Summary: Mrs X complains about the way Plymouth County Council, Livewell Southwest and NHS Devon discharged her father, Mr Y, from hospital. We uphold her complaint. We found fault with the way Mr Y’s discharge was handled. As a result, Mrs X has experienced distress and uncertainty. The organisations have agreed to apologise to Mrs X, make systemic improvements and pay a financial remedy.

The complaint

1. Mrs X complains about the way Plymouth County Council (the Council), Livewell Southwest and NHS Devon Integrated Care Board (the ICB) handled her father, Mr Y’s, discharge from hospital in August 2024. She complains the ICB refused to fund her father’s placement at her preferred care home and instead offered a cheaper unsuitable placement. She says the decision was made for financial reasons and that the professionals involved did not consider the family’s individual circumstances. She is also unhappy that there was no option to allow her to top up the fees.
2. Mrs X also complains about delays completing Mr Y’s Care Act assessment and Continuing Healthcare (CHC) assessment.
3. As a result, Mrs X says she has been caused a significant amount of stress which has negatively impacted on her health.
4. Mrs X would like her father to be reimbursed for the six weeks of care home fees which she says should have been paid for as a Discharge to Assess (often referred to as D2A) placement. She would also like to be reimbursed for the £2,200 fee paid for a private CHC assessment for her father.

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The Ombudsmen’s role and powers

5. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
6. 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).
7. 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.
8. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our 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)

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How I considered this complaint

9. I have considered the information Mrs X provided in support of her complaint. I have also received information from the Council, the ICB and Livewell Southwest including relevant discharge records. I have carefully considered all the written and oral evidence submitted, even if it is not all mentioned within this decision statement.
10. Mrs X, the Council, the ICB and Livewell Southwest 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

Key legislation and guidance

NHS Quick Guide: Discharge to Assess

11. Definition of ‘Discharge to Assess – ‘Where people who [no longer need hospital treatment], but may still require care services, are provided with short term funded support to be discharged to their own home (where appropriate) or another community setting. Assessment for longer-term care and support is then undertaken in the most appropriate setting and at the right time for the person.
12. Principles for Discharge to Assess model include:
• Putting people and their families at the centre of decisions, respecting their knowledge and opinions and working alongside them to get the best possible outcome.
• Take steps to understand both the perspectives of the patient and their carers… [and] their needs…’

Hospital discharge and community support guidance – July 2022

13. Section 3 ‘Health and care professionals who are facilitating hospital discharges should work together with individuals, and – where relevant – families and unpaid carers, to discharge people to the setting that best meets their needs. This process should be person-centred, strengths-based, and driven by choice, dignity and respect.’
14. Section 11 ‘Planning and implementation of discharge should respect an individual’s choices and provide them with maximum choice and control possible from suitable and available options.

What happened

15. Mr Y lived independently at home. In July 2024, Mr Y was admitted to Derriford Hospital with a suspected stroke. The hospital’s D2A Team is a multidisciplinary team of health and social care professionals run by Livewell Southwest in partnership with the Council and the ICB.
16. In early August 2024, Mr Y was ready to be discharged. The discharge team considered Mr Y lacked the mental capacity to make decisions around his discharge. Mental capacity is the ability to make an informed decision based on understanding a situation, the options available, and the consequences of the decision. Mrs X is Mr Y’s attorney, which means she can make decisions about his health and welfare on his behalf.
17. The discharge team spoke with Mrs X about Mr Y’s discharge destination. Mr Y was to be discharged under the D2A process to a short-term care home placement while his longer-term needs were assessed. Mrs X expressed a strong preference for a particular care home (the Nursing Home) which was close to her and Mr Y’s home.
18. Livewell Southwest assessed Mr Y’s needs and passed this information to its Bed Bureau to source a D2A funded bed. The Bed Bureau sent Mr Y’s details to the Nursing Home. The Nursing Home declined to accept the D2A funded rate, which was significantly below its usual care fees. The Bed Bureau reached out to other care homes.
19. Another local care home (the Care Home) said it could meet Mr Y’s needs and offered him a D2A funded bed. Mrs X declined the placement due to concerns including distance and whether it was suitable.
20. The Bed Bureau approach several other care homes but were unable to source an alternative placement for various reasons including lack of availability. The Bed Bureau asked the ICB whether it would agree to fund the Nursing Home at a higher than usual rate.
21. The ICB declined higher rate funding for the Nursing Home. It said the Care Home was able to meet Mr Y’s needs within the usual rate. Mrs X said the ICB failed to consider the family’s individual circumstances. She offered to pay the fee difference, but the ICB told her this was not possible for D2A placements.
22. Shortly after, Mrs X told the Bed Bureau that she felt she had no choice but to move Mr Y to a privately funded placement at the Nursing Home. Livewell Southwest advised Mrs X that this would remove Mr Y from the D2A process and she would need to request a needs assessment separately, which may take some time.
23. In mid-August 2024, Mr Y was discharged to the Nursing Home. Two days later, Mrs X contacted Livewell Southwest to request a needs assessment from Mr Y. In mid-September 2024, Mrs X raised concerns that Livewell Southwest had delayed in assessing Mr Y. She said Mr Y was running out of funds and she could not make long term decisions, such as whether to sell his house, until the needs assessment had been completed. A manager reviewed Mrs X’s request and added Mr Y to the waiting list for a needs assessment.
24. In mid-October 2024, a social worker visited Mr Y to assess his needs. The social worker did not complete a CHC checklist. The assessment confirmed Mr Y needed a 24-hour residential care in a specialist dementia care placement.
25. In early November 2024, Mrs X’s advisor wrote to the ICB requesting a CHC assessment happened as soon as possible. The ICB made a referral to arrange this.
26. In December 2024, the ICB completed a CHC checklist for Mr Y, with Mrs X and her advisor present. Following this, Mr Y had a full CHC assessment and was approved for full CHC funding from January 2024.

Analysis

Delayed discharge

27. Mrs X complains about the way her father, Mr Y, was discharged from hospital in August 2024. Mrs X says Mr Y was ready for discharge after ten days in hospital, but his discharge was delayed for six weeks due to issues around discharge location. Mrs X says this delay caused Mr Y to deteriorate.
28. Mr Y was admitted to hospital on 13 July 2024. On 6 August, the discharge team began to explore discharge options with Mr Y and Mrs X. Following this, the Bed Bureau promptly sent a referral to the Nursing Home, which was Mrs X’s preferred option. Over the next week, the Bed Bureau sent referrals to another five care homes. On 16 August, Mrs X decided to move Mr Y to a private placement at the Nursing Home.
29. There were nine working days between the Bed Bureau becoming involved and the decision to move Mr Y privately. During this time, the Bed Bureau made several timely attempts to source a D2A placement for Mr Y. The ICB also responded promptly to queries about funding. I have not found any evidence of undue delay.

Lack of choice

30. Mrs X complains about lack of choice of discharge options as Mr Y was only offered one D2A bed, in a placement she considered unsuitable.
31. Patient choice is a core principle of the NHS Act 2006. As above, the general duty for patient choice is also part of the Hospital Discharge and Community Support Guidance – July 2022. However, there is no legal requirement to offer a choice of D2A beds.
32. Mr Y was only offered one funded option, the Care Home. However, the Bed Bureau made several attempts to find alternative placements for him. The records show the Bed Bureau acted with regard to its patient choice duties. Unfortunately, most of the enquiries were unsuccessful due to a range of reasons outside of their control.
33. The only potential alternative placement was the Nursing Home, which the ICB declined to pay a higher rate. This decision should have considered many factors, choice being just one of them. I have addressed the way this decision was taken below.

Individual circumstances

34. Mrs X complains that the organisations’ refusal to approve additional funding for the Nursing Home was made solely for financial reasons and failed to take Mr Y’s individual circumstances into account. During the discharge process, Mrs X raised several concerns including the quality of the Care Home, distance from Mr Y’s friends and family, the benefits of a familiar area and avoiding potentially moving him twice.
35. Mrs X also raised the impact of discharge location on herself, as Mr Y’s primary carer and attorney. Mrs X explained the hospital regularly called her to attend the ward to calm Mr Y down when he became agitated and confused. She explained she was primary carer to another family member and would have difficulties travelling to the Care Home. Mrs X advised she was also experiencing very high levels of stress.
36. We 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. 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, and Health Service Commissioners Act 1993, sections 3(4)- 3(7)).
37. I have carefully reviewed the documents provided by Livewell Southwest and the ICB about how they made this decision. In response to Mrs X’s complaints and my investigation enquiries, both organisations have provided detailed responses addressing the concerns raised by Mrs X about her and Mr Y’s individual circumstances.
38. However, the contemporaneous records relating to Mr Y’s discharge do not show the same level of consideration.
39. On 9 August, Mrs X had a lengthy telephone conversation with a social worker in the discharge team. Mrs X raised numerous concerns including the impact the situation was having on her. Mrs X was noted to be “extremely stressed” and “at significant risk of carer and emotional breakdown”.
40. On 13 August, the Bed Bureau put the request for additional funding to a senior manager. This included an email chain discussing Mrs X’s various concerns about distance and the impact on her personal wellbeing. The manager declined the funding request as “we have sourced a placement within D2A rates who can suitably meet [Mr Y’s] needs” and noted that the Nursing Home was unwilling to negotiate to accept the D2A funded rate short term. The ICB’s senior management was also copied into the emails and added “I appreciate the difficult situation, however this is in line with ICB policy – the cost differential is significant and we are therefore unable to support a placement at [the Nursing Home]”.
41. On 14 August, the discharge team spoke with Mrs X where she raised ten specific concerns about Mr Y’s individual circumstances. The discharge team passed these on to the ICB and the Bed Bureau. There is no evidence that the organisations considered these concerns any further at the time. Shortly after, Mrs X advised the Bed Bureau of her decision to place Mr Y privately at the Nursing Home.
42. Mrs X presented her concerns about the impact of placing Mr Y outside the local area on multiple occasions. I have found no evidence the organisations properly considered her concerns at the time of Mr Y’s discharge. This is not in line with the ICB policy which includes the need to consider individual circumstances as part of decision making around requests for more expensive care. The decisions taken not to fund the Nursing Home at a higher rate focuses wholly on financial reasons.
43. The organisations’ complaint responses refer to the obligation to spend public money wisely and balance the needs of all patients. I acknowledge this is a key consideration. However, they must also have regard for a person’s wishes and individual circumstances. Mr Y lacked the capacity to decide his discharge arrangements. This made Mrs X’s views particularly important as she was advocating on his behalf, as both his main carer and health and welfare attorney. Mrs X’s concerns are noted in Livewell Southwest’s records, but I have not seen any meaningful consideration of her views by the organisations when making the decision about Mr Y’s discharge location.
44. When responding to my enquiries, Livewell Southwest indicated that managing relationships with family would be considered as part of longer-term care planning, noting that the short-term D2A placement. However, given that Mrs X was playing an active role in managing Mr Y’s agitation, her ability to visit him should have been considered by the organisations for short term placements too. While the organisations have later said they consider the Care Home to be a reasonable distance for Mrs X to travel, there is no evidence that distance was considered at the time of the decision.
45. NHS England’s Quick Guide: Discharge to Assess (the Guide) outlines key principles for the D2A process. This includes focus on patient centred care to ‘put people and their families at the centre of decisions, respecting their knowledge and opinions…’ and taking ‘steps to understand both the perspective of the patient and their carers…[and] their needs…’. It further mentions building networks of care ‘…including non-paid circles of support such as family and friends...’ Failure to adequately consider Mrs X’s role in Mr Y’s life, even for a short-term placement, was not in line with the Guide’s principles.
46. In summary, while Mrs X’s concerns have been addressed retrospectively as part of the complaint process, I have found no evidence that these were properly considered at the time of Mr Y’s discharge. Therefore, I cannot be satisfied that the decision around funding was properly made. This is fault. As a result, Mrs X experienced significant frustration. Mrs X did not feel heard. This was distressing for her.
47. Mrs X says that as a result of the organisations’ actions, she felt she had no choice but to remove Mr Y from the D2A process and privately fund his place at the Nursing Home. Mrs X says this cost Mr Y £1,100 a week. Mrs X would like this money refunded to Mr Y as she feels it should have been covered under the D2A process for six weeks.
48. Had the organisations properly considered Mrs X’s concerns at the time of the decision, we cannot know what the outcome would have been or whether it would have been different. I cannot say that, had the decision been taken properly and taking all relevant factors into account, higher rate funding would have been agreed for the Nursing Home. As such, there is insufficient evidence that Mr Y has had a direct financial loss as a result of the organisations’ actions.

Blanket decisions

49. The ICB’s complaint response said it must “ensure it applied robust controls over public funding and ensures equitable and consistent decisions for commissioning and contracting care home placements...To be equitable to all patients, the NHS can only offer placements where the provider is able to accommodate an acceptable NHS fee.”
50. An organisation should not adopt a blanket or uniform approach or policy that prevents it from considering the circumstances of a particular case. We may find fault in the actions of organisations that fetter their discretion in this way.
51. When responding to my enquiries, the ICB confirmed there is flexibility to pay a high rate where individual needs necessitate it. The ICB pointed to its ‘Individual Package of Care Panel Policy’ which outlines how funding decisions should be made. Points ‘5 .1.5 – 5.1.8 say “The ICB does not have an unlimited budget. Spending decisions in one area of healthcare affect the ICB’s ability to afford healthcare in other areas. When deciding whether to pay for care that is not the most cost-effective option….if the individual or their carers prefer a more expensive option, the ICB will consider each request according to their duties and responsibilities towards the individual and their carers as well as their duties to the whole population….including whether a decision not to pay for a more expensive option would be reasonable balancing the overall cost with the likely effect on the individual, taking into account their home and family situation.”
52. 5.3.2 of the policy lays out a list of factors to be considered including whether care can meet a person’s needs, whether care is safe, individual’s preferences and the balance of overall cost and the individual’s circumstances.
53. The ICB’s complaint response statement that it can only offer placements where the provider accepts the NHS fees is inaccurate and not in line with the ICB’s own policy.
54. While the ICB later confirmed there is flexibility to approve higher rates, there is no evidence the ICB properly considered the range of factors when deciding on Mr Y’s funding. Instead, the Bed Bureau and the ICB both focused solely on the fact that there was an available bed within the standard D2A rate. This is not in line with the relevant policy. The ICB has fettered its discretion and this is fault. The ICB’s failure to make this decision properly has caused Mrs X frustration and uncertainty.

Refusal of top up payment

55. Mrs X complains that she offered to pay a top up to meet the Nursing Home’s fees but was not allowed to. This was frustrating for Mrs X. However, it is correct that there is no mechanism or infrastructure for care fee top ups through the NHS. This is not permitted under the D2A process. The ICB policy confirms ‘5.4.1 Top ups cannot be used to fund any element of care that is set out in the individual’s care plan. This is due to rules about NHS care.’ Therefore, the ICB would not have been able to accept Mrs X’s offer.

Delays to needs assessment

56. Mrs X complains Mr Y’s needs assessment was significantly delayed because he left the D2A process when he moved to a privately funded placement. Mrs X says Mr Y was disadvantaged due to the ICB’s decision around discharge funding.
57. Mrs X says this delay meant she needed to make long term decisions about her father’s care, including whether to sell his property to pay for care fees, before his long-term needs had been properly assessed.
58. Livewell Southwest’s records note Mrs X was advised during a phone call that Mr Y was ‘no longer under Discharge Team or Discharge to Assess but can contact Adult Social Care for a Care Act assessment if needed. Mr Y will not be a prioritised as it is risk based and he will be in a safe location; unknown how long assessment will take.’
59. Two days after discharge, Mrs X contacted the Council to request a needs assessment for Mr Y. A month later, Mrs X contacted the Council again saying Mr Y’s funds were running low and he soon would not be able to meet the weekly fees from his savings.
60. On 11 September, a community care worker from Livewell Southwest sent an email to the Council raising concerns that it had not acted upon the referral for needs assessment and Mrs X had been left without support. Following this, a manager reviewed the matter, agreed a care needs assessment was required and added Mr Y to the waiting list. Mrs X asked for Mr Y’s assessment to be expedited due to his low funds. Mr Y was allocated to an assessor in mid-October and his assessment was completed in mid-November.
61. The Care and Support Statutory Guidance (the Guidance) says that an assessment should be carried out over an appropriate and reasonable timescale, taking into account the urgency of needs and considering any fluctuation in them. We expect councils to complete assessments in a timescale that is proportionate to the complexity of the issues, and normally within 4-6 weeks. Councils should tell the individual how long their assessment will take and keep them informed about this throughout the process.
62. There was an avoidable delay of a month between Mrs X requesting the assessment in mid-August and Mr Y being added to the waiting list in mid-September. Mrs X was not kept up to date about when she could expect an assessment. Mr Y waited around 10 weeks from discharge for his needs to be assessed and a total of 13 weeks for the process to be completed. While the Council needs to balance the needs of all service users, the time taken to complete Mr Y’s assessment was in excess of a reasonable timeframe. This is fault.
63. This delay caused Mrs X a significant amount of stress as she was struggling to make major financial decisions for Mr Y without knowing his long-term care needs.

CHC assessment

64. Mrs X complains Livewell Southwest refused carry out a CHC checklist, so she had to pay a private company to complete this at a cost of £2,200.
65. Livewell Southwest say that, at the time of Mr Y’s care needs assessment in November 2024, a CHC list was considered but the social worker did not complete it as she was felt Mr Y was unlikely to meet the criteria for a positive checklist.
66. Mrs X sought legal advice. In early November 2024, her advisor wrote to the ICB asking it to complete a CHC Checklist. The ICB completed a checklist in December 2024. Following this, the ICB carried out a further assessment and Mr Y was awarded full CHC funding in January 2025.
67. The ICB has completed a Previously Unassessed Period of Care review to see whether Mr Y could have been eligible for CHC funding from an earlier date. In September 2025, the ICB decided that Mr Y would not have been eligible for CHC funding between August 2024 and early January 2025 as records indicate he did not have a primary health need at the time. Mrs X is unhappy with this decision.
68. As this matter was still on going at the time of this investigation, I have not taken a view on whether a CHC checklist should have been carried out for Mr Y sooner. There is a formal appeals process open to Mrs X, and this is the most appropriate route for her to challenge the ICB’s decision.
69. I have considered whether Mrs X incurred unnecessary costs. The ICB has clarified that Mr Y’s CHC checklist was not completed privately. The ICB arranged for this work to be completed on its behalf, at no charge to Mrs X. Mrs X’s advisor was invited to attend the CHC checklist assessment, at Mrs X’s request. I appreciate that Mrs X was frustrated that a CHC checklist had not been completed at the time of the needs assessment, however it was ultimately her choice to engage private advice. We would not hold the ICB responsible for this.
70. Mrs X said the ICB told her to seek legal advice. However, this was specifically in relation to her request for compensation only. The CHC process does not require legal advice. Therefore, we would not recommend that Mrs X be reimbursed for these costs.

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Action

ICB and Livewell Southwest

71. Within one month of my final decision statement, both organisations will:
• apologise to Mrs X for the impact of failing to proper consider her and Mr Y’s individual circumstances when deciding on discharge arrangements; and
• each pay £150 to Mrs X for frustration and uncertainty.
72. Within three months of my final decision statement, the ICB and Livewell Southwest will explain what action they will take to
• properly consider and record the reasons for any discharge decisions, ensuring this includes the individual circumstances of each case.

Council

73. Within one month of my final decision statement, the Council will:
• apologise to Mrs X for delays to completing Mr Y’s needs assessment; and
• pay £150 to Mrs X for frustration and distress.

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Decision

74. I have found fault in the way the ICB and Livewell Southwest made decisions around Mr Y’s discharge options. The Council delayed completing Mr Y’s needs assessment. As a result, Mrs X has been caused uncertainty, frustration and distress.
75. I have not found fault with the timeliness of Mr Y’s discharge, lack of choice or the refusal to accept fee top ups for an NHS funded placement.
76. I have not made findings in relation to Mr Y’s CHC assessment. This is because Mrs X has a route to formally appeal the ICB’s decision.
77. I have now completed my investigation.

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Investigator's decision on behalf of the Ombudsman