Background Care home residents are more likely to attend and be admitted to hospital in unplanned, emergency situations than age-matched people living in their own homes, yet some transfers and admissions can be burdensome, leading to declines in health and well-being. Existing research has acknowledged the importance of understanding the local context in which transfers occur, yet research conducted in England is lacking.

Methods To develop an in-depth understanding of care home staff transfer decisions in England, data collection occurred in two phases. Firstly, semi-structured interviews were carried out with 30 care home staff across six care homes in the East and West Midlands. Secondly, 113 hours of ethnographic work (consisting of observations, documentary analysis and informal conversations) occurred across three of the six homes. Data gathered in both phases were analysed together using the Straussian approach to grounded theory.

Results Staff preferred to care for residents in the care home where possible. Transfers often occurred following a series of escalations in which staff sought to balance a number of risks. Staff primarily understood risk by drawing on their experiential knowledge of what was usual for each resident, yet also drew upon advance care plans and observations of early warning signs. Staff sought to manage risks by involving others in decision-making (colleagues, residents, relatives, healthcare professionals), yet this required staff to anticipate and mitigate potential disagreements.

Conclusions This study highlights a substantial amount of work care home staff undertake prior to calling external services and offers a novel approach to understanding hospital transfers from care homes, by foregrounding the different forms of risk staff feel responsible for balancing. Further research is needed to assess the ways new and existing interventions enable care home staff to manage risk during transfer decisions. The implications for emergency care services will be discussed.