The Ombudsman's final decision:
Summary: Oxleas NHS Foundation Trust should have made a referral to a community physiotherapist to assess Mrs Y. As a result, Mrs Y’s mobility would have most likely improved sooner than it did. Also, its communication was fault, but has already remedied the distress the family suffered. London Borough of Bexley made it clear to Mrs Y that she would need to pay for her care on discharge, and this was not fault.
- Mrs X complains about London Borough of Bexley’s (the Council) assessment of her mother’s (Mrs Y) needs and right to reablement care. This was carried out at Meadow View Unit, part of Oxleas NHS Foundation Trust (the Trust).
- Mrs X says the Trust did not provide acceptable physiotherapy to Mrs Y, which caused her condition and reablement potential to worsen. Mrs X also says the Trust should have made a referral to a community physiotherapist on discharge. Mrs X says her mother’s mobility improved after she was discharged, so she did have reablement potential.
- Mrs X says the Council and Trust’s communication was poor and confusing. The family were not kept updated about Mrs Y’s progress. Also, the family found out Mrs Y would not be receiving free reablement care three weeks after she was discharged. While the Council has offered to fund 50% of Mrs Y’s care costs for the first six weeks, Mrs X does not accept this offer.
- Mrs X would like an apology for the lack of care and support provided to Mrs Y, and the poor communication from both the Trust and the Council. Mrs X would also like the Council to waive all the care costs after discharge.
The Ombudsmen’s role and powers
- The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting for both Ombudsmen. (Local Government Act 1974, section 33ZA,as amended, and Health Service Commissioners Act 1993, section 18ZA)
- 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).
- 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.
- When investigating complaints, if there is a conflict of evidence, the Ombudsmen may 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.
- 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)
How I considered this complaint
- I have considered the complaint information Mrs X has provided to me. I have asked the Council and the Trust to comment on the complaint, and provide supporting documentation. I have taken the relevant law and guidance into account. I have also sought advice from an independent nurse.
- I have written to Mrs X, the Council and the Trust with my draft decision and considered their comments.
What I found
- In 2016 the Health and Care Profession Council produced guidance called Standards of conduct, performance and ethics. The guidance states that clinicians must delegate work to staff who have the necessary skills and experience needed to carry out tasks safely and effectively. Also, staff must provide appropriate supervision and support to those who have work delegated to them.
- The Care and Support (Preventing Needs for Care and Support) Regulations 2014 say that local authorities must not charge for intermediate care and reablement support services for the first six weeks of the specified period.
- The General Medical Council’s Good medical practice (2014) guidelines state that clinicians must be considerate to those close to the patient and be sensitive and responsive in giving them information and support. Also, clinicians must record their work clearly and accurately.
- In August 2016 the Council produced guidance called Reablement Team: Guidance for Referrers & Referral pathway.
- In late November 2016, Mrs Y fell in the road and was admitted to Princess Royal University Hospital (Princess Royal), part of another Trust. An x-ray showed Mrs Y had broken the bone between the shoulder and elbow on her left arm. Princess Royal put her arm in a sling, to allow the weight of the arm to pull the broken bone downwards, to heal in the correct position.
- Princess Royal later transferred Mrs Y to the Trust on 12 December 2016 for rehabilitation, to ensure she could mobilise at home. Over the next two days a physiotherapist and occupational therapist assessed Mrs Y and developed a plan to help her mobilise, which nurses carried out.
- On 18 December 2016, the physiotherapist noted that Mrs Y’s pain was affecting her progress.
- On 20 December, a social worker assessed Mrs Y’s needs. Mrs Y provided answers to all her questions. The next day, the social worker called Mrs X to get her input into the assessment, and explained the needs assessment process. On 23 December, the social worker completed her assessment of Mrs Y’s needs. She noted Mrs Y would need two people to help her. Also, she noted that in the short-term, Mrs Y had no potential for further rehabilitation.
- The occupational therapist discussed the discharge plan with Mrs X and the family on 29 December 2016. Mrs X’s brother, and his wife, met with the occupational therapist on 10 January 2017.
- On 12 January 2017, the social worker confirmed that Mrs Y could not move her arm in her sling.
- Four days later, the occupational therapist again explained the details of the discharge plan to Mrs X’s family. On 23 January, Mrs X’s brother spoke to the occupational therapist again, as he was unsure about the discharge plan. The Trust discharged Mrs Y later that day, when her care plan came into effect. Mrs Y received care in the community, which was chargeable.
- In February 2017, Mrs Y had an outpatient appointment at Princess Royal. The registrar recommended that Mrs Y continue with physiotherapy, and it would take six to nine months to recover from her injury. The registrar also discharged her from their service.
- On 14 February 2017, the Council visited Mrs Y and Mrs X. They discussed individual budget choices, Mrs Y’s financial assessment and how the budget would be spent on providing Mrs Y’s care.
- Mrs Y’s GP referred her for physiotherapy in November 2017. This was because Mrs Y could not do daily living activities, but reported no further pain.
- In response to a complaint by Mrs X, in July 2017 the Council disagreed that Mrs Y was eligible for free care, or that it had told Mrs X this was the case. However, the Trust may have discussed a reablement package, which could have lead Mrs X to believe the care would be free. Also, Mrs Y did have rehabilitation potential as her mobility improved at home. Therefore, the Council offered to refund 50% of the care costs for the first six weeks following Mrs Y’s discharge from the Trust.
- In response to a complaint by Mrs X, in February 2018 the Trust said there is no evidence that staff discussed charges with Mrs X and the family. The Council was responsible for that. As the Trust identified Mrs X as not suitable for reablement care, her follow up care would always be chargeable.
- First, I am satisfied the physiotherapist’s mobility plan was suitable taking Mrs Y’s condition into account. Mrs Y would not have been able to use a walking aid, as she could not bear her weight from her broken arm. The physiotherapist wanted Mrs Y to practice sitting to standing using a rota stand, with the help of staff.
- Mrs X is unhappy the physiotherapist only saw her mother a few times after she developed the plan.
- The physiotherapist’s decision to delegate tasks in Mrs Y’s care plan to nurses was in line in the relevant guidelines. Those nurses had the necessary experience to carry out the sitting to standing exercises. Also, the Trust’s records show the physiotherapist was checking Mrs Y’s progress.
- The Trust’s records show that both nurses and the physiotherapist tried to encourage Mrs Y to become more independent. Specifically, they practised the exercises in the plan, tried to encourage Mrs Y to eat and drink by herself and manage her personal hygiene. This shows the Trust tried to get Mrs Y used to daily living. Mrs Y struggled with pain when completing the exercises, so it was not fault the physiotherapist (and the social worker) noted that Mrs Y’s had no reablement potential. Overall, I do not consider the Trust’s reablement care was fault.
- The physiotherapist mobility plan included Mrs Y attending exercise classes. This did not occur during the admission. However, I have seen evidence that Mrs Y was reluctant to take part in other aspects of her reablement care. Therefore, on the balance of probabilities, it was unlikely that Mrs Y would have attended those exercise classes anyway.
- When the Trust discharged Mrs Y, it did not make a referral for a community physiotherapy assessment. This was fault, especially considering that her mobility was good before she fell in November 2016. The Trust should have made the referral on discharge, or when Mrs Y’s break had healed enough to enable her to bear her weight on a walking aid. I can see in February 2017 Princess Royal wanted Mrs Y to continue with physiotherapy and was under the impression she was receiving some.
- Mrs X told me that Mrs Y’s mobility improved after she was discharged from the Trust, but she still struggled with daily activities. This is confirmed in the November 2017 physiotherapy referral. Mrs X told me that she had to push her GP for a physiotherapy referral, and her mother’s independence improved after the November physiotherapy sessions. Therefore, there was a delay in Mrs Y receiving the care which, on the balance on probabilities, would have improved her independence sooner. The Trust needs to put right this injustice.
- From the Trust’s records, I have not seen any evidence the Trust updated the family on Mrs Y’s condition. It only documented communication with the family about the discharge plan. This is not in line with the General Medical Practice’s guidelines, and I consider this was fault.
- I can understand this fault would have been distressing for the family, not knowing how their mother was progressing. The Trust has recognised this fault, apologised and completed an action plan to avoid a similar fault happening to other people. I am satisfied that this remedied the distress the family suffered, and will not be asking the Trust to take more action.
- The Council was correct to say Mrs Y had no rehabilitation potential based on the advice of the Trust. Therefore, her care was chargeable after discharge. This was in line with the Care and Support (Preventing Needs for Care and Support) Regulations 2014.
- It was not the Trust’s responsibility to detail Mrs Y’s care package to the family, because this was arranged by the Council. Also, I have not seen any evidence from the Trust’s records that staff discussed a potential rehabilitation package for Mrs Y.
- From the Council’s records, I have not seen any evidence the social worker told Mrs X or the family Mrs Y’s care would be free for six weeks.
- On 20 December 2016, the social worker provided Mrs Y with a financial assessment form and discussed personal budget information. I consider the Council made it clear to Mrs Y that she would need to pay for her care on discharge, and this was not fault.
- The Council offered to refund 50% of the care costs to the family incurred in the first six weeks, but Mrs X has refused this offer. I am satisfied this is a fair offer considering Mrs Y’s improvement on discharge.
- Within four weeks of the final decision, the Trust:
- Apologise to Mrs Y and accept the impact of not making the referral for a physiotherapy assessment on or after January 2017.
- Pay Mrs Y £250 in recognition of the delay to improve her mobility.
- The Trust’s reablement care was in line with the relevant guidance, but it should have made a referral to a community physiotherapist when Mrs Y was discharged. I have recommended the Trust put right the injustice Mrs Y suffered. Also, while the Trust did not update the family on Mrs Y’s progress, it has already remedied the family’s injustice.
- The Council were right to charge Mrs Y for care after discharge, and there is evidence that she was aware it was chargeable. This was not fault.
Investigator's decision on behalf of the Ombudsman