Summary: Mrs X complained about the Council’s actions and decisions around her mother’s discharge from hospital and admission to a residential care home. We found fault through poor communication and record keeping about the discharge to assess process and charging arrangements for a short-term bed which caused distress and uncertainty. The Council has agreed to apologise and make a symbolic payment.

The complaint

1. Mrs X complains about the Council’s actions and decisions around her mother’s discharge from hospital and admission to a residential care home in March 2025. In particular, Mrs X says the Council failed to provide accurate and timely information to her mother and family about the type of short-term residential placement being proposed and the charges for this. Mrs X also says the Council has not provided her with documents promised following the outcome of her complaint.
2. Mrs X says this has resulted in unexpected care costs and caused her mother and the family distress during an already difficult period.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may recommend a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. 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)
5. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
6. We may investigate complaints made on behalf of someone else if they have given their consent. (Local Government Act 1974, section 26A(1), as amended)
7. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(1), as amended)

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How I considered this complaint

8. I considered evidence provided by Mrs X and the Council as well as relevant law, policy and guidance.
9. Mrs X and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

Background

Hospital discharge

10. Schedule 3 to the Care Act 2014 and the Care and Support (Discharge of Hospital Patients) Regulations 2014 set out arrangements for the discharge of hospital patients with care and support needs. The NHS can claim money back from councils that have caused delays transferring patients. The NHS must issue a notice to the council where it considers an NHS hospital patient receiving acute care may need care and support as part of a transfer from an acute setting regardless of whether it intends to claim repayment.
11. The NHS should try to give the council as much notice as possible of a patient’s impending discharge. This is so the council has as much notice as possible of its duty to start a needs assessment. The Care and Support Statutory Guidance says local agreements should be in place between NHS bodies, councils and other relevant partners to set out each organisation’s responsibilities to achieve timely and safe hospital discharge.
12. On receiving an assessment notice, the council must assess the person’s care and support needs and (where applicable) those of a carer to determine whether it considers the patient and carer have needs. The council must then decide whether any of these identified needs meet the eligibility criteria. If so, it should confirm how it proposes to meet any of those needs. The council must inform the NHS of the outcome of its assessment and decisions.
13. To avoid any risk of having to pay back money, the council must start a needs assessment and put in place any care arrangements for meeting eligible needs before the ‘relevant day’. The relevant day is either the date when the NHS proposes to discharge the patient or the minimum period (two days after the council has received the assessment notice), whichever is the later.
14. The NHS body should tell patients and carers the discharge date at the same time as, or before the council does. Hospital staff may give the council early warning of when discharge is likely, to help their planning.

Discharge to Assess

15. Discharge to Assess (D2A) is a model whereby people with new or additional health and/or social care needs on discharge from hospital receive post-discharge recovery support, and where assessments of longer-term or ongoing needs (if required) are fully completed only once a person has reached a point of recovery and stability. As discharge to assess is underpinned by simple principles rather than rigid criteria, there is no fixed delivery model.

Intermediate Care and Reablement

16. Intermediate care and reablement support services are for people usually after they have left hospital or when they are at risk of having to go into hospital. They are time-limited and aim to help a person to preserve or regain the ability to live independently. The National Audit of Intermediate Care lists four types of intermediate care:

• crisis response – services providing short-term care (up to 48 hours);
• home-based intermediate care – services provided to people in their own homes by a team with different specialties but mainly health professionals such as nurses and therapists;
• bed-based intermediate care – services delivered away from home, for example in a community hospital; and
• reablement – services to help people live independently which are provided in the person’s own home by a team of mainly care and support professionals.

17. Regulations require intermediate care and reablement to be provided without charge for up to six weeks. This is for all adults, whether or not they have eligible needs for ongoing care and support. Councils may charge where services are provided beyond the first six weeks but should consider continuing providing them without charge because of the preventive benefits. (Reg 4, Care and Support (Preventing Needs for Care and Support) Regulations 2014)

Mental Capacity Act

18. The Mental Capacity Act 2005 is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves. The Act (and the Code of Practice 2007) describes the steps a person should take when dealing with someone who may lack capacity to make decisions for themselves. It describes when to assess a person’s capacity to make a decision, how to do this, and how to make a decision on behalf of somebody who cannot do so.

Mental capacity assessment

19. A person aged 16 or over must be presumed to have capacity to make a decision unless it is established they lack capacity. A person should not be treated as unable to make a decision:

• because they make an unwise decision;
• based simply on: their age; their appearance; assumptions about their condition, or any aspect of their behaviour; or
• before all practicable steps to help the person to do so have been taken without success.

20. The council must assess someone’s ability to make a decision when that person’s capacity is in doubt. How it assesses capacity may vary depending on the complexity of the decision.
21. An assessment of someone’s capacity is specific to the decision to be made at a particular time. When assessing somebody’s capacity, the assessor needs to find out the following:

• Does the person have a general understanding of what decision they need to make and why they need to make it?
• Does the person have a general understanding of the likely effects of making, or not making, this decision?
• Is the person able to understand, retain, use, and weigh up the information relevant to this decision?
• Can the person communicate their decision?

22. The person assessing an individual’s capacity will usually be the person directly concerned with the individual when the decision needs to be made. More complex decisions are likely to need more formal assessments.
23. If there is a conflict about whether a person has capacity to make a decision, and all efforts to resolve this have failed, the Court of Protection might need to decide if a person has capacity to make the decision.

Charging

24. The Care Act 2014 (section 14 and 17) provides a legal framework for charging for care and support. It enables a council to decide whether to charge a person when it is arranging to meet their care and support needs, or a carer’s support needs. The charging rules are set out in the Care and Support (Charging and Assessment of Resources) Regulations 2014 and councils should also have regard to the Care and Support Statutory Guidance.

Key events

25. The following is a summary of key events. It does not include everything that happened.
26. Mrs X’s mother, Mrs Z, had been living at home independently before being admitted to hospital following a stroke.
27. The Council met with Mrs Z, her sister and physiotherapist on the hospital ward in mid-March 2025. The following information was recorded:

• Mrs Z was aware she was not safe to mobilise on the stairs at home due to vision impairment in her right eye and she felt ‘daunted’ by the prospect of returning home
• Mrs Z’s sister stated the property was not suitable for Mrs Z to return home due to a full refurbishment including being rewired, redecorated and not having any flooring
• the possibility of a short-term bed (STB) was discussed
• Mrs Z advised a care home made her feel old
• physiotherapist advised that currently stroke rehabilitation would not be beneficial due to Mrs Z making slow gains and although functionally quite capable was limited in potential due to her visual impairment
• advice was provided about a STB and that this would only be temporary
• Mrs Z’s sister advised the family could support Mrs Z in sourcing a flat which would be more suitable
• Mrs Z agreed to STB and consented for the Council to speak with her children
• manager approval for a STB was sought on the basis Mrs Z’s home was not suitable to return to due to large amounts of work being completed and she was limited in her mobility due to visual impairments

28. The Council spoke with Mrs Z’s son on 20 March 2025 to discuss several offers of a STB placement that had been received with their weekly costings. It is recorded that Mrs Z’s son accepted a particular placement (the care home) and it was confirmed this would be on a short-term basis.
29. The Council subsequently confirmed with the care home that the placement was for a STB until a social worker was allocated to determine long term plans and discharge could be arranged from 26 March 2025.
30. Mrs Z was discharged to the care home on 27 March 2025.
31. The Council telephoned Mrs Z’s son on 17 April 2025 to explain the purpose of an assessment visit to Mrs Z which had been arranged for 22 April 2025. Mrs Z’s son advised that he or another family member would attend.
32. The Council completed an assessment of Mrs Z’s care and support needs at the care home on 22 April 2025. Mrs X also attended. The following information was recorded:

• Mrs Z advised she was able to manage all her care and support needs independently and wanted to return home as soon as her home was in a suitable condition
• both Mrs Z and Mrs X advised the home was not in a suitable condition until renovations were completed following being vandalised
• Mrs X stated she did not want Mrs Z using the stairs as she felt she would fall
• setting up downstairs living was discussed but Mrs X stated the property was too small
• an occupational therapist could visit to check the property and there was a discussion about alternative living arrangements on a temporary basis with Mrs X to consider this
• feedback from the care home noted Mrs Z was independent with all care and support needs but was not attempting to use the stairs
• no concerns around Mrs Z’s capacity although it was noted she was aware she had issues with her memory and had some days better than others
• the recommendation was for Mrs Z to return home as she was fully independent with managing her care and support needs
• financial implications were discussed and advice given that the STB became chargeable from the point of the assessment
• Mrs X said they had been told by the neurology team at the hospital that Mrs Z would be funded for up to 6 weeks and there had been no discussion about the financial implications before Mrs Z was discharged
• savings threshold was discussed but no information was provided about Mrs Z’s savings

33. Mrs X says she made clear her view at the above meeting that the works at her mother’s property were not a barrier to discharge and alternative options could be explored. Mrs X also says she does not recognise the term ‘vandalised’ which was inaccurate or that she advised the property was too small but rather had highlighted there was not a downstairs bathroom. Mrs X accepts that financial implications were discussed at this meeting but she understood further clarification would be provided. Mrs X does not consider her mother could manage all her care and support needs at that time or that she had full capacity.
34. The Council completed a follow up visit later the same day for Mrs Z to sign receipt of the financial implications document that had been discussed during the visit earlier that day.
35. Following the above visit the Council telephoned Mrs X. It was recorded that Mrs X advised she preferred for Mrs Z to remain at the care home until they had sourced rented accommodation. Mrs Z had advised she was happy to remain there if needed and wanted Mrs X to support her with organising accommodation. It is recorded that information was provided about the rates at the care home and that the financial implications were discussed and understood. Mrs X was told there was no record about the 6 weeks funding she said she had been advised about at the hospital. Mrs X says it was not made clear this was the concluded position and she still considered the matter of funding ongoing.
36. The Council emailed Mrs X a copy of the financial implications discussion document (discussed on 22 April 2025) on 24 April 2025.
37. The Council emailed the care home on 27 May 2025 asking for confirmation that Mrs Z would be privately funding the placement following the assessment on 22 April. The Council emailed the care home again on 4 June 2025. It noted that both Mrs Z and Mrs X had confirmed this was the case but the Council needed confirmation from the care home directly. The care home responded the same day to confirm Mrs Z was now self-funding. Mrs X disputes she confirmed to anyone that her mother would be self-funding.
38. No private contract with the care home was signed by Mrs Z or Mrs X. There remains an outstanding invoice for Mrs Z’s stay of £18,470.72.
39. Mrs X complained to the Council in July 2025. Mrs X said they had been told by the neurology team at the hospital that Mrs Z would go to a neuro-rehabilitation placement for a minimum of 6 weeks and a financial assessment would follow depending on progress. There had been no allocated social worker and no contact about discharge planning and they were not told the care at the care home would be chargeable until the 22 April 2025 assessment meeting. Mrs X also said there had been no documents provided and her mother had been asked to sign a document without a mental capacity assessment.
40. The Council responded to Mrs X’s complaint in August 2025. This letter set out the following:

• an acknowledgement there had been poor discharge coordination and communication and upheld this element of the complaint
• provided details of a ward visit in March 2025 where it was agreed Mrs Z would be referred for a STB as her home was unsuitable due to ongoing renovations, therapeutic input was not recommended as Mrs Z would make slow progress and not benefit significantly and no mental capacity concerns were noted
• apologised that a copy of the 22 April 2025 assessment had not been provided to Mrs Z or Mrs X and a copy would be sent out
• the above assessment had not noted any concerns about Mrs Z’s capacity to make decisions about her care and accommodation and so a mental capacity assessment was not completed
• financial implications were discussed at the above assessment and the social worker visited later the same day to ask Mrs Z to sign the financial documents and apologised if the process had not been clearly communicated to them both
• the above assessment had concluded Mrs Z was independent and not eligible under the Care Act and was not eligible for any assistance with the funding of her placement at the care home following the STB period which ended on 23 April 2025
• it had been agreed Mrs Z would stay at the care home under a private contract due to her savings exceeding the threshold of £23,250 until her home was ready

41. The Council confirmed it would use Mrs X’s feedback to improve the journey for individuals leaving hospital and would raise the learning identified with relevant staff and its partners in the NHS. This would focus on:

• the importance of effective communication with all parties involved in a person’s care; and
• the need to ensure factually accurate information is provided at all stages of the process.

42. There is a note dated 27 July 2025 about a bannister being needed at Mrs Z’s property which says she had been discharged home with the support of her sister and son.
43. In responding to the Ombudsman, the Council noted that the social worker provided both Mrs Z and Mrs X paper copies of the financial implications booklets for both home care and residential care. The Council says it was considered Mrs Z had capacity and understood the question presented, was able to retain and recall previous conversation with the social worker. It was noted the Lasting Power of Attorney (LPA) was in place for Mrs Z for when she did not have the capacity to make financial decisions. However, at this point, it was deemed she did and was able to openly engage in conversations about her finances. The document that was signed by Mrs Z was to confirm the conversation had taken place. The Council said it had taken learning from this as the financial implications document should have been signed by the LPA.
44. The Council also confirmed that on 22 April, Mrs Z was unable to be specific about her savings but further discussions confirmed she was over the threshold. The Council has apologised for not recording the details of the further discussions to reach that conclusion and will ensure an adequate record is kept in future.
45. The Council also acknowledged that every assessment should result in an outcome letter and this did not happen in this case. This would have confirmed to Mrs Z and Mrs X the outcome of the assessment and that this would be self-funded. The professional recommendation was for Mrs Z to return home with a package of care to assist as she did not require or meet the criteria for residential care or funding for residential care by the Local Authority. If Mrs Z was to be supported in line with this recommendation, the Council would have completed a financial assessment to consider her contribution to her ongoing care and support needs. However, as the family opted for Mrs Z to remain in the care home, there was no option to further complete a plan to support her in the community. Support remained ongoing by the Care Home.
46. However, the Council has also acknowledged that a full assessment and support plan should have been completed to indicate how Mrs Z’s needs would have been met in the community. This did not happen.
47. The Council apologised as Mrs X had not been received a copy of her mother’s social care assessment as promised in its complaint response of 19 August 2025. The Council confirmed a copy had been sent by hybrid mail on 21 May 2026 and provided a record of this. I do not propose further investigation on this point.

My analysis

48. The Council has provided contemporaneous evidence that Mrs Z’s stay at the care home was discussed with her family and that this would be on a short term basis before her discharge from hospital. There is also contemporaneous evidence that the weekly cost of the placement was discussed with a family member before Mrs Z’s discharge.
49. However, there is no evidence that written confirmation of the type of placement or its cost was provided to either Mrs Z or Mrs X before her discharge. There is also no evidence that clear information was provided about the discharge to assess process to Mrs Z or her family ie that there would be no charge until an assessment was completed but the care would then become chargeable before the 22 April 2025 assessment. The Council has already acknowledged poor discharge planning and record keeping as set out above.
50. This is fault which will have caused avoidable distress and uncertainty to Mrs Z and her family which requires a remedy.
51. We do not normally consider it to be appropriate to recommend a council ‘waive’ or reimburse payments for care that has been received. This is because, the person received the care and should be assumed to have expected to make some contribution, unless there is evidence of misleading advice. We would instead usually recommend a symbolic payment.
52. I note the Council confirmed the placement was a STB at the assessment on 22 April 2025 and that it would now become chargeable. From that point up to Mrs Z being discharged both she and her family were aware of ongoing costs. It may have been the case that Mrs Z and her family would have had more time to make alternative arrangements if clear and timely information had been provided earlier, but I cannot say, even on a balance of probabilities, that this would have resulted in a different outcome in these circumstances.
53. The Council has already issued a reminder to relevant staff about the need to provide clear communication to patients and their families including about STB and any financial implications. Therefore, I have not made any additional service improvement recommendations.

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Action

54. The Council will take the following action within one month of the date of my final decision:
1. apologise to Mrs X and Mrs Z for the failure to provide clear and timely information about the discharge to assess process and charging arrangements for a short-term bed; and
2. pay Mrs X and Mrs Z £300 each to recognise their avoidable distress and uncertainty.
55. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.
56. The Council should provide us with evidence it has complied with the above actions.

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Decision

57. I find fault causing injustice. The Council has agreed actions to remedy injustice.

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Investigator's decision on behalf of the Ombudsman