Summary: We found fault in the process a Trust followed before discharging an elderly woman from hospital to her own home. While it carried out proportionate assessments of her needs it did not hold adequate discussions with the patient and her family about how those needs would be met. This caused avoidable frustration and has left uncertainty, for which the Trust has agreed to apologise. We have not found fault in the way the Council checked the woman’s support package in the days following her return home. We found the Council was at fault for failing to respond to a complaint within the agreed timeframe. However, we have not been able to link this to a specific injustice.

The complaint

1. Mrs X’s mother left hospital and returned home in August 2022. Mrs X complains the support arranged for Mrs Y was inadequate. She said it did not take account of, and did not meet, Mrs Y’s needs.
2. Mrs X complains that:
1. professionals did not consult Mrs Y’s family about discharge arrangements before deciding on her post-hospital care. Mrs Xsaid the only contact they had with social care staff was initiated by the family and, by that point, a decision had already been made about Mrs Y’s post-discharge care.
2. the Council did not respond adequately to the family’s repeated calls for help in the days after Mrs Y left hospital.
3. the Council unreasonably relied on one telephone call with Mrs Y, two days after she returned home, to assess whether the care package was adequate for her needs.
4. the Council did not make an immediate offer to fully assess Mrs Y’s care needs when she was at home.
3. Mrs X said, because of these failings, the family had to ensure a member of the family was always with Mrs Y. Mrs X said this was unsustainable and, in turn, meant the family had to privately arrange for Mrs Y to move into a residential care home. Mrs X said this left the family financially disadvantaged. She said that if the Council had arranged this level of care in the first instance they would not have had to pay the full cost of Mrs Y’s residential care for a period.
4. Mrs X also said these events caused “extreme emotional upset”.
5. In addition, Mrs X complained that:
1. It took three months for the Council to respond to her initial complaint.
2. The Council’s complaint response of 5 January 2023 was inaccurate.
3. The Council failed to respond to her follow-up complaint of 20 January 2023.
6. In bringing the complaint to the Ombudsmen Mrs X said the family would like:

• The Ombudsmen to recommend the Council refunds any costs the family has incurred due to a failure to follow the correct processes.
• Service improvements to prevent others from having to go through the same experience.

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The Ombudsmen’s role and powers

7. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
8. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
9. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
10. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)
11. This complaint involves events that occurred during the COVID-19 pandemic. The Government introduced a range of new and frequently updated rules and guidance during this time. We can consider whether the council followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19”.

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How I considered this complaint

12. I considered Mrs X’s written complaint to the Ombudsmen. A colleague spoke to Mrs X on the telephone I took account of their detailed notes of this conversation. I also spoke to Mrs X on the telephone. I wrote to the Council and the Trust to explain what I intended to investigate and to ask questions and for relevant evidence. I considered all the papers I received in response. I read relevant legislation and guidance.
13. I shared a draft decision with Mrs X, the Council and the Trust and considered the comments I received in response. This led me to write a revised draft decision.
14. I shared a confidential copy of the revised draft decision with Mrs X, the Council and the Trust and invited their comments on it. I considered the comments I received in response.

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What I found

Relevant legislation and guidance

Hospital discharge during the COVID-19 pandemic

15. In August 2020, in response to the COVID-19 pandemic and the need to keep hospital beds free, the Government introduced the Hospital Discharge Service: Policy and Operating Model.
16. The model set out that patients must be discharged from hospital as soon as it was clinically safe. It consisted of four care pathways:

• Pathway 0 applied to people with simple discharge needs and no requirement for ongoing health and social care support.
• Pathway 1 applied to people who could return home with support from health and/or social care services.
• Pathway 2 applied to patients requiring rehabilitation or short-term care in a 24‑hour bed-based setting.
• Pathway 3 applied to people who required ongoing 24-hour nursing care on a long-term basis, often in a bed-based setting.

National guidance on hospital discharge – April 2022

17. On 1 April 2022 the Department of Health and Social Care guidance: Hospital discharge and community support guidance (the National Discharge Guidance) came into force. This provided guidance to NHS bodies and local authorities on discharging adults from hospital. It said that, from this date, local areas should adopt discharge processes that best meet the needs of the local population. This could include the ‘discharge to assess, home first’ approach.
18. The Council confirmed that a Discharge to Assess model was still in operation when Mrs Y left hospital. It said Mrs Y went home on Pathway 1.
19. The National Discharge Guidance said under such models:

“the vast majority of people are expected to go home (to their usual place of residence) following discharge. The discharge to assess model is built on evidence that the most effective way to support people is to ensure they are discharged safely when they are clinically ready, with timely and appropriate recovery support if needed. An assessment of longer-term or end of life care needs should take place once they have reached a point of recovery, where it is possible to make an accurate assessment of their longer-term needs… Everyone should have the opportunity to recover and rehabilitate at home (wherever possible) before their long-term health and care needs and options are assessed and agreed.” It notes that best practice dictates that Care Act assessments should happen in a person’s own home.

20. It said that the benefits to this approach are that:

• It reduces individuals’ exposure to risks such as hospital-acquired infections, falls and the loss of physical and cognitive function by reducing time in hospital, and
• It enables people to regain or achieve maximum independence as soon as possible.

21. The National Discharge Guidance also notes that people should be “discharged in a safe and timely way to ensure they are only hospitalised for as long as they require hospital care. Discharging people once they no longer need acute care improves their outcomes and reduces the risk of medical complications such as deep-vein thrombosis, hospital acquired infections, and loss of independence.”
22. Further, the National Discharge Guidance said:

“Where relevant, the decision about when to discharge a person, and any support they might need before an assessment of their long-term needs, should take into account the views and circumstances of any unpaid carers as well as those of the individual. Hospital discharge teams should also consider unpaid carers’ preferences and involve them to ascertain whether they are both willing and able to provide care and support post-discharge, before an assessment of longer-term needs.”

23. It also reiterates that “If care, treatment or support is needed, the individual should be fully involved in considering what form that might take and in weighing up the risks and benefits of the options that are available. This includes, if required by the person, consultation with family members and any carers who are willing and able to provide care and support.”

Trust discharge policy

24. In July 2021 the Trust approved its Community Hospitals Admissions Transfers and Discharge Policy (the Hospital Discharge Policy). This remained in place at the time of Mrs Y’s admission and discharge.
25. The Hospital Discharge Policy said:

• “Timely discharge…should be planned from an early stage with full involvement of the patient and their carer…” (Part 9)
• “…Patients, family and carers should be involved and have timely and appropriate information in order to make an informed choice on their care following discharge. The involvement of the patient and family/care is an integral and essential part of the discharge process.” (Part 9.1)
• “…The Choice Policy supports people’s timely, effective discharge from an NHS inpatient setting, to a setting which meets their diverse needs and is their preferred choice amongst available option…” (Part 9.3)

Complaint handling

26. Councils and NHS organisations’ responsibilities for handling complaints are set out in the Local Authority Social Services and NHS Complaints (England) Regulations 2009 (the Regulations).

• The Regulations do not specify how long an investigation should take. However, section 13 states that the likely timescales for completing the investigation and providing a response should be determined at the start of the process. This can be done in discussion with the complainant. If the complainant does not want a discussion the body must determine these timescales itself and confirm them to the complainant in writing.
• Section 14 states that, during the investigation, the body must keep the complainant informed of progress “as far as reasonably practicable”. In addition, if the body has not provided a response after six months (or, at the end of any previously agreed longer period), the body must write to the complainant to explain why.
• Section 14 of the Regulations state that, once the investigation is completed, the body must provide a response which:
• Explains how the complaints have been considered;
• Includes the conclusions the body has reached about the complaints – including whether remedial action is needed and, if so, whether this has been arranged or completed;
• Advises the complainant of their right to complain to the relevant Ombudsman.

Background

27. In 2022 Mrs Y lived alone in her own home. In May 2022 she went into hospital after falling. When she returned home, in the middle of the month, professionals arranged 24‑hour support for two weeks. The Council later extended this to three weeks because it had been unable to arrange ongoing support for Mrs Y in time. After the three weeks Mrs Y’s family privately arranged some support for Mrs Y. This consisted of a visit from a paid carer in the morning to: get Mrs Y out of bed; help her to have a shower; and, to make sure she took her morning medications. Members of Mrs Y’s family supplemented this by visiting Mrs Y several times a day. In addition, for a time, Mrs Y received support from a night care service which involved two carers visiting Mrs Y during the night to check she was ok. The family stopped the night service around the middle of June because Mrs Y was often sleeping when they arrived.
28. Mrs Y returned to hospital in late July because of a chest infection. The hospital discharged her to her home in early August. The Council arranged for staff from the Short Term Assessment and Reablement Team (START) to visit Mrs Y three times a day, for half an hour at a time.
29. A member of START visited Mrs Y at home in the afternoon of the day she returned home. Mrs X told us that the professional told the family not to leave Mrs Y alone. A therapist from Integrated Community Services (ICS) assessed Mrs Y later that day. They planned to arrange some chair risers for Mrs Y but did not recommend any other action. The next day the Council increased Mrs Y’s support from three to four visits a day.
30. Mrs X said that, from this point of Mrs Y coming home, she and her two siblings divided the days into three eight-hour shifts for them to stay with Mrs Y. Mrs X said they did not feel she could be left alone safely. Mrs X said Mrs Y could not make a cup of tea or use the toilet on her own.
31. In the following days Mrs X and other members of the family raised concerns about the adequacy of the support Mrs Y had. The Council did not make any changes to Mrs Y’s support plan.
32. Later in August, around a week after Mrs Y returned home, her family privately arranged for her to move into a residential care home.

Analysis

Complaint A: That professionals did not consult Mrs Y’s family about discharge arrangements in August 2022 before deciding on her post‑hospital care

33. Mrs X said the only contact they had with social care staff was initiated by the family and, by that point, a decision had already been made about Mrs Y’s post-discharge care. Mrs X said the family were simply told that a package of care had been arranged. Mrs X said this was despite the family having repeatedly asked to have discussions about this.
34. In its response to the complaint the Trust noted conversations its staff had with Mrs Y’s family on 3 August about discharge arrangements. It did not note any failings in its actions.
35. In its reply, the Council said before deciding on its recommendation for Mrs Y’s post-discharge care it listened to the family’s views and discussed them with Ward staff.
36. Records from the Trust show that:

• A Physiotherapist assessed Mrs Y on 25 July and again on 29 July. On both occasions they completed a Moving and Handling Assessment. This detailed the professional’s view about the equipment and support Mrs Y would need to move around and to sit and stand up.
• An Occupational Therapist (OT) assessed Mrs Y on 27 July and completed a Personal Care Assessment. This set out the support they considered Mrs Y would need to complete personal care tasks.
• An OT completed an Initial Assessment of Mrs Y on 29 July. This noted that the OT spoke to one of Mrs Y’s daughters to gather the information. The assessment documented Mrs Y’s usual ability to complete a range of tasks of everyday living. The assessment recorded that Mrs Y’s preference was to return home with support. The OT also noted that Mrs Y’s family would support her with domestic activities.
• One of Mrs Y’s daughters spoke to a member of staff in the afternoon of 2 August. The daughter raised concerns about the hospital discharging Mrs Y on 4 August without care in place, and without the family’s consent. The member of staff said the family would be told of any discharge conversations. They also said the estimated date of discharge was 4 August but said this was just an estimate.
• Hospital staff completed a Fact Finding Assessment on 2 August. This noted Mrs Y’s current condition and gave an account of her home and the equipment she had. It also noted the care that Mrs Y would need when she returned home. It said she would need three visits from a care worker a day, to help with personal care, meal preparation and to prompt Mrs Y to take her medication.
• Hospital staff spoke to one of Mrs Y’s daughters on 3 August. They said the hospital would discharge Mrs Y the next day and that she would receive three visits a day from a care worker. The staff said the Intermediate Care Service would then visit Mrs Y to assess her in her home environment.

37. The records show that professionals based their conclusions about the support Mrs Y needed at home on their own assessments of her abilities. There is evidence to show that professionals considered Mrs Y’s ability to complete a range of tasks and activities and found that she would need support. The assessments included information about Mrs Y’s home circumstances.
38. Having gathered information about Mrs Y’s needs professionals also had to think about how those needs could and should be met. There is some evidence, on 29 July, that staff spoke to a member of Mrs Y’s family to gather information to help inform their assessments. However, there is very little evidence to suggest that staff engaged in the type of inclusive, person‑led conversations about post‑hospital care described in both the National Discharge Guidance and the Hospital Discharge Policy.
39. The evidence shows that members of Mrs Y’s family called the hospital and asked to discuss Mrs Y’s post-hospital care and support. I have not seen evidence to show these requests were responded to in a meaningful way. This includes a lack of evidence of discussion about what informal care members of the family may be able to provide on a consistent basis. Given professionals had documented that members of Mrs Y’s family would be supporting her, there needed to be a full exploration of the extent and nature of that support and about the unpaid carers’ ability and willingness to provide the necessary support. In addition, there should have been more explicit, documented discussions about Mrs Y’s wishes and her understanding of the associated risks and benefits of any alternatives.
40. Overall, on balance, the Trust did not act in line with the National Discharge Guidance or its own Hospital Discharge Policy when planning and arranging Mrs Y’s discharge from hospital. This was fault.
41. In terms of the impact, the National Discharge Guidance is clear in setting out an expectation that most people will return home from hospital, and that this should happen as soon as possible. It is also clear that it does not expect to people to be fully back to normal at the point of leaving hospital, and that there will be a period of recuperation.
42. We cannot say what would have happened if there had been fuller discussions with Mrs Y and her children about her post-discharge care. On balance, it is likely that Mrs Y’s family would have advocated for more support and, perhaps, more time in hospital. However, it is also probable that the professionals who had assessed Mrs Y’s needs would have maintained that the additional care (over and above the one care visit Mrs Y received pre-admission) would be an adequate level of care. This is because, when professionals reviewed Mrs Y at home, they did not recommend that any significant changes to her care were needed. I will come to this later in this decision. The limited evidence of consultation with Mrs Y suggests that it was her wish to return to her own home.
43. Therefore, I cannot say on the balance of probabilities that, had the fault not occurred, there would have been a different plan for Mrs Y’s post-discharge care. Nevertheless, Mrs X and her siblings were caused upset and frustration by their lack of involvement in the discharge planning process. And they have been left with some uncertainty about whether this could have altered subsequent events. This is an injustice to Mrs X and her siblings.

Complaint about the adequacy of the care package Mrs Y received

44. Mrs X said Mrs Y needed the support of one person for all personal tasks and was at high risk of falling. Mrs X said professionals found Mrs Y needed 24-hour care when she left hospital in May 2022. Mrs X said that, since then, Mrs Y’s confusion had increased and her ability to move around on her own had worsened. In addition, Mrs X said she could not see any evidence in Mrs Y’s medical records that Mrs Y was able to perform any tasks independently.
45. In its response to the complaint the Trust noted that its therapy staff assessed Mrs Y’s needs three times over four days at the end of July 2022. It said these assessments led to a view that Mrs Y could be adequately supported by one carer visiting her three times a day. The Trust did not explicitly say so, but it did not note any fault in any of the assessments or in the conclusions they led to.
46. Similarly, the Council did not comment explicitly on whether its decisions and actions had been appropriate. However, it did not include any acknowledgements of any failings or omissions.
47. As noted above, the available evidence shows that several professionals were involved in assessing Mrs Y’s needs while she was an inpatient. They assessed Mrs Y’s abilities in a range of areas and considered nursing staff’s observations about how Mrs Y had coped on the ward. Further, they took account of the level of care she had been receiving before she entered hospital. As noted in paragraph 9, as I have not found fault in how the Trust and Council assessed Mrs Y’s needs, we cannot question the outcome of its assessments.

Complaint B: That the Council did not respond adequately to the family’s repeated calls for help in the days after Mrs Y left hospital; and

Complaint C: That the Council unreasonably relied upon on one telephone call with Mrs Y, two days after she returned home, to assess whether the care package was adequate for her needs

48. I have looked at these complaints together as they are very closely linked.
49. Mrs X said when Mrs Y was at home the family repeatedly telephoned the Council to ask for help. Mrs X said they made it clear they could not continue to provide the same amount of support they were providing. Mrs X said she was only able to speak to a Social Worker about this several days after Mrs Y returned home. Mrs X said the Council ignored the family’s concerns and failed to recognise that the situation was unsustainable.
50. In addition, Mrs X said the Council relied on one conversation with Mrs Y, soon after she got home, to judge the adequacy of the care package. Mrs X said this was inappropriate because Mrs Y was 85 years old and in the early stages of dementia.
51. In its response to the complaint the Council said a Senior Support Worker visited Mrs Y and was satisfied the existing package was sufficient, and that Mrs Y would benefit from a period of reablement.
52. As noted above, a member of ICS assessed Mrs Y on the day she returned home and recommended further equipment but did not raise any concerns about the support package being inadequate. The Council agreed to increase the amount of support the next day; from three to visits a day. A Senior Support Worker met Mrs Y and two of her children the same day. They observed Mrs Y at home and concluded it would be reasonable to continue with the current plan and then assess Mrs Y after she had had more time at home.
53. A Social Work Assistant called Mrs Y the next day and asked her how she was. The records detail that Mrs Y gave a coherent, detailed response and did not raise any concerns about her care.
54. On the following day a Social Work Assistant spoke to one of Mrs Y’s daughters who said they were struggling to help Mrs Y during the night. The daughter said the family could not continue to support Mrs Y full time because they all had full‑time jobs. The Social Work Assistant requested a new assessment of Mrs Y’s needs.
55. Social Work staff spoke to Mrs Y’s family the following day. Two days later the Council recorded that Mrs Y’s family had decided to move Mrs Y to a residential home on a self-funding basis.
56. I have not found evidence of fault here. It is evident that professionals and Mrs Y’s family did not agree about the level of care Mrs Y needed. However, there is evidence to show that the Council’s views were based on in-person visits and assessments as well as the telephone call to Mrs Y. I have noted what Mrs X said about what a START support worker told the family on the day Mrs Y returned home (see paragraph 24). However, the daily records of START’s visits to Mrs Y do not record any concerns about the adequacy of her support package, or any concerns about Mrs Y’s safety.
57. Overall, there is evidence to show the Council was actively keeping Mrs Y’s situation under review.

Complaint D: That the Council did not make an immediate offer to fully assess Mrs Y’s care needs when she was at home

58. In explaining the family’s decision to arrange a residential home place for Mrs Y, Mrs X highlighted the unsustainability of the situation. In addition, Mrs X said that in the week Mrs Y was at home the Council never offered to complete a full assessment of Mrs Y’s needs.
59. As detailed in paragraphs 14 to 19, the Discharge to Assess Guidance included funding for six weeks to allow time for a comprehensive assessment of the person’s needs in their home environment. It did not specify a set time within which assessments should be completed, within those six weeks.
60. When a Senior Support Worker say Mrs Y shortly after she returned home they recommended allowing more time for Mrs Y to recover from her inpatient admission. In the context of the assessments of Mrs Y’s needs that were completed in hospital and in the community I do not consider that was unreasonable. Overall, I have not found fault in relation to this complaint.

Complaint E: That it took three months for the Council to respond to her initial complaint

61. Mrs X wrote to the Council on 1 October 2022 (a Saturday) to complain about the events of July and August. The Council acknowledged the complaint on 6 October. The Trust and the Council initially intended to provide a joint response to the complaint. In late October the Trust said it aimed to provide this by 3 January. However, the Trust then provided its own response in late December. The Council sent its response on 5 January, 66 working days after receiving the complaint.
62. The Council’s Adult Social Care complaints policy sets out that it aims to acknowledge complaints within three days and then aims to set a timescale to respond. This approach is in keeping with the Complaint Regulations.
63. The Council did not acknowledge the complaint within three working days, and it did not meet the deadline of 3 January. I have not seen evidence to show the Council kept Mrs X updated about progress, explained it would not meet the set deadline. In relation to this, the complaint involved a relatively short period of time and there were not a significant amount of documents to compile and consider.
64. There was fault here as the Council did not meet the requirements of its own complaints policy. I appreciate the wait was frustrating for Mrs X, and the rest of the family. However, in the overall context of the complaint I do not consider this frustration was so severe to constitute an injustice. As such, I have not recommended any remedial action by the Council.

Complaint F: That the Council’s complaint response of 5 January 2023 was inaccurate

65. Mrs X said the Council’s claim that a member of staff initiated contact with her was untrue. Mrs X said the only she spoke to the named member of staff in the late morning on the day Mrs Y left hospital.
66. The contemporaneous records from the Council include a progress note about a Social Worker calling Mrs X in the late morning of the day Mrs Y left hospital. It notes that they called because Mrs X had tried to call the Social Worker three times that morning while they were doing ward rounds.
67. I have not found fault here. The Council’s response to the complaint is supported by the records professionals made at the time of the events, and I consider it was reasonable for the Council to rely on these records.

Complaint G: That the Council failed to respond to her follow-up complaint of 20 January 2023

68. Mrs X emailed the Council on 20 January 2023, in response to its complaint response earlier that month. The email set out detailed reasons why Mrs X was dissatisfied with the Council’s response.
69. The Council acknowledged this correspondence and passed it to the service manager. However, on 1 February Mrs X told the Council she had decided to go straight to the Ombudsman. The Council acknowledged this the next day and said it would await contact from the Ombudsman.
70. In view of this exchange I have not found fault here.

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Agreed actions

71. Within one month of the final decision the Trust will write to Mrs X to acknowledge the fault identified in paragraph 41 of this statement. It will also apologise for the injustice this caused, as detailed in paragraph 44.
72. Within two months of the final decision the Trust will take proportionate steps to ensure the learning from this complaint is shared with relevant staff with a view to helping to prevent recurrences. Specifically, that staff are aware of the need to ensure there is appropriate communication with, and involvement of, patients and their families and/or carers during planning for post-discharge support.

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Decision

73. I have completed this investigation on the basis there was fault by the Trust in the way it managed the discharge process. This caused avoidable frustration and has left avoidable uncertainty. The Trust has agreed to apologise to address this. I also found some fault in the Council’s complaint handling but this did not lead to an injustice.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman