Summary: We found fault by the Council, Hospital Trust and Community Trust with regards to the information they provided to Mr X and Mrs Y regarding available care and support services in the area. We also found fault by these organisations concerning their handling of Mr X’s complaint. They will apologise to Mr X and Mrs Y and take action to ensure appropriate information is available to people as part of the hospital discharge process.

The complaint

1. The complainant, who I will call Mr X, is complaining about the care provided to his mother, Mrs Y, by Lincolnshire County Council (the Council), United Lincolnshire Hospitals NHS Trust (the Hospital Trust), Lincolnshire Community Health Services NHS Trust (the Community Trust) and NHS Lincolnshire ICB (the ICB) in March and April 2021.
2. Mr X complains that these organisations failed to properly consider Mrs Y’s eligibility for intermediate and reablement care prior to her discharge from hospital in April 2021. He says these organisations subsequently failed to respond properly to his queries and complaints and have still not provided him with a proper rationale for the decision that Mrs Y was not eligible for intermediate and reablement care.
3. Mr X says this caused Mrs Y significant anxiety and uncertainty over her post-discharge care arrangements and the funding for them.
4. Mr X would like to receive apologies for failure of the organisations involved in the complaint to take responsibility for their actions. He would also like them to take action to prevent similar problems occurring in future. Furthermore, Mr X would like these organisations to pay a financial remedy in recognition of the impact of these matters on him and Mrs Y.

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The Ombudsmen’s role and powers

5. 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).
6. 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.
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)
8. This complaint involves events that occurred during the COVID-19 pandemic. The Government introduced a range of new and frequently updated rules and guidance during this time. We can consider whether the council followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19”.

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How I considered this complaint

9. In making my final decision, I considered information provided by Mr X and discussed the complaint with him. I also considered relevant information from the Council, Hospital Trust, Community Trust and ICB. This included the clinical and care records. I also invited comments on my draft decision statement from all parties and considered the responses I received.

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What I found

Relevant legislation and guidance

COVID-19 pandemic

10. In response to the COVID-19 pandemic and the need to keep hospital beds free, the Government introduced the Hospital Discharge Service: Policy and Operating Model (the discharge to assess guidance). This guidance came into effect in August 2020.
11. The model set out that patients must be discharged from hospital as soon as it was clinically safe.
12. The discharge to assess model consisted of four care pathways:

• Pathway 0 applied to people with simple discharge needs and no requirement for ongoing health and social care support.
• Pathway 1 applied to people who could return home with support from health and/or social care services.
• Pathway 2 applied to patients requiring rehabilitation or short-term care in a 24-hour bed-based setting.
• Pathway 3 applied to people who required ongoing 24-hour nursing care on a long-term basis, often in a bed-based setting.

13. The model set out that the NHS would fully fund the cost of post-discharge recovery and support services, rehabilitation and reablement care for up to six weeks following discharge from hospital. This was to enable care to continue until a person’s longer-term care needs had been assessed, at which point the person’s care would move to normal funding arrangements.
14. Section 10.5 of the operating model said that, if all relevant health and social care assessments had not been completed within this six-week period, the relevant ICB and/or council should continue to fund the person’s care until the assessments were complete.

Intermediate care and reablement

15. Intermediate care and reablement services provide support to 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.

16. 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)

Transitional Care

17. Under the discharge to assess system, the Community Trust operates an integrated Transitional Care model. The central principle behind this system is the ‘home first’ principle, whereby people are supported to return home as soon as it is safe for them to do so.
18. This model uses several care pathways to differentiate between those with recovery or rehabilitation needs and those with long-term care needs.
19. The model identifies two transitional care pathways. The first is the ‘recovery and reassessment’ pathway. This is for people who require “a period of recovery (including non weight bearing) and/or assessment to determine ongoing needs and/or funding.”
20. The second pathway is the ‘rehabilitation/reablement pathway’. This is for people who require “a period of rehabilitation, motivation confidence building. Optimising individuals’ levels of independence.”
21. The Community Trust also operates a managed stock of beds in the community within community hospitals and residential care homes. Responsibility for deciding whether a person is eligible for a transitional care bed rests with the Community Trust’s Transitional Care Team.

Reablement in Lincolnshire

22. Section 3 of the Care Act 2014 sets out services for which a council must not charge. This includes ‘intermediate care and reablement support services’, which should be provided free of charge for up to six weeks.
23. Section 3(3) of the Care Act says intermediate care and reablement support services:

• consists of a programme of care and support, or support;
• is for a specified period of time; and
• has as its purpose the provision of assistance to an adult to enable the adult to maintain or regain the ability to live independently in their own home.

24. The Lincolnshire Reablement Service (LRS) offers home-based support to people with reablement goals. In order to be eligible for this support, a person must have been “[i]dentified (and where appropriate assessed) by a health and/or social care professional as having potential to achieve Reablement goals.” The person must be “[i]n need of short-term support to facilitate discharge from hospital or remain in the community.” LRS provides this service free of charge on behalf of the Council, further to its duties under the Care Act.

Background

25. Mrs Y was living at home with her adult daughter, who had complex care needs. Mrs Y was her daughter’s main carer.
26. On 21 March 2021, Mrs Y suffered a fall at home. She was admitted to hospital (under the care of the Hospital Trust), where it was found she had broken her hip and required surgery. In the meantime, Mr X arranged for Mrs Y’s daughter to be admitted to a care home on a temporary basis.
27. Between 22 and 28 March, the hospital therapy team (consisting of physiotherapists and Occupational Therapists (OT) reviewed Mrs Y several times. The clinical records suggest she made steady progress during this period.
28. On 24 March, an OT noted that Mrs Y would likely be suitable for discharge under Pathway 2 of the discharge to assess model. That day, the Hospital Trust referred Mrs Y to the Council’s adult social care service.
29. On 29 March, Mrs Y spoke to an OT and hospital discharge coordinator. Mrs Y reported feeling very tired and said she did not feel ready to return home, even with a package of care. Mrs Y said she did not want to move into the care home arranged by Mr X and would prefer to continue working with the therapists. Mrs Y agreed to be referred to the Transitional Care Team for consideration for a transition bed.
30. The discharge coordinator spoke to Mr X that day. She noted his view that the care home he had organised would be better placed to care for Mrs Y as her home was not ready for her. She also noted that Mr X agreed to arrange and fund private physiotherapy for Mrs Y. However, Mr X denies agreeing to this. After further discussion, Mrs Y agreed to be discharged to the care home.
31. On 30 March, Mr X spoke to a social worker. Mr X explained that he hoped to arrange for Mrs Y to be discharged to the same care home as her daughter on a temporary basis. Mr X said this would allow him to plan for Mrs Y to return home.
32. Mr X asked whether Mrs Y’s placement in the care home would be funded for a six-week period under the intermediate care process. The social worker said she had discussed Mrs Y’s care with the transitional care team and that she would not be eligible for a rehabilitation bed as she could move around independently. The social worker said Mrs Y’s care needs could be met at home and that she may be eligible for home-based support from LRS. However, Mr X felt she was not yet ready to return home. The social worker told Mr X that Mrs Y would therefore need to self-fund the care home placement.
33. The social worker also advised Mr X that a referral would also be made for Mrs Y to the Community Trust’s community therapy service. She warned this service would not begin immediately on discharge as there was a waiting list.
34. On 31 March, Mr X spoke to a ward discharge practitioner. Mr X explained that he was in the process of preparing Mrs Y’s home for her eventual return. He also explained that Mrs Y’s home had stairs. The nurse explained that she would ask the therapy team to complete a stairs assessment with Mrs Y.
35. A physiotherapist completed the assessment on 1 April. This identified no concerns about Mrs Y’s ability to manage stairs. The discharge practitioner explained this to Mr X later that day. The discharge practitioner said Mrs Y would not be suitable for a transitional bed and could return home with support from the LRS. Mr X said Mrs Y’s home was not yet suitable for her to live in. The discharge practitioner said Mr X would hear from social services “with a decision about the funding for possible placement under the covid criteria” but that she thought Mrs Y was unlikely to be eligible.
36. On 3 April, the Council’s records show Mr X’s wife told a Council officer that Mrs Y would self-fund her placement in the care home. It should be noted that Mr X’s wife does not recall saying this.
37. Mr X spoke to the social worker again. The social worker advised that Mrs Y would be eligible for home-based reablement support from LRS, or a package of care funded under the discharge to assess process. Mr X reiterated that Mrs Y’s home was not yet ready for her to return to. The social worker advised this was not an adequate reason to delay her discharge. The social worker confirmed that Mrs Y was not eligible for a rehabilitation bed and that she would need to self-fund a care home placement.
38. Mrs Y was discharged to the care home on 5 April under Pathway 3 of the discharge to assess model.
39. Mr X spoke to the discharge practitioner again on 7 April to query whether a referral had been made to the community therapy team. This had not been done. The discharge practitioner made the referral the following day.
40. An OT and social worker visited Mrs Y at the care home on 22 April at Mr X’s request. The OT’s assessment found Mrs Y and her daughter were keen to return home. The OT noted that Mrs Y was able to move around with her frame and was independent with personal care. Mrs Y said she did not want to return home without her daughter but felt unable to provide care for her. The OT agreed to arrange a home assessment and noted that the social worker would work with Mrs Y and her daughter to establish their care needs.
41. The home assessment was completed on 29 April. This found Mrs Y would be able to cope at home with some additional equipment.
42. On 22 May, the social worker completed a social care assessment. This established that Mrs Y did have eligible care needs under the Care Act 2014. As she had savings above the threshold, she agreed to self-fund a package of care arranged by Mr X.
43. Mrs Y was assessed several times by the community therapy team between June and September. She was noted to have good mobility and could move around independently with her frame. However, Mrs Y was ultimately reluctant to engage with therapy. The community therapy team discharged her from the service on 8 September.

My analysis

Discharge arrangements

44. Mrs Y was admitted to hospital in March 2021 during the height of the COVID-19 pandemic. This placed a duty on health and social care organisations to facilitate the discharge of patients from hospital as soon as it was clinically safe to do so. This was to ensure acute hospital beds would be available for those affected by the COVID-19 pandemic, while also reducing the risk of transmission for other inpatients.
45. The discharge to assess model anticipated that most people (around 95%) would be suitable for discharge home. Of these, the model anticipated 50% (Pathway 0) would require no health or social care input. The remaining 45% (Pathway 1) would need some support to recover at home.
46. In 4% of cases (Pathway 2), it was anticipated that people would need some form of rehabilitation or short-term care in a 24-hour bed-based setting. The final 1% (Pathway 3) would require 24-hour nursing care and likely would need care on a long-term basis.
47. The discharge to assess model allowed for up to six weeks of care and support to be provided to support the recovery of those being discharged home. The guidance was not prescriptive about what support should be provided. In some cases, this might be reablement care. This would ordinarily entail a number of daily care visits to support the person to regain confidence and independence. In other cases, this might entail a structured period of NHS therapy (such as physiotherapy) to support that person’s recovery. In the Lincolnshire area, the reablement services are provided by LRS on behalf of the Council. Any therapy services were provided by the Community Trust.
48. For those requiring bed-based care (those under Pathways 2 and 3), the Community Trust’s Transitional Care Team manage a stock of beds in the community. These are located in community hospitals, as well as nursing and residential care homes in the area.
49. The care records show Mr X discussed the possibility of Mrs Y receiving “intermediate care for up to 6 weeks paid for” with a social worker on 30 March.
50. This appears to have caused some confusion as the social worker thought Mr X was requesting a transitional care bed for Mrs Y. In fact, he was exploring whether Mrs Y would be entitled to a period of free intermediate or reablement care in line with the discharge today process.
51. This confusion was compounded as professionals appear to have used terms such as ‘rehabilitation’ and ‘transition’ interchangeably when these terms did not necessarily refer to the same service.
52. There is also some disparity between Mr X’s recollections and the information contained in the care and clinical records. In his complaint, Mr X says he only became aware of the LRS in March 2022, when he obtained copies of the clinical records. However, two of the professionals Mr X spoke to during Mrs Y’s admission noted that they discussed this service with him. The case records show a social worker also told Mr X that Mrs Y may be entitled to “a package of care under covid-19 funding” at home.
53. Further confusion developed regarding whether Mrs Y could return to her own home. In the Council’s records, a social worker noted on 30 March that Mr X was going to “tidy the property”. The same social worker recorded on 3 April that Mrs Y’s house “needed tidying…I advised that coming into hospital was not a reason to not return home for tidying purposes and some appropriate time frame could be given for the home to be tidied.” There is a similar reference to “de-cluttering” in the Council’s complaint response.
54. However, in his complaint correspondence, Mr X said he was required to make extensive changes to Mrs Y’s accommodation to ensure it would be ready for her and her daughter to return to. This included making space for mobility aids and new household equipment, along with a live-in carer if necessary.
55. The evidence I have seen suggests there was a lack of clarity regarding the care and support that was available to Mrs Y, how she could access this and how her eligibility would be determined. Furthermore, I found no evidence to suggest Mr X or Mrs Y were provided with written information leaflets giving them with further information about these services. This was fault. The Hospital Trust, Community Trust and Council share responsibility for this. This caused frustration and uncertainty for Mr X and Mrs Y.

Eligibility for support

56. Mr X complained that the organisations involved in Mrs Y’s care failed to properly consider whether she should have been entitled to a period of free reablement or intermediate care on discharge. Mr X highlighted confusion surrounding the use of terminology regarding discharge arrangements and care pathways.
57. An OT initially assessed Mrs Y as potentially suitable for a Pathway 2 discharge. This would have required her to be placed in a 24-hour bed-based setting (such as a community hospital or care home). A referral was therefore made to the Community Trust for a transitional care bed. However, as Mrs Y was independently mobile on the ward, the Community Trust concluded she did not need a transitional care bed and could be discharged home with support.
58. In his correspondence, Mr X points out that these were only very basic assessments and that professionals did not properly consider Mrs Y’s ability to cope at home. However, the purpose of the discharge to assess process was to ensure that people were discharged from hospital as soon as possible, with further assessments being carried out in the community as necessary.
59. This means that professionals would have visited Mrs Y at home following her discharge to determine what support she required. This did not happen until 29 April as Mr X chose to have Mrs Y transferred to the care home instead.
60. I acknowledge that Mr X had good reasons for arranging for Mrs Y to enter the same care home as her daughter. However, the professionals who assessed Mrs Y concluded that she did not require a residential placement and could be supported at home. It was ultimately Mr X’s decision to arrange for Mrs Y to enter the care home. I am satisfied the professionals supporting Mrs Y made clear to Mr X that she would need to self-fund the placement and that the family agreed to this. I found no fault on this point.

Physiotherapy

61. The records show that Mrs Y had an assessed need for ongoing therapy services. Despite this, the Hospital Trust had still not made a referral to the community therapy team at the point of her discharge from hospital. This omission represents fault by the Hospital Trust.
62. Mrs Y was first assessed by an Occupational Therapist (OT), on 5 June, almost two months after the referral had been made to the therapy service. The OT found Mrs Y could transfer independently from her bed to a standing position and could use her walking frame to move around. The OT could not assess Mrs Y’s ability to manage stairs as there were none in the care home. However, Mrs Y said she had been able to manage the stairs when she visited her home with Mr X.
63. A health care support worker visited Mrs Y the following day to trial her with a new slimline walking frame that would make it easier for her to move about at home. However, Mrs Y preferred her current frame.
64. The OT spoke to Mr X that day to update him. She said Mrs Y’s mobility was “extremely good” and that she was able to move around safely. The OT advised that the team could visit Mrs Y at home following her discharge to assess her.
65. A physiotherapist visited Mrs Y at home on 21 June. The physiotherapist gave Mrs Y some chair-based exercises and encouraged her to complete these twice per day. She noted Mrs Y had a “good range of movement and had no pain or discomfort completing the exercises”.
66. Members of the team visited Mrs Y at home on three further occasions during July and August. The records of these visits show Mrs Y was reluctant to complete her exercises and was not engaging with the therapy.
67. The team made a final visit to Mrs Y on 8 September. She was described as “very reluctant to participate in therapy”. The team noted that Mrs Y had reached her therapy potential and discharged her.
68. In summary, there is some evidence of delay from the point the referral was made (April 2021) to the point that Mrs Y was assessed (June 2021). However, the assessments carried out by the therapy team revealed Mrs Y had good mobility and was able to move around independently. I am satisfied the delay did not have a significant impact on Mrs Y, therefore.

Complaint handling

69. Mr X said the organisations involved in his complaint failed to work together to provide him with a properly coordinated response. As a result, he said they failed to properly address his concerns and did not provide him with a clear rationale for why Mrs Y was not eligible for intermediate or reablement care.
70. The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (the ‘complaints regulations’) place a duty on health and social care providers 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 another.
71. Section 9 relates to the duty to cooperate to address complaints that concern more than one responsible body. It states that, in these circumstances, the responsible bodies must co-operate in handling the complaint. This includes a shared duty to: establish who will lead the complaint process; share relevant information; and provide the complainant with a coordinated response.
72. The complaints correspondence I have seen shows the Hospital Trust responded to a complaint from Mr X in June 2021. However, this simply signposted Mr X to the Council.
73. When Mr X subsequently complained to the Council as directed, he was advised that the decision on a person’s eligibility for intermediate or reablement care is the responsibility of the Community Trust.
74. Mr X then complained to the Community Trust in April 2022. The Community Trust identified that the complaint contained elements that would require responses from the Council and Hospital Trust and began the process of formulating a joint response. However, the departure of a senior Community Trust manager meant the complaint passed to the ICB for a coordinated response. This did not happen until late September 2022.
75. The ICB provided a joint response in December 2022, around eight months after Mr X had submitted it. Even then, the response was incomplete as the Council declined to contribute to it.
76. The evidence I have seen shows the Hospital Trust, Council and Community Trust failed to work together to address Mr X’s complaint as required by the complaints regulations. This was fault.
77. This failure caused significant delay and put Mr X to unnecessary time and trouble. Furthermore, the various complaints responses were confusing and contradictory. In my view, this might have been avoided if these organisations had provided a coordinated complaint response at the outset.
78. I found no fault by the ICB in this case, which did not become involved in the complaint until September 2022 and made appropriate efforts to arrange a properly coordinated response.

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Agreed actions

79. Within one month of my final decision, the Council, Community Trust and Hospital Trust will write a joint letter to Mr X. They will:

• apologise for the frustration and confusion caused to Mr X and Mrs Y by their shared failure to provide him with clear and appropriate information about Mrs Y’s care options;
• apologise for the further frustration caused to Mr X by their shared failure to handle his complaint in accordance with the complaints regulations; and
• each pay Mr X £100 (a total of £300) in recognition of the impact of these events on him.

80. Within three months of my final decision, the Council, Community Trust and Hospital Trust will:

• explain what action they will take to ensure appropriate information is provided to patients, carers and families about available care options as part of the discharge planning process;
• explain what action they will take to ensure relevant care staff are aware of these care options and the eligibility criteria for accessing them; and
• review their complaints procedures to ensure there is a clear process in place for handling joint complaints in accordance with the complaints regulations.

81. The organisations will provide us with evidence they have completed the above actions.

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Final decision

82. I found fault by the Council, Hospital Trust and Community Trust with regards to the information they provided to Mr X and Mrs Y regarding available care options. I also found fault with their subsequent handling of Mr X’s complaint.
83. I am satisfied the agreed actions set out above represent a reasonable and proportionate remedy for the injustice caused to Mr X and Mrs Y by this fault.
84. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman