Summary: The Council was at fault. It delayed carrying out Mrs Y’s assessments when she was discharged from hospital, communicated poorly with Mrs Y’s family about her care placement and care charges and ordered incorrect equipment which delayed Mrs Y returning home. The Council will apologise, refund Mrs Y’s care contributions and pay Mrs Y a symbolic payment to acknowledge the distress and frustration caused to her because of the need for her emergency care home stay. The Council will also pay Mrs Y’s daughter, Mrs X, a symbolic payment for the frustration, confusion and distress caused. The Council has already put service improvements in place.

The complaint

1. Mrs X complained on behalf of her mother, Mrs Y. Mrs X complained about the Council’s handling of Mrs Y’s reablement care in a care home. Mrs X said the Council communicated poorly, provided unclear and incorrect information on the discharge to assess process and initially failed to carry out reviews and assessments. Mrs X said Mrs Y’s health was in danger on discharge from the care home to her home and the incorrect equipment was provided causing Mrs Y to have crisis care which delayed Mrs Y settling back into her home. Mrs X said it caused the family distress, uncertainty, confusion, frustration and a financial burden for a care home bill she said the family did not owe and it caused her to take time off work to help her mother.

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The Ombudsman’s role and powers

2. 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)
3. 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

4. I considered the information the Council and Mrs X provided and spoke to her about the complaint on the telephone. I also considered relevant law and guidance, as set out below and our guidance on remedies, published on our website.
5. Mrs X and the Council had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Relevant law and guidance

Discharge to Assess

6. Discharge to Assess (D2A) placements are short-term care home placements which are free of charge, usually for around four to six weeks. They allow councils to carry out social care assessments to decide on longer-term care arrangements for an adult with eligible social care and support needs.

Intermediate Care and Reablement

7. 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.
8. 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)

Care Plan and Assessment

9. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.
10. The Care Act 2014 does not specify timeframes for when an assessment should be undertaken but Councils must carry out assessments over a suitable and reasonable timescale considering the urgency of needs and any variation in those needs. We would expect the assessment to be completed within a timescale proportionate to the complexity of the issues, and normally within around eight weeks from referral. Councils should tell people when their assessment will take place and keep them informed throughout the assessment.

What happened

11. Mrs Y lived at home with her husband, Mr Y. Mrs Y had mobility issues following a stroke many years ago.

Background

12. Mrs Y had a domiciliary (at home) care package with two carers to help with her personal care needs, three times a day including transfers. Mr Y also helped with Mrs Y’s care.
13. In late October 2024 Mrs Y had a fall, broke her ankle and was admitted to hospital. In early November 2024 the hospital carried out an assessment of Mrs Y and recommended Discharge to Assess (D2A).
14. In mid-November 2024 Mrs Y was discharged from hospital to a step-down hospital discharge facility. Council records showed in late November 2024 a social worker carried out an assessment at the hospital discharge facility. Mrs Y’s daughter, Mrs X, and Mrs Y were present at the assessment and discussed Mrs Y’s discharge and considered two options. Option 1: additional care at Mrs Y’s home or Option 2: Mrs Y discharged to a Short-Term Care bed to allow Mrs Y to have a further period of assessment. Council records showed Option 2 was agreed. Mrs X said the social worker gave her a booklet.
15. The Council records noted Mrs Y did not pay for her care at the hospital discharge facility and that was paid for by the NHS.

December 2024 onwards

16. In response to my enquiries the Council said in early December 2024 financial implications information was emailed to Mrs X following a telephone call, but it did not provide me with a copy of this information. In early December 2024 the Council case notes said ‘Mrs Y was discharged on 9 December 2024 into a Short-Term Care bed residential (at Care Home 1). Requires review’. This was funded by the Council for four weeks. The Council also said in response to my enquiries no written information was provided to Mrs Y or her family about a Short-Term Care Bed but this had now been addressed and officers now made sure information was provided on discharge from hospital.
17. Mrs X, said when Mrs Y was discharged to Care Home 1 the Council did not initially carry out any assessments for Mrs Y or contact Mrs X. In response to my enquiries the Council said it should have given Mrs X its Short-Term Support Services direct number when Mrs Y was discharged from hospital, but it did not do so. It said that was now standard practice.
18. In late December 2024 and early January 2025 Mrs X and her sister, Mrs Z, rang the Council several times about Mrs Y’s assessments and next steps and requested a call back each time. Mrs X was concerned Mrs Y was almost at the end of her reablement care at Care Home 1 and would have to pay for her care. Mrs X said there was confusion about which Council team was dealing with Mrs Y. Council case notes said the Council confirmed with Mrs X on the telephone that Mrs Y’s placement at Care Home 1 would be chargeable after 6 January 2025, explained income and expenses and there may be a need for a third party top up. The Council explained the need for an Occupational Therapist (OT) equipment assessment and said Mrs Y may not return home on 6 January 2025.
19. On 6 January 2025 Mrs Y was allocated a Council student social worker, Social Worker 1 and a Social Care OT, OT 1. Mrs X was told the allocation, and assessment delay was due to staff sickness and holidays. In response to my enquiries the Council said the delay was due to backlog and demands of work.
20. In early January 2025 Council case notes showed Social Worker 1 and another Council officer spoke to Mrs Z and Mrs X on the telephone several times. Mrs Z and Mrs X both explained they were unhappy about Mrs Y’s assessment delays, poor communication from the Council about Mrs Y’s placement and care fees which caused the family distress, frustration and confusion. Mrs X said it delayed Mrs Y’s rehabilitation, treatment and Mrs Y’s move back home. A Council officer provided Mrs X with information around short-term support services.
21. In early January 2025 Council case notes showed the Council explained to Mrs X that Mrs Y still needed a care review and financial assessment before she could go home and made an OT referral. OT 1 visited Mrs Y. They discussed equipment required for Mrs Y including a hospital bed, chair and hoist but did not complete the assessment and said they would do that the following day. On the same day, Mrs Y suffered a small stroke and went back to hospital. It was agreed Mrs Y’s OT assessment would be delayed until Mrs Y felt better.
22. In mid-January 2025 Mrs Y was discharged from hospital to Care Home 1. Social Worker 1 rang Mrs X and arranged a meeting for later in January 2025.
23. In late January 2025 Social Worker 1 carried out Mrs Y’s face to face review at Care Home 1. Council records of the review noted Mrs Y wanted to return home and regain her independence with the help of her previous care provider and private OT. The review noted Mrs Y needed ongoing rehabilitation and if Mrs Y returned home she would need a standing aid and hoist and carers four times a day. The review noted Mrs Y would need help with her personal hygiene, continence, meal preparation, medication management, support with mobility and accessing the local community.
24. Mrs X raised concerns at the review about poor Council communication on Mrs Y’s current funding arrangements. Mrs X said she was not informed about how much funding was available for Mrs Y’s stay at Care Home 1 and was unsure who was funding Mrs Y’s placement. Social Worker 1 said Mrs Y’s health and well-being was being prioritised and she would not be put in any financial strain and there would be a financial assessment.
25. A few days later Social Worker 1 emailed Mrs X asking her to confirm Mrs Y’s package of care. Mrs X said she was unsure what Mrs Y needed and they should ask Care Home 1 instead. Mrs X was concerned about procedures around Mrs Y’s care package.
26. In late January 2025 OT 1 carried out Mrs Y’s OT assessment with Mrs Y’s private OT and a few days later a stand-up hoist was delivered to Mrs Y’s home but was not assessed by an OT.
27. In early February 2025 Social Worker 1 called Mrs X and said Mrs Y would be discharged from Care Home 1 in four days. Mrs X said she discussed the Care Home 1 fees and Social Worker 1 said the Council funded Care Home 1 and the family would not receive a care home fee bill and the Council would source the taxi from Care Home 1 to Mrs Y’s home. Mrs X said 15 minutes later Social Worker 1 said Mrs X needed to source the taxi for Mrs Y. The Council’s case notes did not include information about the above care home fee discussion and noted Mrs X would arrange the taxi.
28. In mid-February 2025 Mrs Y left Care Home 1 and moved back home. Mrs Y was unable to use the standing hoist because it could not fit under the bed. OT 1 ordered a new bed which was due to arrive later that day and a recliner riser chair which was due to be delivered that day or the following day. OT 1 left the property with Mrs Y still in her wheelchair. In the early evening Mrs X rang the Council out of hours telephone number because the bed and chair had not arrived and Mrs Y remained in her wheelchair. The Council arranged for Mrs Y to have an emergency stay at Care Home 1. Mrs X said no transport was provided or available and they walked Mrs Y for approximately half a mile in her wheelchair back to Care Home 1 in cold wet conditions.
29. Over the next two days Mrs Y’s bed and chair were delivered and Mrs Y moved back home. Mrs X said the full hoist was not initially assessed by an OT and could not be used until several days later. Mrs X also had concerns about Mrs Y’s care package hours at home which the Council quickly increased. The Council started to undertake Mrs Y’s financial assessment.
30. In late February 2025 Mrs X complained to the Council and provided a detailed time-line of events between late December 2024 and mid-February 2025. She was concerned about poor communication from the Council, misinformation around Mrs Y’s care funding and poor discharge from Care Home 1 to her home. She said Mrs Y needed emergency care due to the incorrect equipment being sourced. She said the stress impacted on Mrs Y and the wider family’s mental health.
31. The Council issued Mrs X with its final complaint response in mid-April 2025 and apologised for any perceived lack of clarity or misinformation from Social Worker 1. It said Social Worker 1 was a student and any issues were due to knowledge gaps and they received weekly supervision support. It said staff were aware of discharge to assess timeframes and it was engrained within its induction and training programme. It apologised for the frustration caused to Mrs X and Mrs Y. It said OT assessments were arranged as soon as possible and although the transfer equipment was not suitable the OT requested a riser recliner chair and hospital bed as an emergency delivery and said delivery times could not be pre-arranged with specific times. It said it arranged for Mrs Y to go back to Care Home 1 and new equipment was ordered and delivered. It said it regretted the mistakes. It said it had learnt from this case and the learning would be shared and OTs had been advised to take additional measurements. It gave Mrs X our contact details.
32. Mrs X remained unhappy and complained to us.

Enquiries

33. In response to my enquiries the Council said Mrs Y did not receive an invoice for her placement at Care Home 1 because she paid by direct debit and it had sent an advanced notification letter in late March 2025. The Council debited £747.02 on 9 April 2025 for Mrs Y’s Care Home 1 fees based on a £137.61 weekly contribution between 6 January 2025 and 13 February 2025 for 38 nights and there were no outstanding fees. There was no explanation of how the fees were calculated.
34. The Council provided evidence of service improvements it has already put in place for discharge to assess timeframes and new OT procedures, including ensuring staff measured furniture and OT equipment to ensure it was suitable and introducing an environmental assessment template.

My findings

Mrs Y’s care fees and initial assessments

35. The NHS paid for Mrs Y’s care in hospital and the hospital discharge facility. The Council and family agreed to Mrs Y’s discharge to Care Home 1 to further recover and so Care Act and OT assessments could be carried out to ensure she had the appropriate support in place to return home. The Council paid for Mrs Y’s placement at Care Home 1 between early December 2024 and 5 January 2025 which was appropriate for a reablement/intermediate care placement.
36. The Council said it provided Mrs X with financial information before Mrs Y moved to Care Home 1 but did not provide evidence of this. The Council acknowledged it did not give Mrs X any written information about short-stay care beds or give her the Short-Term Support Services direct telephone number in December 2024 which was fault. This poor communication caused Mrs X confusion and frustration about Mrs Y’s care and how to contact the Council. She was put to avoidable time and trouble contacting the Council in late December 2024 and early January 2025. The Council has put new service improvements in place which partly remedied the injustice caused but it has also agreed to pay Mrs X a symbolic payment.
37. When Mrs Y moved to Care Home 1 the Council delayed contacting Mrs X or her family and carrying out the review assessments which it had agreed to do. It took until early January 2025 for the Council to allocate a Social Worker and OT for Mrs Y and until late January 2025 for the Council to carry out Mrs Y’s care review. The ongoing delay was fault and delayed Mrs Y returning home. Mrs Y was in Care Home 1 on an intermediate care/reablement basis. Given Mrs Y’s stay was extended due to the Council’s delays it should have considered extending its funding of the Care Home. It’s failure to do so was fault.
38. The Council gave no clear confirmation of Mrs Y’s Care Home 1 fees during January to mid-February 2025 and the Council did not carry out a financial assessment in this period. The Council records show it started Mrs Y’s financial assessment once she had returned home, it said it sent the family a letter about her fees and direct debit payment in March 2025 and took a direct debit in April 2025 without providing the calculations behind the contributions. This was fault and caused Mrs X confusion and frustration over what Mrs Y was required to pay and why.
39. The delays meant Mrs Y remained in Care Home 1 longer than she should have, resulting in care fees she should not have had to pay.

OT equipment

40. The Council did not start to carry out Mrs Y’s OT assessment until early January 2025 and then ordered the incorrect equipment for Mrs Y. This was fault and caused Mrs X and Mrs Y frustration and confusion and meant Mrs Y had to have emergency care back at Care Home 1. The Council was not obliged to provide the transport back to Care Home 1. The Council has already apologised and put a new service improvement in place regarding measuring OT equipment so no further service improvements were needed.
41. When OT 1 was aware of the incorrect equipment they quickly ordered the correct equipment which was the right process so Mrs Y could move home. There was a short delay in the Council checking the new equipment but it did not cause Mrs Y a significant injustice.

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Action

42. Within one month of the final decision the Council will:
1. Apologise to Mrs Y, refund her care home contributions between 6 January 2025 and 13 February 2025 and pay her £200 to acknowledge the distress and frustration caused by the emergency care home stay she needed due to the Council’s delays in ordering the correct equipment; and
2. Apologise to Mrs X and pay her £200 to acknowledge the distress, frustration and confusion caused by the faults identified in this decision. 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.
43. The Council will provide us with evidence it has complied with the above actions.

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Decision

44. I have completed this investigation finding fault causing injustice. The Council has agreed to take action to remedy the injustice caused. The Council has already put service improvements in place.

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Investigator's decision on behalf of the Ombudsman