Summary: Mrs X complains the Council failed to provide appropriate care and support when her sister (Miss Y) was discharged from hospital. We found Miss Y’s needs were documented appropriately but the Council failed to ensure the agency providing the care had sufficient time to complete the required tasks. We found this was fault. We recommended an apology and a review of learning to avoid the same situation re-occurring.

The complaint

1. Mrs X complains the Council failed to provide appropriate care and support when her sister was discharged from hospital. She complains the planning and coordination of care was inadequate and the care plan did not adequately reflect all of her sister’s needs. She complains that her sister was given incorrect assurances about the length of care calls that had been arranged, the Council did not consider whether an Enhanced Assessment Bed was more appropriate than care at home. She also complained that the family were not consulted about the care arrangements.
2. Mrs X says her sister had to be re-admitted to hospital within 48 hours of her discharge from hospital and the situation caused her sister significant stress and concern. The period following the first discharge and the process of re-admitting her sister was arduous for her because she was very poorly and vulnerable.

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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 suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. 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(i), as amended)
5. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

6. I spoke to Mrs X and considered the information she provided. I asked the Council for information and considered its response to the complaint.
7. Mrs X and the Council and the organisation had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

What Happened

8. Mrs X complains about care put in place for her sister (referred to as Miss Y in this statement) following a discharge from hospital.
9. Miss Y was in hospital for around 5 weeks in early 2023. On 23 March the hospital made a referral to social services stating Miss Y was medically fit for discharge.
10. A social worker (SW) visited Miss Y while she was in hospital and discussed discharge arrangements. Care Records noted that prior to being in hospital, Miss Y had two care calls per day, Lunch and Tea. Miss Y requested an additional care call in the morning to help her. The record stated the SW discussed what care was needed with Miss Y. The detail itself was not recorded in the notes. However, a separate Description of Needs document recorded the tasks carers needed to carry out.
11. The SW stated that Miss Y’s original care package would be restarted when she was discharged but the additional morning call would be with a different care agency provided through the Early Intervention Team (EICT). I have referred to them as Care Provider B. Later in the afternoon, the SW noted a telephone call from Miss Y. Miss Y felt she needed longer for the additional morning care call. The notes state the SW assured her, due to her current care needs and shortness of breath, that the care provided by Care Provider B would be task orientated. This meant that the carers would stay with her and support her until all tasks were completed.
12. On 31 March, the SW adjusted Miss Y’s package of care to include an additional evening care call as well as the additional morning one. On 31 March the SW noted that she assured Miss Y that Care Provider B would support her with all tasks in the care plan and care would be for longer than 30 minutes.
13. Miss Y’s discharge was delayed for a few days as she was no longer medically fit for discharge. Miss Y was discharged home on 5 April 2023. The Description of Needs document set out Miss Y’s needs at the point of discharge.
14. On 6 April 2023, Miss Y was re-admitted to hospital. The case notes state that Miss Y’s regular care agency did an additional 11pm check-in call with Miss Y. They were then called out at 1am and stayed with Miss Y for four hours because her breathing deteriorated.
15. On 6 April, Care Provider B emailed the EICT. Amongst other things Care Provider B stated:
• they could only provide task-orientated care visits up to 30 minutes. They were told by Miss Y’s other carer that the necessary care would take more than two hours;
• the tasks in the care plan were correct but there needed to be significant pauses in between tasks because Miss Y was breathless and needed to rest;
• there were missing tasks from the care plan. Miss Y’s other carers stated liquids must be injected into Miss Y’s nebuliser as part of the care. However, this was not in the care plan and Care Provider B could not do this in any event; and
• There was a list of other care tasks at Miss Y’s property which were not in the care plan.
16. Care Provider B stated they were very concerned for Miss Y and her other carer had explained Miss Y was upset and stressed not to have the longer calls she expected.
17. Mrs X told us that EICT had called for an ambulance and arranged for Miss Y to be re‑admitted to hospital. EICT stated this had been a failed discharge.
18. Mrs X stated that re-admission was arduous for Miss Y because she had to wait 12 hours in Accident and Emergency prior to being admitted. She felt this could have been avoided if appropriate care and support had been arranged for Miss Y at the outset. Miss Y was then referred to an Enhanced Assessment Bed (EAB) before being discharged again. Mrs X felt this should have been an option previously.
19. Mrs X complained that her sister was not provided with correct support when she was originally discharged. She stated this placed her in an unsafe position. She stated the 30-minute care calls were not sufficient to meet her needs and they turned out to be for 15 or 20 minutes in practice. Mrs X complained that the family should have been consulted about Miss Y’s needs.
20. Mrs X explained her sister was now back in hospital and her discharge had been regarded a failed discharge. Mrs X wanted the staff involved to explain the decisions they had made and learn from the situation.
21. In response to Mrs X’s complaint, the Council stated the social worker concerned had discussed and agreed Miss Y’s care plan with her. She had initially agreed 3 care calls and increased this to four when Miss Y was anxious about being discharged. It stated when Miss Y was re-admitted this had been because of breathing difficulties. It considered the arrangements for discharge were appropriate.
22. The Council stated the care records stated the SW had explained that care calls would be task-orientated and she would receive the care she required based on the task delivered rather than a set amount of time. The Council did not uphold Mrs X’s complaint.

Was there fault by the Council

23. I recognise that Mrs X considered the Council should have consulted the family about her care needs. However, as Miss Y had capacity and was able to discuss her needs with the SW, it was not fault that the Council did not speak to the family separately.
24. The Council’s records indicate that the SW in Miss Y’s case spoke to her to establish her needs and agreed with her what support she required. The case notes do not document what specific tasks were discussed and agreed upon. However, a separate Description of Needs document lists various tasks that carers needed to help Miss Y with.
25. There is conflicting information about whether the Description of Needs document captured all of Miss Y’s needs. On one hand, Care Provider B were told by Miss Y’s existing carer that Miss Y’s needs were set out correctly in the document. However, she also advised Care Provider B of other tasks that were not listed. These included tasks relating to a Nebuliser used by Miss Y. The Council stated Miss Y was self-caring and able to manage her Nebuliser machine herself, with the support of family. However, Miss Y’s carer told Care Provider B that there were tasks need to help Miss Y with this. It is unclear whether this was an action Miss Y needed help to carry out upon discharge in April 2023. And if so, how this breakdown in communication occurred.
26. When considering complaints we make findings based on the balance of probabilities. Sometimes the evidence we have is contradictory. This means that we have to consider all the available relevant evidence and decide the complaint weighing up what was most likely to have occurred.
27. On balance, I do not consider that there was a failure to accurately record the care tasks that Miss Y required. I say this because there is evidence that the correct process was followed; the SW spoke with Miss Y and hospital ward staff to understand and agree her needs. The care plan was seemingly agreed by Miss Y. I note Miss Y’s other carer took Care Provider B through a more detailed list of tasks at Miss Y’s home and this included a task related to Miss Y’s Nebuliser. However, as whole, the care plan was also considered an accurate reflection of Miss Y’s needs by Miss Y’s other carer.
28. However, I have found that insufficient attention was paid to the time that the care calls may take. This was fault. In Miss Y’s case this seems a key issue. I say this because:
• Miss Y had specifically expressed concern about the time that the carers would have available to attend to her needs. Mrs X provided the Council with copy texts sent by Miss Y to a SW before discharge. These set out her concern that the time allowed would not be sufficient. In them she explained that every action made her breathless and she needed time to recover.
• The Council’s case notes clearly record that the SW told Miss Y that the carers would stay and complete all tasks and the care calls would be longer than 30 minutes. Whether or not all the required tasks were documented in the care plan, comments made by Care Provider B indicate that the Council was wrong to give Miss Y an assurance that the additional care calls could be longer than 30 minutes. This was not correct. Care Provider B stated in correspondence with EICT that while their calls were task‑orientated, they were up to 30 minutes only, not as long as Miss Y required.
29. The evidence indicates that the reason for Miss Y’s re‑admittance to hospital was because she had become breathless and her carers were concerned, rather than being directly attributed to the difficulties in meeting her needs in the time available. However, I found the issues with Miss Y’s care planning and failed discharge are likely to have caused distress to her family.
30. I note Mrs X complained that an Enhanced Assessment Bed (EAB) was not considered for her sister on discharge on 5 April. The assessment of Miss Y’s health and needs indicated that she was medically fit for discharge and could return home (rather than remain in hospital or go to a EAB) subject to suitable care calls and assistance. It was noted she could manage between care calls. While I appreciate Mrs X may disagree, this was a judgement for social workers to take in conjunction with Miss Y and I do not have grounds to question the decision not to propose an EAB originally.

Response to the Complaint

31. Care Records the Council sent to us noted this was a failed discharge. However, the Council’s response to the complaint does not respond to or properly consider the points made by Mrs X and the evidence she provided. It relies heavily on the concept of the arranged care being ‘task-orientated’. While Care Provider B does take a task-orientated approach, an important distinction is that the care calls are still subject to a maximum amount of time. I found the Council did not properly respond to Mrs X’s complaint because it did not properly consider this issue and what learning there may be to prevent an issue like this re-occurring.

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Agreed action

32. Within four weeks of my final decision:
33. The Council should send a written apology to Mrs X for the faults we have identified and the distress that the matter caused. The apology should adhere to our guidance on making effective apologies. This can be found on our website, within our Guidance on Remedy here.
34. Within six weeks of final decision:
35. A manager with responsibility for social workers dealing with hospital discharge should meet with a management counterpart in the Early Intervention and Care Team (EICT). They should discuss Care Provider B’s feedback regarding Miss Y’s discharge and care planning and document lessons learned. They should produce a briefing note for staff dealing with hospital discharge to set these out. They should ensure that the briefing note covers care providers’ capabilities and how to establish that a given care provider can meet a service user’s needs and has sufficient time at care calls to do so.
36. The Council should provide us with evidence it has complied with the above actions.

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Final decision

37. There was fault by the Council. I have completed my investigation.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman