Summary: We found no fault with the support provided to Mrs Y by a Council following her discharge from hospital. Nor did we find any fault with the information provided to Mrs Y’s family regarding charging arrangements for her care. We found fault with a Trust’s failure to refer Mrs Y for rehabilitation at the point of discharge. This delayed her access to therapy. The Trust will apologise and pay a financial remedy.

The complaint

1. The complainant, Mrs X, is complaining about the care provided to her mother, Mrs Y, by East Sussex County Council (the Council) and east Sussex Healthcare NHS Trust (the Trust).
2. Mrs X complains about the information provided to her and Mrs Y by the Council and Trust when Mrs Y was discharged in May 2023. Mrs X says Mrs Y should have received reablement in the community when she returned home but this did not happen. She said reablement did not happen until months later and this had a damaging impact on her mother’s rehabilitation. Mrs X says the Council did not explain its charging rules and she was told the first six weeks of care would be free. She also says the Council took too long to complete a financial assessment.
3. Mrs X says this situation was extremely stressful for her and Mrs Y. She says she was required to deal with Mrs Y’s affairs as result of the failure of the Council and Trust to support her.

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The Ombudsmen’s role and powers

4. 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).
5. 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.
6. If we are satisfied with the actions or proposed actions of the bodies 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

7. In making my final decision, I considered information provided by Mrs X. I also considered relevant information from the Council and Trust, including the care records. I shared a copy of my draft decision statement with all parties for comment and considered the responses I received.

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What I found

Relevant guidance and legislation

Reablement, Rehabilitation and Intermediate Care

8. In 2023, NHS England produced the guidance document ‘Intermediate care framework for rehabilitation, reablement and recovery following hospital discharge’ (the intermediate care guidance). This is a guidance document for health and social care providers.
9. The terms ‘reablement’, ‘rehabilitation’ and ‘intermediate care’ are often used interchangeably. These terms relate to provision of health or social care services (or a combination of both) for a limited time (not usually longer than six weeks). These services are usually provided to a person in their own home or in a short-term residential placement.
10. Intermediate care services are intended to support a person to regain confidence to perform activities of daily living (such as personal care, preparing food and cleaning) following a hospital admission. In some cases, a person may need a programme of structured physical therapy support to help them recover mobility and physical function after a fall or other injury.
11. Regulations require intermediate care and reablement to be provided without charge for up to six weeks. 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. (Regulation 4, Care and Support (Preventing Needs for Care and Support) Regulations 2014)
12. Discharge services in the East Sussex area are provided by the Joint Community Reablement/Rehabilitation Team. This is an integrated team providing health and social care services.
13. The reablement service consists of social care professionals providing support to help people regain confidence with activities of daily living. The Council is responsible for these services under the Care Act 2014.
14. The rehabilitation service consists of therapy professionals (such as Occupational Therapists (OTs) and physiotherapists. Rehabilitation services ordinarily involve a programme of therapy intended to help a person regarding mobility. The Trust is responsible for these services.

Care Act 2014

15. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment of any adult who appears to need care and support. They must assess anyone, regardless of their finances or whether the council thinks they have eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the outcomes they want to achieve. It must involve the individual and where appropriate their carer or any other person they might want to be involved.
16. An assessment should be carried out over an appropriate and reasonable timescale taking into account the urgency of needs and a consideration of any fluctuation in those needs. Councils should let the individual know of the proposed timescale for when their assessment will be conducted and keep the person informed throughout the assessment process.

Background

17. Mrs Y was living at home with one daily care visit from a private carer. She was admitted to hospital in March 2023 following a fall. The clinical team established that Mrs Y had not sustained a fracture, and she was discharged home with pain relief medication.
18. Mrs X subsequently contacted the Council to report that Mrs Y was struggling to move around her home following the fall. The Council referred Mrs X to the Joint Community Reablement Team (JCR).
19. The JCR began a programme of reablement support for Mrs Y on 21 March. However, she continued to experience mobility difficulties and extreme hip pain. This led to her being readmitted to hospital on 24 March. The Trust then transferred Mrs Y to a rehabilitation unit for physiotherapy.
20. The physiotherapy team that treated Mrs Y as an inpatient concluded she would no longer be suitable for reablement services on discharge. This was due primarily to Mrs Y’s dementia diagnosis and her need for long-term care services to support her at home.
21. In April, an OT completed a home assessment for Mrs Y. The assessment found Mrs Y could move around using a walking aid but would need additional support with personal and domestic tasks on discharge.
22. In May, a Council officer completed a Care Act assessment. As part of this assessment, the officer obtained the views of Mrs X and Mrs Y. the assessment found Mrs Y would need long-term care visits to support her with activities of daily living, such as personal care and meal preparation.
23. On 11 May, the Council officer contacted Mrs X. She noted that “I advised [Mrs X] of the financial process and explained that [adult social care services] are means tested and that [Mrs Y] will be eligible for a contribution to her care from the start of the service.” However, Mrs X said Mrs Y did not have savings above the charging threshold.
24. The Trust discharged Mrs Y on 22 May. The discharge summary noted that Mrs Y was “deemed medically ready for discharge home with JCR rehab”. This would be provided by the community therapy team, which is managed by the Trust. However, the Trust subsequently acknowledged it did not make a referral to the team.
25. Mrs Y returned home as planned with two daily care visits arranged by the Council.
26. On 13 June, the care provider contacted the Council to request funding for a longer care visit in the morning. This was because Mrs Y was noted to be moving very slowly around her home and care staff needed longer to support her.
27. Mrs X discussed the charging arrangements with a Council officer on 14 June. She said she had been advised that Mrs Y’s care would be free for six weeks following her discharge. However, the Council officer said this was incorrect and that Mrs Y would be considered a self-funder from the point of her discharge from hospital. Mrs X said Mrs Y would not be able to fund the package of care on an ongoing basis.
28. On 27 June, Mrs Y’s GP referred her to the rehabilitation team. Mrs Y was placed on a waiting list for physiotherapy review.
29. In July, the Council contacted Mrs X to arrange a review of Mrs Y’s care needs. However, Mrs X declined this as she was awaiting the outcome of Mrs Y’s financial assessment.
30. The Council subsequently confirmed that Mrs Y was a self-funder and would need to pay the entirety of her care fees.
31. The rehabilitation team eventually assessed Mrs Y in March 2024. The team provided Mrs Y with a home exercise programme to complete with her carers. In addition, the team arranged for ramps for Mrs Y’s property to allow wheelchair access.

My analysis and findings

Reablement services

32. In its response to our enquiries, the Council explained that Mrs Y had initially been in receipt of reablement services until her readmission to hospital. However, following a period of inpatient care and rehabilitation, the assessing professionals felt Mrs Y would no longer be suitable for the reablement service. Rather, they concluded Mrs Y would need a long-term package of care to support her on discharge.
33. It is important to be clear that reablement is a short-term service (not usually more than six weeks). The Care and Support (Preventing Needs for Care and Support) Regulations 2014) define “intermediate care and reablement support services” as services which:
1. consist of a programme of services, facilities or resources;
2. are for a specified period or time; and
3. have as their purpose the provision of assistance to an adult to enable the adult to maintain or regain the ability need to live independently in their own home.
34. During her time in hospital, Mrs Y was assessed by the physiotherapy team and an OT completed a home assessment. Further, a social worker completed a Care Act assessment for Mrs Y. In each case, the assessments concluded that Mrs Y’s needs were no longer short-term in nature and that she would need support at home on a long-term basis.
35. In her assessment, the social worker found Mrs Y needed support with several activities of daily living, including washing, dressing and meal preparation. She concluded Mrs Y would need two daily care visits (in addition to the ongoing support from her private carer) to assist her with these tasks. The care records therefore support the Council’s position that Mrs Y needed a package of long-term care and was no longer suitable for reablement services. Indeed, I note Mrs Y remains in receipt of this care package. I find no fault by the Council on this point.

Charging information

36. As part of her assessment in May 2023, the social worker spoke to Mrs X. She noted “I advised [Mrs X] of the financial assessment process and explained that ASC services are means tested and that [Mrs Y] will be eligible for a contribution to her care from the start of the service.”
37. On 14 June, the social worker spoke to Mrs X again. During this call, Mrs X said she had been told by the care agency supporting Mrs Y that the care should be provided free of charge for the first six weeks. However, the social worker advised this was not correct. The social worker also explained that the Council’s finance team had confirmed Mrs Y would be a self-funder. The record of the call suggest Mrs X did not agree with this.
38. I understand Mrs Y’s family subsequently appealed this decision. However, the Council did not uphold the appeal and informed Mrs Y’s family of the outcome in October 2023.
39. The case records show Council offices did provide Mrs X with charging information and made clear that Mrs Y would be eligible to contribute to her care from the beginning of the care package.
40. I find no fault by the Council in this regard.
41. I recognise there were some complexities regarding Mrs Y’s financial assessment. Specifically, these concerned whether Mrs Y’s second property should be disregarded as part of the financial assessment process. This did cause some delay. However, I do not consider the delay was so great as to be considered fault by the Council.

Rehabilitation services

42. In its response to our enquiries, the Trust acknowledged that it did not make a referral for Mrs Y for rehabilitation at the point of discharge. The Trust further acknowledged that rehabilitation “would have been beneficial” for Mrs Y. Nevertheless, the Trust said that, following a triage in July 2023, the therapy team concluded that Mrs Y did not have any urgent therapy needs.
43. The care records show a referral was eventually made for Mrs Y for rehabilitation on 27 June 2023. This was over a month after her discharge from hospital. There was then a further delay as there was a waiting list for the service. This meant the service did not assess Mrs Y until March 2024, almost ten months after her discharge. This was an inappropriate delay and represents fault by the Trust.
44. While there was some delay in making the referral, it is not now possible to say precisely what impact this had on Mrs Y’s recovery. This is because there would likely have been a significant delay in any case due to the waiting list for the service. Nevertheless, the failure to refer Mrs Y for rehabilitation represented a missed opportunity to properly explore her care needs at the point of discharge.
45. In its response to our enquiries, in recognition of the above, the Trust has offered to pay Mrs Y’s outstanding care fees of £1,036.39. In my view, this payment represents an appropriate and proportionate remedy for the injustice caused to Mrs Y by the fault I identified.

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Agreed actions

46. Within one month of my final decision, the Trust will:

• write to Mrs X to apologise for its failure to make a referral for rehabilitation therapy for her when she was discharged from hospital in May 2023; and
• pay the suggested remedy of £1,036.39 to settle Mrs Y’s outstanding care fees.

47. The Trust will provide us with evidence it has complied with the above actions.

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Final decision

48. I found no fault with the care and support provided to Mrs Y by the Council. However, I did find fault by the Trust as it failed to make a timely referral for rehabilitation for Mrs Y.
49. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman