing of any one team.
- A plan written on the ward usually lives on the hospital record, or travels as an attachment. Whether it reaches the community record depends on scanning and filing in busy teams.
- Care providers often say the information they receive at discharge is incomplete. In one national survey, 55% of homecare providers said discharge paperwork does not reflect the person's needs.1
- Home care providers have been found the least likely of any service type to receive sufficient discharge information.2
- When a person changes provider, the plan often stays with the first one, on paper or in its own system.
Two routes for the community practitioner
Without a shared plan
Reassess, or chase the old copy
- Arrange and travel to a home visit.
- Reassess Ada with the new carers present.
- Write the plan again from the start.
- Or: phone and email Agency A for the copy, and wait for it to arrive.
Agency B waits, or starts without a plan in hand.
With Handling Plan
Review the plan already prescribed
- Open Ada's plan: hoist, sling type and size, carers, and the images for each technique.
- Confirm nothing has changed, by phone with Ada or Agency B, or visit if anything has.
- Update it, search Agency B on the CQC register and send it.
The updated plan is in Agency B's inbox, ready to print.
What changes
| Repeat assessment | Handling Plan | |
|---|---|---|
| Home visit | Always | Only if something has changed |
| Starting point | A blank plan | The plan already prescribed, and its history |
| Getting it to the provider | Posted, faxed or attached by hand | Straight to their inbox, ready to print |
| Evidence it was read | A signature, if kept | A record of who opened it, and when |
| Old copy | Remains in circulation | Marked no longer in use |
When acute and community practitioners both write on Handling Plan, the plan written on the ward is the plan the community sees.
Clinical safeguards
- Reusing a plan never replaces clinical judgement. The practitioner confirms it still fits before it is sent.
- Any change in condition, weight, environment, equipment or carers means reassessment.
- The updating practitioner's name and registration number go on the updated plan.
- Plans carry a client reference, so they can be shared between providers without a name.
Sources
- Homecare Association. Expecting the Unexpected: homecare providers' views of hospital discharge. June 2024. Survey of 283 providers.
- Care Quality Commission. Beyond barriers: how older people move between health and social care in England. 2018. Reported in Community Care.
- Healthwatch England. From hospital to home: improving patient discharge. February 2025.
Keep the plan with the person.
Fourteen days free on every plan, with no card.