How staff, teams and services work together: requires improvement

E4. How well do staff, teams and services work together within and across organisations to deliver effective care and treatment?

What we see in services that require improvement in this area

There is limited participation in multidisciplinary working. Teams do not include all necessary staff, are not coordinated or do not meet frequently enough to provide effective care. Discharge, transition and referral planning is undertaken but is not timely or does not consider all of the person’s needs. There may be delays or poor coordination when people are referred or discharged or when they transition to other services.

Unexpected discharges, transfers and transitions are not managed effectively and the provider does not consistently make sure that unplanned departures or discharges do not leave people unduly at risk.