Summary: Mrs Y and Mrs X complained about Norfolk County Council (the Council), Norfolk & Norwich University Hospitals NHS Foundation Trust (the Hospital Trust) and Norfolk Community Health and Care NHS Trust (the Community Trust). They complained about flawed hospital discharge, poor communication and poor care in a residential reablement unit. We have upheld some of their complaints about poor communication by the Hospital Trust and the Council, and poor care by the Council. We consider the faults we found led to avoidable distress and loss of dignity for Mrs X, and avoidable frustration, uncertainty and worry for both complainants. The Hospital Trust and the Council have accepted our recommendations for remedy. We have not upheld the other complaints. We have now completed our investigation.

The complaint

1. Mrs Y complained on behalf of herself and her mother, Mrs X. The organisations she complained about are Norfolk County Council (the Council), Norfolk & Norwich University Hospitals NHS Foundation Trust (the Hospital Trust) and Norfolk Community Health and Care NHS Trust (the Community Trust).
2. Mrs Y complained about Mrs X’s flawed discharge from hospital to a Council residential reablement unit (the Reablement Unit). This includes flawed information about the services on offer at the Reablement Unit before Mrs X was discharged there and failure to ensure Mrs X received physiotherapy and appropriate wound care while she was there.
3. Mrs Y also complained about poor care of Mrs X and poor communication by the Reablement Unit between February and April 2023. This includes hydration, nutrition, turning, general personal care, lack of appropriate pressure care mattress, lack of on-site nursing and physiotherapy, and failure to ensure Mrs X received physiotherapy.
4. Mrs Y said Mrs X experienced avoidable physical and psychological discomfort and got infections and pressure sores because of poor care. She said Mrs X also missed out on necessary rehabilitation therapies. She said these all had a long-term impact on Mrs X’s physical health and led to her being unable to return to an independent life in her own home. Mrs X’s family believes that:
• the absence of on-site professionals such as a physiotherapist significantly contributed to Mrs X’s deterioration;
• Mrs X would have had the opportunity to regain her mobility, and potentially return home, had she received appropriate care and support at the Reablement Unit; and
• Mrs X’s move into long-term residential care could have been avoided, had she received on-site professional support following her discharge from hospital.
5. Mrs Y said the distress of witnessing her mother in these circumstances negatively affected her mental health, and that of her siblings. She said she also incurred travel and accommodation expenses when visiting Mrs X at the Reablement Unit, which she would not have incurred had Mrs X been discharged to a community hospital instead.
6. Sadly, Mrs X died during the course of this investigation.

Back to top

The Ombudsmen’s role and powers

7. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
8. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something an organisation has done. (Local Government Act 1974, sections 26B and 34D, as amended, and Health Service Commissioners Act 1993, section 9(4).) Mrs Y complained to the Ombudsmen more than 12 months after she and Mrs X became aware of the complaint issues. However, they provided good reasons for the delay in coming to us and I considered there was a realistic prospect of reaching a sound and fair decision despite the passage of time. I therefore decided to investigate even though the complaint was late.
9. We may investigate complaints made on behalf of someone else if they have given their consent. We may also investigate a complaint on behalf of someone who cannot authorise someone to act for them, if we consider them to be a suitable representative. (Health Service Commissioners Act 1993, section 9(3) and Local Government Act 1974, sections 26A(1) and 26A(2), as amended)
10. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we 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).
11. If it has, we 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.
12. When investigating complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
13. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(1), as amended)

Back to top

How I considered this complaint

14. I considered evidence provided by Mrs Y, the Council, the Hospital Trust and the Community Trust. I have also considered relevant law, policy and guidance and referred to these where applicable in this decision statement.
15. The complainants, Council, the Hospital Trust and Community Trust have had an opportunity to comment on a draft version of this decision. I considered all comments before making a final decision.

Back to top

What I found

Organisational responsibilities

16. The hospital that discharged Mrs X to the Reablement Unit is part of the Hospital Trust. It was responsible for completing a transfer of care (TOC) document before discharging Mrs X. The TOC document details a person’s care needs following discharge and recommends a type of discharge destination (for example, a residential care home or an accommodation based reablement unit). The Hospital Trust was also responsible for providing Mrs X and her family with information about hospital discharge and for onward referrals to community health services.
17. The Council and Community Trust were responsible for a joint discharge hub called Home First Hub. Its role was to coordinate discharge planning based on information in the TOC forms. This included organising alternative discharge destinations for people who could not go to their own homes after leaving hospital.
18. The Community Trust was also responsible for:
• a community access team (CAT) based at the Hospital Trust’s hospital. CAT was responsible for acting on the Hospital Trust’s referrals for community hospital admissions and rehabilitation; and
• community physiotherapy in parts of the local area, if commissioned by the NHS to provide this. The Community Trust says it was not commissioned to provide physiotherapy within the Reablement Unit.
19. The Reablement Unit was part of the Council. It was a unit where people stayed for up to six weeks of accommodation based reablement (ABR). As the Reablement Unit was part of the Council, we hold the Council responsible for:
• deciding whether the Reablement Unit could meet Mrs X’s personal care and reablement needs based on the information in the TOC; and
• meeting Mrs X’s personal care and reablement needs while she was at the Reablement Unit.

A – Discharge from hospital to reablement unit

Relevant law, guidance and policy

20. If a person is likely to need care and support after leaving hospital, the Trust must take appropriate steps to involve the person and their carers in planning their discharge. (Section 74(1) of the Care Act 2014)
21. The Government guidance on hospital discharge valid at the time of this complaint is called "Hospital Discharge and Community Support Guidance”, (Hospital Discharge Guidance) published in March 2022 by the Department of Health and Social Care. It says:
• local areas should have their own hospital discharge processes based on the principles in the guidance; and
• councils and NHS bodies should have local protocols that set out each organisation’s role.
22. The Hospital Discharge Guidance also provides more detailed guidance on what local hospital discharge processes should include.
23. The National Institute for Health and Care Excellence (NICE)’s guideline NG27 is relevant. The guideline is called “Transition between inpatient hospital setting and community or care home settings for adults with social care needs”. It contains guidance on how hospitals and community services should work together to provide support for older people, from hospital admission through to their discharge home.
24. NICE’s guideline CG124, “Hip fracture: management” is also relevant. It provides guidance on what hospitals should consider when discharging people following hip fracture treatment.
25. Intermediate care is a range of short-term services with aims including supporting timely hospital discharge. Reablement is a type of intermediate care and is funded by council social care services. It includes assessment and interventions to help people recover skills and confidence, and to maximise their independence, even if full recovery is not possible.
26. Rehabilitation is different from reablement. It is a health service with the aim of helping people regain or re-learn some capabilities where these capabilities were lost because of illness, injury or accident.

What happened?

27. In 2023, Mrs X was in her 90s and lived on her own, in her own home. Her three children lived a significant distance away. She had occasional privately funded support with cleaning and personal care, but was largely independent. Mrs X had a long-term health condition, the symptoms of which can include pain, fatigue, a poor appetite and weight loss. Some of her medication had possible side effects of nausea, vomiting and loss of appetite.
28. In January 2023, Mrs X fell at home and broke her hip. She went into hospital, where she had an operation to repair the fracture. After a few weeks recovering in hospital, Mrs X was discharged to the Reablement Unit for accommodation based reablement (ABR).
29. While in hospital, Mrs X:
• sustained an accidental skin tear on her leg during her hip operation;
• was documented to have bladder retention. This is when someone cannot fully empty their bladder. It can lead to urinary incontinence and urinary tract infections;
• saw a physiotherapist who noted the plan was to await ABR; and
• developed a swelling in the lower part of the same leg that had the hip fracture. The hospital decided this needed further investigation but should not delay her discharge. It organised an ultrasound scan to take place after she left hospital, to check whether a blood clot was causing the swelling.
30. At the time of Mrs X’s discharge from hospital, the Council and Community Trust had an integrated discharge hub in place. Acute hospitals such as the one Mrs X was in would complete a standardised Transfer of Care (TOC) form and send it to the discharge hub. The TOC form included a recommendation for the type of discharge destination. The discharge hub would organise support following discharge and/or a discharge destination in accordance with the TOC form’s recommendations. The discharge hub would then make practical arrangements with the acute hospital and discharge destination, for example discharge dates, transport, and equipment.
31. The Hospital Trust completed a TOC form. This included a section on care planning. It recommended an accommodation based reablement (ABR) bed as Mrs X’s discharge destination. The TOC form did not recommend any rehabilitation or therapies. The form said Mrs X was moving short distances with the help of a walking frame and supervision, but was not safe to return home because she needed help to:
• get into and out of bed and with personal hygiene; and
• use a commode two to three times a night.
32. The TOC also said Mrs X did not need oversight from a registered nurse.
33. Around the same time as completing a TOC form, the Hospital Trust made a referral to the Community Trust’s CAT for a rehabilitation community hospital bed. There was initially some confusion about whether Mrs X needed a rehabilitation community hospital bed or an ABR bed, because of contradictory information from the Hospital Trust about this. The two Trusts quickly established Mrs X needed an ABR bed and the CAT referral was closed.
34. Mrs Y says the family wanted Mrs X to be discharged to a community rehabilitation hospital, but the Hospital Trust told Mrs X and her family that the Reablement Unit was well equipped for Mrs X’s needs. Mrs Y says the Hospital Trust told them the Reablement Unit had a nurse, physiotherapist and occupational therapist on site.
35. The Reablement Unit confirmed it could meet Mrs X’s needs based on the TOC form. Mrs X moved there in early February 2023. The Reablement Unit did not have a nurse or physiotherapist on site. On the day the Hospital Trust discharged Mrs X to the Reablement Unit, it:
• made a referral to the district nursing service for daily injections to prevent blood clots, care of the skin tear on Mrs X’s leg, and checks of her pressure areas;
• provided a transfer of care letter to the Reablement Unit with information about Mrs X’s health and care needs; and
• sent a pressure relief mattress and cushion with Mrs X when she went to the Reablement Unit.

Was there fault causing injustice?

36. The organisations did not have a local area discharge policy or protocols at the time of the events in this complaint (February to April 2023). This was contrary to Government guidance on hospital discharge and therefore fault.
37. In the absence of a local discharge policy and protocols, I have considered whether what happened followed the Government guidance, together with NICE guidelines NG27 and NG124. Having done so, I consider the Council and Hospital Trust acted within the guidelines when deciding to discharge Mrs X to the Reablement Unit without a referral for community physiotherapy because:
• Mrs X did not have a right to remain in hospital if she did not need acute care;
• the Council and Hospital Trust did not have to discharge Mrs X to her preferred placement if that was unavailable, or provided more support than they considered Mrs X needed at the time;
• the Hospital Trust took into account physiotherapy and occupational therapy assessments, as well as NICE's guideline CG124, when deciding Mrs X should be discharged to a reablement bed without a referral for post-discharge physiotherapy;
• the Hospital Trust described Mrs X’s personal care and medication needs that required support following discharge within the TOC form care planning section and the transfer of care letter to the Reablement Unit; and
• the Hospital Trust made a referral to the district nurses when discharging Mrs X from hospital.
38. However, there were some faults in the way the Council and Hospital Trust shared information with Mrs X during the discharge process. This was because:
• there are no records the Council or Hospital Trust gave Mrs X information about post-hospital care or rehabilitation, or if they did, what information they gave her;
• it is more likely than not that the Hospital Trust gave Mrs X and Mrs Y inaccurate information about the services and support available at the Reablement Unit. Mrs Y’s account of being told the Reablement Unit had an on-site nurse and physiotherapist is supported by the Council’s records of emails between it and the Hospital Trust, about there being no on-site physiotherapy at the Reablement Unit; and
• there is no record of Mrs X getting a copy of her discharge plan.
39. The faults caused Mrs Y and Mrs X avoidable frustration with the Reablement Unit not having the expected support on site. The faults also caused them uncertainty as they considered Mrs X would have had a better recovery and overall experience had she been discharged to a facility with nursing and physiotherapy on site.

B – Care and communication at the Reablement Unit

Relevant law, guidance and policy

40. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards which care must never fall below. The following Regulations are relevant to this part of the complaint.
• Regulation 9 is about person-centred care. It says care must be appropriate, meet the person’s needs, and reflect their preferences.
• Regulation 10 says staff delivering care must treat people with dignity and respect. This includes ensuring their privacy and supporting their autonomy and independence.
• Regulation 11 says care and treatment must only be provided with the person’s consent, if the person can provide it.
• Regulation 12 says care and treatment must be provided in a safe way. This includes risk assessments, doing everything reasonably practicable to mitigate risks, having appropriately skilled staff, and ensuring premises and equipment are safe.
• Regulation 14 is about meeting nutritional and hydration needs. It says people must have enough to eat and drink to keep them in good health while they receive care and treatment.
• Regulation 17 is about good governance. It says care providers must maintain accurate, complete and contemporaneous records of the care a person receives there.
41. NICE’s guideline NG74 called “Intermediate care including reablement” is relevant to this part of the complaint. It says practitioners should:
• develop goals in a collaborative way that optimises independence and wellbeing;
• carry out an initial risk assessment and document a risk plan;
• discuss and agree goals with the person, then document them;
• share risk plans and goals with the person and review them regularly; and
• work with the person to help them regain their independence and not automatically intervene even when the person is struggling to perform a task
42. NG74 also says:
• when a person enters intermediate care, they should get information about the service’s aims, how it works and the support it will and will not provide; and
• daily care records should log the support given and the person’s progress towards their goals.

What happened?

43. The Hospital Trust sent a specialist pressure care mattress to the Reablement Unit with Mrs X when it discharged her from hospital. The Council ordered an alternative and potentially less noisy pressure care mattress which arrived in early March 2023.
44. Mrs X was in the Reablement Unit between 1 February and 1 April 2023, with a brief return to hospital on 2 February because of an infection.
45. The Council completed a reablement assessment and personal plan for Mrs X on 4 February 2023. This contained the following information:
• Mrs X’s desired outcome to return home as soon as possible;
• Mrs X’s daily routine including personal care, eating, and what she liked to do;
• Mrs X’s goals of improving her walking and returning to managing her own personal care and medication;
• objectives and plans for helping Mrs X achieve her goals; and
• risk management information.
46. Mrs X signed a form confirming she understood the support she got at the Reablement Unit would vary if her levels of independence varied.
47. The TOC form sent to the Reablement Unit before Mrs X was discharged there stated she was at risk of malnutrition and there were concerns about her pressure areas. The TOC form stated the Reablement Unit should start a food record chart. The only food charts the Council has provided are for a few days in February and March.
48. The TOC form, discharge letter and personal plan did not contain specific instructions for daily charts of other support the Reablement Unit provided to Mrs X. The Council has provided records for turning Mrs X in bed and for hydration, for a few days in February and March. The records indicate the Reablement Unit only used these charts when it considered them necessary because Mrs X was unwell. This reflects the agreement between Mrs X and the Reablement Unit that the support it would give her would vary according to her independence.
49. The Reablement Unit had a reablement review document for Mrs X dated 19 February 2023. It contained information about why she was there, what she had difficulties with, her desired outcomes, her daily routine, and her goals associated with her mobility, personal care and medication. The document listed two progress discussions in late February, and three spaced a week or two apart in March.
50. The Reablement Unit’s daily care records show there were days when Mrs X felt nauseous and this affected how much she wanted to eat and drink. Nausea was one of the known side effects of one of her long-term medications. Mrs X also contracted several infections, some of which affected her appetite. The records show the Reablement Unit sought advice and treatment from medical professionals when this happened. They also show that:
• throughout her stay at the Reablement Unit, Mrs X could make her own decisions about medication, food, drink and repositioning. This included whether to accept or ask for help from staff;
• staff at the Reablement Unit encouraged Mrs X to eat and drink;
• in early February 2023, Mrs X could walk short distances with the help of a frame and used the toilet with help from staff;
• in February, there was a medication error involving Mrs X having some medication for two days in a row, rather than the prescribed one dose a week. The Reablement Unit contacted a GP about this. The GP considered the error would not have caused Mrs X harm and advised the Reablement Unit to give Mrs X her usual dose the following week;
• Mrs X contracted COVID-19 in mid-February and this coincided with a decrease in independence, eating and drinking;
• in March, Mrs X needed a catheter because of bladder retention. This was a medical decision and not one made by the Reablement Unit;
• Mrs X showed some signs of recovery in March, but her health declined significantly by the end of March and she went into hospital on 1 April;
• the Reablement Unit ensured a GP, practice nurse or paramedics visited Mrs X when she was unwell; and
• in general, staff assisted Mrs X with going to the toilet and personal care when she asked them. However, there were two occasions in March when she asked for help to use a toilet or commode and staff refused. They recorded telling her to either use a pad she was wearing or that she would not be able to produce anything as she was catheterised, without apparent consideration that she may have needed a bowel movement.
51. The Community Trust’s records say the Reablement Unit took three days to report to the district nurses that Mrs X needed her blood thinning injections to restart after she returned from her brief stay in hospital.
52. The Reablement Unit’s records contain the following information about communication.
• Notes of discussions with Mrs X about reablement reviews, care and reablement planning, medication management, storage of valuables, rules at the Reablement Unit, and consent. Where those records had sections for staff and resident signatures, some are signed by Mrs X but some are not.
• Care staff regularly communicated face-to-face with Mrs X as they delivered her care.

Was there fault causing injustice?

53. I have found no fault regarding Mrs X's mattress, as the Hospital Trust sent a special pressure relieving mattress with her to the Reablement Unit and the Council later ordered an alternative which was less noisy. This means Mrs X had a specialist mattress for her entire stay at the Reablement Unit.
54. The Reablement Unit should have started a food chart in accordance with the advice in the TOC form. It did not do so as soon as Mrs X moved there, and only kept food charts for a few days out of Mrs X’s two month stay. It also took too long to notify the district nurses that Mrs X was missing out on blood thinning injections. This was not in keeping with Regulations 9, 12 and 17 and was fault. Fortunately, Mrs X did not suffer harm from the missed injections or a medication error where she had a dose of weekly medication too soon. We cannot say the Reablement Unit did not offer Mrs X food on the days where there are no food charts, as daily care records also show staff offering Mrs X food and that Mrs X had a reduced appetite when she had COVID-19, oral thrush and nausea. However, these faults caused avoidable uncertainty and worry for Mrs X and Mrs Y about how the Reablement Unit’s actions may have contributed to Mrs X’s ill health while she was there. The Council is responsible for the fault and resulting injustice.
55. Daily care records indicate that overall, Mrs X received appropriate personal care while at the Reablement Unit. However, there were two occasions where staff recorded refusing to help her go to the toilet or use a commode without good reasons. This was not in keeping with Regulations 10 and 12. It was fault, causing Mrs X avoidable distress and loss of dignity.
56. The Reablement Unit’s communication with Mrs X and her family was generally appropriate. However, there were no reablement review discussions until the end of February. The Reablement Unit also failed to ensure Mrs X signed all the care records that she should have signed to confirm accuracy, or to record why she did not sign them. These were faults. Given the amount of time that has passed, we cannot say reliably whether the Reablement Unit shared those documents with Mrs X at the time and the lack of signature was just an oversight, whether Mrs X disputed their accuracy, or whether they were never shared with her. The resulting avoidable uncertainty was an injustice to Mrs X.
57. There was no fault with the provision of hydration and turning, as:
• the care records reflect Mrs X’s agreement with the Reablement Unit that her support would vary along with her levels of independence;
• there are records of turning but also of Mrs X declining to be turned, or being well enough not to need turning. The Reablement Unit respected Mrs X’s wishes in accordance with Regulation 11 and requested medical intervention when it had concerns about Mrs X’s skin integrity;
• the Hospital Trust’s records show Mrs X had restricted her own drink intake in hospital to reduce urination and it is possible she may have done the same at the Reablement Unit; and
• while at the Reablement Unit, Mrs X had infections, which could have affected her willingness or ability to drink. The Reablement Unit promptly sought medical treatment when Mrs X was unwell.

C – Physiotherapy at the Reablement Unit

Relevant law, guidance and policy

58. NG74 says intermediate care teams should have a clear route of referral to and engagement with commonly used services, including specialist and longer-term rehabilitation services.

What happened; was there fault causing injustice

59. Section A above explains why I have found no fault by the Hospital Trust in relation to this part of the complaint.
60. In mid-March 2023, the Reablement Unit made a physiotherapy referral to the Community Trust. The Council says this was in response to requests from Mrs X’s family. The Reablement Unit believed at the time that the Community Trust was responsible for delivering physiotherapy at the Reablement Unit. The Reablement Unit chased the Community Trust for a response a few days later. The Community Trust told the Reablement Unit it did not provide community physiotherapy for patients at the Reablement Unit and closed the referral. Mrs X contracted an infection and returned to hospital less than two weeks later.
61. In response to our enquiries, the Hospital Trust and Council told us they thought the Community Trust was responsible for providing community physiotherapy for patients at the Reablement Unit. The Community Trust told us it was not responsible for physiotherapy at the Reablement Unit, and did not know which organisation was. This lack of a clear route of referral for physiotherapy services is not in keeping with the guidance in NG74. However, I cannot say whether this caused Mrs X an injustice. Even if there had been a clear referral route for community physiotherapy that could be delivered at the Reablement Unit, we do not know whether the referral would have been accepted. Even if the referral had been accepted, we do not know whether physiotherapy could have started and had any effect before Mrs X needed a further hospital admission less than two weeks later.

Summary of faults and injustice

62. The three organisations did not have a local area discharge policy or protocols.
63. The Hospital Trust and Council have no records of sharing Mrs X's hospital discharge plan or information about post-hospital care with her.
64. The Hospital Trust gave Mrs X and Mrs Y inaccurate information about the services and support available at the Reablement Unit.
65. The Reablement Unit, for which the Council is responsible, did not complete all of Mrs X's records as it should have. It also took too long to alert the district nurses that Mrs X was missing out on blood thinning injections. On two occasions, staff at the Reablement Unit refused to help Mrs X go to the toilet and on one of those occasions suggested she soil her pad instead. The Reablement Unit did not carry out reablement reviews with Mrs X in her first few weeks there.
66. At the time these events happened, there was no clear route of referral for community physiotherapy services for the Council's and Community Trust's intermediate care teams.
67. Mrs X suffered avoidable distress and loss of dignity because on two occasions staff refused to help her use the toilet. The other faults caused Mrs X and Mrs Y avoidable frustration, uncertainty and worry.

Back to top

Action

68. The events happened around three years ago. Some of the relevant Government guidance and local policies have changed since then. The Reablement Unit has since closed. I have therefore not made service improvement recommendations in this case.
69. We do not usually recommend remedies in recognition of injustice such as distress, where the person who suffered the injustice has since died. This is because such remedies are for injustice to that person and cannot have that effect once the person has died. We have therefore not recommended remedies for Mrs X’s injustice.
70. To remedy the injustice to Mrs Y, the Council and Hospital Trust will send her written apologies for the faults and injustice identified in this decision. They will do so within one month of our final decision. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisations should consider this guidance in making the apologies I have recommended.
71. The Council and Hospital Trust should provide us with evidence they have complied with the above actions.

Back to top

Decision

72. I have found fault in some parts of the complaint relating to communication and aspects of reablement and personal care, causing injustice to the complainants. I have not upheld other parts of the complaint relating to hospital discharge, physiotherapy referrals and residential care. The organisations have agreed actions to remedy injustice. I have therefore completed my investigation.

Back to top

Investigator's decision on behalf of the Ombudsman