Summary: Ms B complained an NHS Trust and a Council were wrong to decide her father was not eligible for reablement care when he left hospital. She also complained that they did not involve the family adequately in the discharge process. We have not found fault in how the organisations made their decisions or how they involved the family. However, we have found fault in how the organisations handled Ms B’s complaint. We have asked the Trust and the Council to apologise for the impact this had.

The complaint

1. Mr A went to hospital in January 2024 after falling and breaking his wrist. NHS Chelsea and Westminster Hospital NHS Foundation Trust (the Trust) is responsible for the hospital. Mr A returned home three days later. The London Borough of Hounslow (the Council) arranged for care workers to visit Mr A at home four times a day.
2. Mr A’s daughter, Ms B, complains:
1. professionals failed to involve Mr A’s family in discussions about discharge plans;
2. professionals wrongly decided Mr A was not eligible to receive reablement support;
3. there were failings in the care and support the Council-commissioned care workers provided for Mr A;
4. the Council and Trust failed to provide a joint response to her complaint and both said the other organisation was responsible for key actions; and,
5. the Council took longer than 20 days to respond to a complaint she made.
3. Ms B said Mr A has been financially disadvantaged by the decision not to provide him with free reablement care. Ms B said Mr A would not have incurred the care costs he is liable for if the fault had not occurred. In addition, Ms B said these events had been very stressful for the family, and had taken a lot of time to deal with.
4. In bringing her complaint to the Ombudsmen Ms B said she would like:

• the Council not to charge Mr A for the care he received,
• financial redress to be considered for the impact of all the issues on the family, and,
• an apology.

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The Ombudsmen’s role and powers

5. The Local Government and Social Care Ombudsman (LGSCO) 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. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we 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. When investigating complaints, if there is a conflict of evidence, we 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. 
9. We cannot decide what level of care is appropriate and adequate for any individual. This is a matter of professional judgement and a decision that the relevant organisation has to make. Therefore, my investigation has focused on the way that the organisations made their decision.
10. 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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What I have and have not investigated

11. I have investigated issues (a), (b) and (d). I have not investigated issues (c) and (e).
12. Before we start an investigation we assess complaints in line with the LGSCO’s Assessment Code. We do not usually investigate complaints unless we consider it is likely we will find evidence of fault and where we can directly link that to a significant personal injustice which has not been addressed and properly remedied. I do not consider this to be the case for issues (c) and (e).
13. For issue (c), we would be likely to find Mr A received substandard care, based on the evidence I have seen. It seems the care provider accepted this at the time. However, I have not seen evidence to suggest Mr A came to harm because of poor care by the care workers. As such, it does not appear likely that an investigation would find a significant unremedied injustice linked to this issue.
14. Similarly, for issue (e), we would be likely to find fault as it did take the Council more than 20 working days to respond to Ms B’s complaint. However, the Council apologised for the delay. In view of the limited extent of the delay it is unlikely an investigation would find an unremedied injustice here, as the Council’s apology was a proportionate response.

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How I considered this complaint

15. I considered evidence provided by Ms B, the Council and the Trust as well as relevant law, policy and guidance.
16. Ms B, the Council and the Trust were all given an opportunity to comment on my draft decision. I considered the responses I received before making a final decision.

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What I found

Legislation and guidance

Hospital discharge

17. The Department of Health and Social Care issued statutory guidance: Hospital discharge and community support guidance (the National Discharge Guidance) in April 2022 (updated January 2024). This provides guidance to NHS bodies and local authorities on discharging adults from hospital. It said local areas should adopt discharge processes that best meet the needs of the local population. This could include the ‘discharge to assess, home first’ approach.
18. The National Discharge Guidance says in section 2 that planning for discharge should begin on admission to hospital. It also says that, from the outset, “people should be asked who they wish to be involved and/or informed in discussions and decisions about their hospital discharge”. It also says that “Multi-disciplinary teams…should work across hospital and community settings – including with services provided by community health, adult social care and social care providers – to plan post‑discharge care”.
19. Section 3 of the National Discharge Guidance notes that professionals “should consider a range of factors when supporting the individual and their family, unpaid carers or independent advocate to decide an individual’s care pathway and post‑discharge support. This includes the individual’s preferences, existing provision of care, and whether unpaid carers are willing and able to support an individual’s recovery.”

Intermediate Care and Reablement

20. Intermediate care and reablement support services are usually for people 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.

21. 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)

The Community Recovery Service referral criteria in Hounslow

22. The Hounslow Community Recovery Service referral criteria notes the service “accepts patients based on reablement / rehabilitation need rather than diagnosis, however this must be a primary physical health need related [to] an acute physical illness, injury or change in life circumstances”.
23. It also specifies that eligible patients will need to be able to “benefit from a short‑term period (up to 6 weeks) of rehabilitation / reablement to regain their previous level or maintain a new level of function and independence…”
24. The criteria says that people will not be eligible for the service it they need “periodic support to manage their long-term conditions and there are no active recovery goals”. In these circumstances staff are guided to consider referring the patient to adult social care.

Complaint handling

25. Under The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (the ‘Complaints Regulations’) there is a duty to investigate complaints properly and in a way that will resolve them efficiently. There is also a duty to cooperate when a complaint is made to one organisation and contains material relevant to the other.
26. The Complaints Regulations say that the organisations must “co-operate for the purpose of (a) coordinating the handling of the complaint; and (b) ensuring that the complainant receives a coordinated response to the complaint.” This involves a duty on each of them to agree who should take the lead in coordinating the handling of the complaint and communicating with the complainant. They must both provide each other with relevant information if so requested by the other and must attend, or ensure they are represented at any meeting held about the complaint.

Brief summary of events

27. In January 2024 Mr A went into hospital following a fall. He had broken his wrist. Staff assessed Mr A and spoke to his family. They noted he had previously been referred to a falls clinic. And they noted Mr A had been seen by a doctor in the care of the elderly clinic who felt there were several reasons for the falls. Staff also noted that Mr A’s family were concerned about Mr A’s falls.
28. Two days later a physiotherapist saw Mr A on the ward to assess his needs. Later that day an occupational therapist visited Mr A’s home to assess what equipment might be helpful. The therapy team completed an assessment summarising their findings and recommendations. This was sent to a discharge hub which, in turn, sent it to the hospital’s social work team. Therapy staff also ordered some equipment to be delivered to Mr A’s home. The assessment noted that Mr A lived with his wife. It said she had supported him before he went into hospital and would continue to do so in the same way when he returned home.
29. A duty worker from the hospital social work team spoke to Mr A and his family. They said they would arrange for Mr A to return home with four support visits from care workers a day, which would be funded via the NHS for five days. After that, his care would be arranged by the Council and he would have a financial assessment to determine whether he should contribute to the cost of his care.
30. The Council arranged for a care provider to begin visiting Mr A at home that evening, and Mr A returned home later that day.
31. Ms B raised concerns that the Trust and Council should have arranged for Mr A to receive support from a reablement service. Ms B said Mr A’s issues could improve through reablement. Council staff told Ms B and the family that health professionals had determined that Mr A was not eligible for the reablement service.
32. Ms B first complained to the Trust. In its initial response, shortly after Mr A returned home, the Trust said its teams do not manage the process of discharging people from the Emergency Department. The Trust said the Council’s Adult Social Care services were responsible for this. The Trust said, as such, it had passed Ms B’s concern about this on to the Council.
33. The Council said reablement services are only available to residents when inpatient clinical staff had identified clear rehabilitation goals for them. The Council said no rehabilitation goals had been specified for Mr A. The Council said, instead, Mr A’s needs were identified as being ongoing and long-term. The Council also said its staff had spoken to Mr A and his family about the arrangements for his post-discharge care while he was in hospital. The Council also told Ms B to contact the Trust about her concerns that staff had not appropriately involved Mr A’s family in discharge planning.
34. Ms B got back in touch with the Trust. In its response the Trust mirrored the Council’s findings. It said professionals determined that Mr A was not suitable for reablement “as it was felt he had long terms needs relating to his poor co‑ordination and recurrent falls”. The Trust said “long-term needs” means needs that cannot be significantly improved via a programme of reablement in a period of six weeks. The Trust said this decision was made from the information in a physiotherapy report, and the duty worker’s assessment. The Trust said the decision that Mr A was not eligible for reablement had been a joint one with the Council.

Analysis

Complaint (a) –professionals failed to involve Mr A’s family in discussions about discharge plans

35. There is evidence in the Trust’s and Council’s records that staff spoke directly to Mr A and to members of his family about his care after he left hospital. There are references to Mr A being keen to get home. And there are notes about agreeing plans with the family. Overall, I have not found evidence of fault here.

Complaint (b) –professionals wrongly decided that Mr A was not eligible to receive reablement support

36. The Council told us that decisions about discharge from hospital are made using a multi-disciplinary approach. At the time of Mr A’s admission they were made via meetings which were held twice a day.
37. The Council said there are no notes about how the multi-disciplinary meeting reached its decision that Mr A was not eligible for reablement. The Council said it recognised there should have been clear notes. The Council said changes have been made and notes are now kept of what the twice-daily MDT meetings discuss and decide. However, the Council said the wider notes supported the conclusions it reached during the complaints process.
38. While there are no notes of the specific meeting, the wider records from the hospital are relevant and helpful. The records show that staff spoke to Mr A and his family about his history of falls and took account of his previous attendances at relevant clinics. This does provide evidence to support the conclusion that a short rehabilitation programme was unlikely to resolve Mr A’s risk of falling, which had apparently been present for a prolonged period. There is also evidence that clinical and therapy staff completed proportionate and appropriate assessments of Mr A. These records provide evidence that properly qualified staff had considered relevant factors and taken account of the specific circumstances of Mr A’s needs and his history before deciding he was not eligible for support through the reablement service. Because of this, I have not found fault in the process the Trust and Council followed before making its decision. And, as detailed in paragraph 9, without fault in the decision-making process, I do not have grounds to question the decision the professionals made.

Complaint (d) –the Council and Trust failed to provide a joint response to Ms B’s complaint and both said the other organisation was responsible for key actions

39. As detailed in paragraphs 32 to 34, both the Trust and the Council advised Ms B to contact the other organisation and said key decisions had not been their responsibility. As set out in the Complaint Regulations, the organisations should have worked together to investigate and respond to the complaint. It is clear from the evidence that staff from both organisations were involved in Mr A’s care. It would have been helpful and customer focused to have considered events in the round rather than completing two separate processes. It was fault that this did not happen. Because of the fault Ms B was put to avoidable time and trouble in pursuing the complaint and caused frustration. This is an injustice to her. I have made recommendations below to address this.

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Agreed actions

40. Within one month of the final decision the Council and the Trust should both write to Ms B. They should acknowledge it was fault not to take a joint approach to investigate and respond to Ms B’s complaint. And, they should both apologise for the impact this had, in terms of the frustration and time and trouble this caused Ms B in pursuing the complaint.

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Decision

41. I have not found fault in the way the Council and Trust involved Mr A’s family in the discharge process. I have also not found fault in the process they followed before deciding Mr A was not eligible for reablement. However, I have found fault in the way the Council and the Trust handled Ms B’s complaint. This caused Ms B an injustice and I have made a recommendation to address it.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman