The Ombudsman's final decision:
Summary: There is no evidence of fault in the actions of Shropshire Council and Shropshire Community Health NHS Trust when Mr B was discharged from hospital to a care home. The Ombudsmen have not investigated the complaint that the Shrewsbury and Telford Hospital NHS Trust should have carried out a continuing care assessment as it is unlikely that they would find fault.
- Mrs B complains on behalf of her husband Mr B. She says Shrewsbury and Telford Hospital NHS Trust should have undertaken a continuing healthcare checklist (CHC) assessment when Mr B was discharged from hospital. She says Shropshire Council and Shropshire Community Health NHS Trust placed Mr B in a care home as a reablement/intermediate placement as further assessments were still needed to decide what the long term care plan for Mr B would be. She says they should therefore fund the first six weeks of that placement.
What I have investigated
- I have investigated the actions of Shropshire Council and Shropshire Community Health NHS Trust. Paragraphs 39 and 40 explain why I have not investigated the actions of Shrewsbury and Telford Hospital NHS Trust.
The Ombudsmen’s role and powers
- The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start or continue with an investigation if they believe:
- it is unlikely they would find fault.
(Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)
- The Ombudsmen cannot question whether an organisation’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
- 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 discussed the complaint with Mrs B and her representative and I have considered the documents that they, Shropshire Council and Shropshire Community Health NHS Trust have sent and the relevant law, guidance and policies.
What I found
- Where individuals receive care, treatment and support from the NHS, this is provided free.
- Where adults receive care and support from local authorities, they normally do so under the provisions of the Care Act 2014 and may have to pay for them, depending on financial eligibility criteria.
- The Care Act 2014, the Care and Support Statutory Guidance 2014 (updated 2017) and the Care and Support (Charging and Assessment of Resources) Regulations 2014 set out the Council’s duties towards adults who require care and support and its powers to charge.
- The Council has a duty to assess adults who have a need for care and support and provide a care plan.
- If a person needs residential care, the Council will assess their capital and income. The upper capital limit is currently set at £23,250 and the lower limit at £14,250. A person with assets above the upper capital limit pays for their own care.
Intermediate and reablement care
- However, the council must provide intermediate care and reablement care free of charge for up to six weeks, even if the person is above the capital threshold.
- Intermediate care services are provided to people, usually older people, after they have left hospital or when they are at risk of being sent to hospital. Intermediate care is a programme of care provided for a limited time to assist a person to maintain or regain the ability to live independently.
- ‘Reablement’ is a particular type of intermediate care, which has a stronger focus on helping the person to regain skills and capabilities to reduce their needs, in particular through the use of therapy or minor adaptations. There is a tendency for the terms ‘reablement’, ‘rehabilitation’ and ‘intermediate care’ to be used interchangeably.
NHS continuing healthcare
- NHS continuing healthcare is a package of care arranged and funded solely by the health service in England for a person aged 18 or over to meet physical or mental health needs that have arisen because of disability, accident, or illness.
- The NHS can provide continuing healthcare at home or in a care/nursing home. The NHS is responsible for meeting the full cost of care in a care home for residents whose primary need for being in care is health-based. The regulations say the NHS should assess for NHS Continuing Healthcare where it appears somebody may be in need of such care.
- The NHS is also responsible for meeting the cost of care provided by registered nurses to residents in all types of care homes. Council funded and self-funding residents who need to move into care homes with nursing should have a comprehensive assessment to identify any nursing needs, including the possible need for NHS-funded continuing healthcare or for NHS-funded nursing care.
- Shropshire has an Integrated Community Service (ICS) which is jointly run by Shropshire Council and Shropshire Community Health NHS Trust and supports discharges from hospital, among other things.
- There are three pathways that an ICS assessor can recommend.
- Pathway 1: supported care and therapy at home for up to six weeks.
- Pathway 2: Period of rehabilitation at a community hospital.
- Pathway 3. There are two options under pathway 3 which I shall call A and B. Pathway 3A is a ‘discharge to assess’ placement which is a short-term nursing placement to enable a period of assessment to establish what the long-term needs are. This will decide whether a return home is possible or whether a long-term residential placement is needed. Pathway 3b is a discharge to a long-term elderly mentally ill (EMI) residential or nursing placement.
- Mr B is an elderly man who suffers from dementia. He was living at home with support from Mrs B and a carer who attended every day. The care package was privately funded privately as Mr B had capital over the threshold.
- Mr B was admitted to hospital on 25 November 2017. On 29 November 2017, the ICS social worker assessed Mr B and said he lacked mental capacity to decide where he should live when he left the hospital. She also carried out a fact-finding assessment and concluded that Mr B needed long term EMI residential care which would be self-funded
- The social workers and Mrs B held a best interest meeting on 1 December 2017. Mr B needed assistance with all aspects of daily living. Mrs B said Mr B had become aggressive with her, swearing and threatening to hit her. Mrs B said she could no longer cope with caring for Mr B at home, even with the support of a care package.
- The outcome of the best interest meeting was that Mr B needed 24-hour permanent care in a care home.
- Mr B agreed the social worker should ring some residential care homes to check availability. The social worker found two care homes which had long term vacancies and could meet Mr B’s needs. Mrs B said she did not want care home 1 as a family member had died there. On 30 November 2017, care home 2 assessed Mr B and said it could offer him a room. Mrs B visited care home 2 and said she did not want Mr B to move there.
- Mrs B said she wanted Mr B to live at care home 3, but this care home did not have any vacancies. The social worker explained that Mr B was ready to leave hospital and could not keep his hospital bed forever. Mrs B said she would only agree to a move to care home 3.
- Mr B stayed in the hospital in the following months.
- The social worker carried out a needs assessment of Mr B on 16 January 2018. This concluded that Mr B needed 24 hours EMI residential care.
- The social worker spoke to Mrs B on 29 January 2018. Mrs B said that Mr B was waiting for a vacancy at care home 3. The social worker said Mr B was medically fit for discharge and could not stay in hospital. Mrs B said the situation at care home 3 was out of her hands. The social worker said she understood this but Mrs B would have to consider other care homes as it did not look like there would be any rooms at care home 3 in the foreseeable future.
- The social worker found care home 4. Care home 4 assessed Mr B and said it could offer him a room, but Mrs B said she did not want him to go there. Care homes 1 and 2 also assessed Mr B and offered him rooms.
- Mrs B visited care home 1 on 9 February 2019 and signed a contract with the home. Mr B moved to care home 1 on the same day. He moved to care home 3 a few months later when a room became available.
- Mrs B complained to the Hospital Trust and the ICS with assistance of her representative. I have summarised the complaints and the responses that are relevant to her complaint to the Ombudsmen.
- Mrs B said:
- The Hospital should have carried out a CHC assessment before Mr B was discharged from hospital.
- Not all patients need a CHC assessment before discharge. A CHC assessment was normally only done when nursing care was required and this was not the case for Mr B.
- A CHC assessment was done in March 2018 and said that Mr B did not need nursing care.
- Mrs B said:
- The ICS team discharged Mr B to care home 1 for a period of respite/intermediate care. Therefore, he did not have to pay any fees until six weeks had passed or when the CHC assessment had taken place.
- ICS had not fully assessed Mr B’s needs before discharge and therefore he did not have to pay the fees for the first six weeks.
- The long-term plan for Mr B had been residential care since November 2017. There had never been any mention that this was intermediate care or that the long-term plan for Mr B was still undecided.
- Mr B was not entitled to six weeks funding as the placement was his permanent placement and he was a self-funder. He was not entitled to funded nursing care as his most recent CHC assessment said he did not qualify for a further assessment.
- I find no fault in the actions of Shropshire Council and Shropshire Community Health NHS Trust.
- The evidence shows that a 24-hour residential placement was the long-term plan for Mr B. I have read the fact-finding assessment, the mental capacity assessment, the care act assessment and they all support this plan. There was no suggestion, in any of the documents that this was only a short-term plan or that further assessments were needed to decide the long-term plan for Mr B. There was no indication that this was a reablement/intermediate placement.
- I also considered the minutes of the best interest decision. Mrs B and the other attendants all agreed that the decision for Mr B to live in the care home on a long-term basis was in his best interests.
I have completed my investigation and have not found fault by Shropshire Council and Shropshire Community Health NHS Trust.
Parts of the complaint that I did not investigate
- I have not investigated the complaint that the Shrewsbury and Telford Hospital NHS Trust should have carried out a CHC assessment before Mr B was discharged from hospital in February 2018.
- The Hospital Trust has explained that there was no indication that Mr B needed nursing care so a CHC assessment was not required. With no indication of fault, I do not propose to investigate this further. In any event, a CHC assessment was carried out in March 2018 and said that Mr B was not eligible for NHS funding as he did not require nursing care. Mr B has a right of appeal against this decision.
Investigator’s decision on behalf of the Ombudsmen
Investigator's decision on behalf of the Ombudsman