Summary: Mr X complained about Cambridgeshire and Peterborough NHS Foundation Trust (the Trust) and Cambridgeshire County Council (the Council). He complained about faults in his discharge from hospital, reablement, and referrals for community therapy services. He also complained about the Council’s complaint handling. We have upheld parts of the complaint relating to hospital discharge, reablement and referrals for therapy. The Council and Trust have accepted our recommendations, so we have completed our investigation.

The complaint

1. The complainant, whom I shall call Mr X, complains about the actions of Cambridgeshire County Council (the Council) and Cambridgeshire and Peterborough NHS Foundation Trust (the Trust). He complains about the following:
1. a flawed discharge from hospital to a flat which did not meet his needs;
2. lack of referral to occupational therapy and physiotherapy services;
3. reablement services being stopped prematurely;
4. incorrect information from the Council to a neighbouring council’s housing department, stating Mr X could stand in a shower cubicle; and
5. delays in complaint handling.
2. Mr X says this has led to him experiencing financial loss, distress due to not having his needs met, and the loss of services. Mr X considers a delay in receiving physiotherapy has put back his recovery.
3. Mr X would like a financial remedy greater than that already offered by the Council.

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The Ombudsmen’s role and powers

4. 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).
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. When investigating complaints, if there is a conflict of evidence, the Ombudsmen may 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. 
7. 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))
8. 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)

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How I considered this complaint

9. I have considered:
• information the complainant has provided by telephone and in writing;
• the Council’s and Trust’s written responses to my enquiries, and the supporting documents they have provided; and
• the law, national guidance and local policies, where they apply to the issues in this complaint. Where relevant, I have referred to these in the body of this decision statement.
10. Mr X, the Council and the Trust have had an opportunity to comment on a draft version of this decision. I took any comments they made into account before reaching a final decision.

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What I found

Background summary

11. In 2021, Mr X became seriously ill with COVID-19. He needed months of treatment in one of the Trust’s acute hospitals and became homeless while he was in hospital. In October 2021, Mr X no longer needed to be in an acute hospital. The Trust moved him to a rehabilitation unit (CRU) at one of its hospitals. Mr X spent about a month there receiving treatment including therapy to help him improve his mobility. In November 2021, a neighbouring council sourced interim accommodation in a furnished flat (Property 1) for him.
12. Mr X was discharged to Property 1 on 10 November 2021. Mr X was unhappy about Property 1 because:
• he could not use the shower without adaptations;
• the property owner would not allow adaptations;
• he therefore had to have strip washes instead of showers;
• the mattress on the bed was uncomfortable; and
• the chair in the living room was too low for him.
13. Mr X complained about the conditions in the flat and the neighbouring council moved him to Property 2 in January 2022. Mr X says that this caused him a financial loss because Property 1 was funded by a government grant at no cost to him, whereas he had expenses for Property 2.

A – Hospital discharge

Relevant guidance

14. National guidance called “Hospital Discharge Service: Policy and Operating Model” published in August 2020 was in place for hospitals, councils and social care providers in November 2021. The following are relevant points from that guidance.
• The Government provided extra funding to help cover the cost of post-discharge recovery and support services. This was for up to six weeks following discharge from hospital or a “Pathway 2 facility”.
• Hospitals should use a “discharge to assess pathways model”. Pathway 2 was for people well enough for discharge from an acute hospital but not well enough to live in the community, who needed rehabilitation or short term care in a 24-hour bed-based setting. The CRU was a “Pathway 2 facility”. Pathway 1 was for people who could live independently in the community but needed time-limited support from health or social care to help them do so.
• Hospitals must transfer information “essential to the continued delivery of care and support” to social care services on discharge.
• “Health and care systems should ensure effective information sharing, and full and carefully documented assessments of need, to ensure care providers can deliver the care and support people require”.
• Individuals must be fully informed of the next steps.
• This guidance should be read alongside the National Institute for Health and Care Excellence (NICE) guideline NG27 “Transition between inpatient hospital settings and community or care home settings for adults with social care needs”.
15. NG27 says:
• discharge planning should start as soon as a person with complex needs is admitted to hospital;
• hospitals should keep people regularly updated about any changes to their plans for transfer from hospital; and
• hospitals should have discharge coordinators who are responsible for coordinating people’s discharge from hospital. Discharge coordinators are the central point of contact for health and social care practitioners, the person and their family during discharge planning.
16. NG27 says discharge coordinators should:
• be involved in all decisions about discharge planning;
• work with hospital- and community-based multidisciplinary teams and the patient to develop and agree a discharge plan;
• arrange follow-up care;
• discuss the need for any specialist equipment, including housing adaptations, with relevant professionals;
• ensure any essential specialist equipment is in place at the point of discharge; and
• agree the plan for continuing treatment and support with the community-based multidisciplinary team.

What happened

17. The Trust transferred Mr X from the acute hospital to the CRU on 12 October 2021 under Pathway 2. The Trust’s records of Mr X’s care at the CRU show that:
• on 25 October, Mr X asked staff to discuss discharge planning with him;
• on 27 October, the Trust became aware that Property 1 would be available from the following week. The Trust was aware the flat had no adaptations and a shower cubicle with a tray to step up into;
• on 2 November, the Trust contacted the Council’s reablement team for more information about Property 1 but the team had no information about it. This is despite the Council’s occupational therapy team assessing Property 1 and preparing a detailed report on it. The Trust therefore asked the neighbouring council, which had sourced the flat, for the information. The Trust also issued a walking frame to Mr X;
• on 3 November, the Trust created a discharge notification document and sent it to the Council. The document said Mr X would be discharged under Pathway 1 and that equipment was to be assessed and ordered pending an update about Property 1 from the neighbouring council. It also said Mr X needed to sit to wash himself;
• on 8 November, a Trust doctor told Mr X that his accommodation was ready and he could be discharged the next day. However, following discussion with the Council’s reablement team, the Trust told Mr X that reablement was not in place for the following day. Mr X still had a urinary catheter in place. The doctor explained to Mr X that taking the catheter out in hospital at that point may delay his discharge. This was because the hospital would need to observe him to check his bladder was emptying properly without the catheter in place. Mr X told the doctor he was unhappy with the level of discussion about the catheter so far. A therapist who saw Mr X that day noted he could get on and off a chair, and get to and use the toilet independently with the help of a walking frame;
• on 9 November the Council’s reablement team considered Mr X’s referral and agreed to start supporting him from the following day. The Trust successfully removed Mr X’s catheter and booked transport to Property 1 for the following day;
• Mr X was discharged from the CRU to Property 1 on 10 November. The Trust gave him his discharge paperwork, advice leaflets, and two urinal bottles. Mr X told staff he was upset about the discharge because nobody told him he was going until that morning.
18. The Council’s reablement team started visiting Mr X in the afternoon of 10 November. Mr X received a perching stool on 22 November 2021. The expectation was that he would sit on the perching stool in the kitchen to prepare food and wash himself.

Was there fault causing injustice?

19. At the time Mr X left the CRU, government guidance said people should be discharged from hospital as soon as it was safe to do so. This was the case even if their discharge destination was not their preferred one.
20. There was no fault in the Trust’s decision that Mr X was ready for discharge from the CRU. This is because he had received therapy, his mobility had improved, and he could function without a catheter.
21. However, there were several faults in the way Mr X was discharged and some caused him injustice. I will set out my views on these below.
22. There is no evidence the Trust started planning Mr X’s discharge as soon as he moved to the CRU. This was contrary to the guidance in place at the time. But it did not cause Mr X an injustice, as there was no undue delay in him being able to leave hospital.
23. There is no evidence the Trust proactively discussed discharge arrangements, including a trial without catheter, with Mr X. The Trust also failed to keep Mr X adequately informed about the details of the discharge in the days before he left hospital. Instead, Mr X asked the Trust to discuss discharge planning about two weeks after he transferred to the CRU. A doctor first discussed hospital discharge and catheter removal with him only one day before the Trust believed he would be discharged, on 8 November. There was plenty of time for the Trust to discuss these issues with Mr X before then, since it issued a discharge notice to the Council on 3 November. What happened was contrary to relevant guidance and therefore fault. This caused significant distress to Mr X, who was very vulnerable at the time, and naturally anxious about the discharge process.
24. The Trust and Council were aware that Mr X would need to sit to wash himself. They were also aware through the Council’s occupational therapy report that this was impossible in Property 1’s shower. The organisations did not discuss this with Mr X before his discharge from hospital. None of the records the Council and Trust provided indicate they considered:
• whether not being able to shower while waiting for a permanent home for weeks or months was appropriate in Mr X's circumstances; and
• how this might affect his health, wellbeing and dignity.
25. We cannot say, even on balance of probability, that the Council and Trust would have decided Property 1 was an unsuitable discharge destination had they considered these matters more explicitly. This is because the property was a temporary one and Mr X was due to receive reablement services with a view to increasing his ability to care for himself. However, the lack of explicit records of consideration leaves Mr X with an uncertainty that things might have been different. The uncertainty is an injustice to Mr X.
26. The Trust and Council failed to ensure Property 1 had a perching stool in place when Mr X was discharged from hospital. This was not in keeping with the relevant guidance or the aim of increasing Mr X’s independence, and was therefore fault. It meant Mr X had to either perform washing and food preparation tasks without the safety and comfort of a perching stool, or wait for reablement carers to do these tasks for him, even though he was capable of washing himself with the proper equipment in place. This happened for about two weeks after Mr X moved into Property 1.
27. When Mr X received the perching stool, the Council expected him to use it in the kitchen for both food preparation and washing himself. We asked the Council to explain how it considered the impact of this on food hygiene and on Mr X’s dignity.
28. The Council told us that its occupational therapy service asked in late November 2021 why Mr X could not have a second perching stool and its reablement manager decided this was because of limited space. The Council has not provided any explanation or evidence to show how it considered the impact on food hygiene and Mr X’s dignity when expecting him to wash himself in a food preparation area. The Council’s own records for the same date say its reablement team decided to refuse the occupational therapist’s request for a second perching stool because “at the moment, [Mr X] is being provided what is essential for his needs. He has a perch stool in kitchen, and although it is not ideal, he would benefit from using it for a strip wash in the kitchen till he moves. Not essential to provide a second stool at present”.
29. Based on the available evidence, the Council did not properly consider the occupational therapist’s professional opinion together with the impact on food hygiene and Mr X’s dignity before refusing a second perching stool. This was fault.
30. While Mr X was very dissatisfied because he could not use the shower in Property 1, there were sinks in the flat. The reablement service care workers were available to help him wash when he could not wash himself. There is also evidence the single perching stool was moved between the kitchen and the bathroom at times. Mr X was therefore not completely without access to services to maintain his personal hygiene. However, because of the Council’s failure to properly consider the occupational therapist’s request for a second perching stool, he lost the opportunity to access a more convenient and dignified way of doing so. This is an injustice to Mr X.
31. I have made recommendations for a remedy for Mr X at the end of this statement.

B – Referrals for therapy services

32. Mr X complains that the Trust and Council failed to refer him for physiotherapy and occupational therapy.
33. The Trust told us that the plan for discharging Mr X from the CRU involved:
1. the CRU referring Mr X to the Council’s reablement team, which would provide care and rehabilitation; and
2. the reablement team referring Mr X to community physiotherapy once his “functional ability improved”.
34. However, the Trust has not:
• provided evidence to show b) above was part of the plan for Mr X’s discharge at the time;
• provided evidence that it communicated this part of the plan to the reablement team; or
• explained how this plan would have been in keeping with the relevant guidance and Mr X’s condition at the time.
35. The lack of records is not enough for me to conclude the planning for discharge was not as described by the Trust. I cannot rule out the possibility it is evidence of poor record keeping only. However, the poor record keeping and lack of a rationale for the plan are themselves faults by the Trust. We cannot now say that Mr X would have received community therapy services earlier, if the faults had not happened. This is because there were too many unknown variables at the time, including how Mr X would respond to reablement care. However, Mr X is left with a distressing sense of uncertainty because of the poor record keeping and lack of a reasoned explanation for the Trust’s decision not to refer him for community therapy services. This sense of uncertainty is an injustice to Mr X.
36. The Council’s reablement team referred Mr X to its occupational therapy service seven days after he moved into Property 1. It did so after assessing his needs, setting goals, ordering a perching stool and storage container, reviewing Mr X’s progress and noting his dissatisfaction with some of the furniture and being unable to use the shower. The time the Council took to refer Mr X for occupational therapy was not fault. The Council needed a few days to assess Mr X’s needs and how he was managing in the flat. The occupational therapy service considered the referral within eight days and:
• noted the owner of Property 1 would not agree to adaptations;
• advised the Council on equipment to help Mr X use Property 1;
• suggested referring Mr X to a charity which could provide him with alternative furniture; and
• closed the case as there was no further support it could provide until Mr X moved to a different property.
37. There was no fault in the time the Council’s occupational therapy service took to consider Mr X’s case.
38. In late November 2021, Mr X told the Council’s reablement team that he was not receiving physiotherapy. The reablement team did not take any action at the time. It also incorrectly told the occupational therapist that Mr X was waiting for a physiotherapist’s input. This was fault. In early February 2022, Mr X told the reablement team again that he was not getting any physiotherapy. At this point, the Council contacted Mr X’s GP to request a physiotherapy referral. The Council has already apologised to Mr X for the eight-week delay this fault caused and offered him £150 in recognition of his distress.
39. I have made recommendations for a remedy for Mr X at the end of this statement.

C – Stopping reablement

Background and relevant guidance

40. Reablement services are services to help people live independently. They are provided in the person’s own home by a team of mainly care and support professionals. Reablement has a focus on helping the person regain skills and capabilities to reduce needs, including through therapy and minor adaptations. Where councils provide reablement to those who need it, they must do so free of charge for up to six weeks. However, councils can provide reablement for longer than six weeks, or end it sooner, if appropriate.
41. The Government’s Care and Support Statutory Guidance (CSSG) says councils should consider the potential impact and consequences of ending reablement.
42. NICE guideline “Intermediate care including reablement” (NG74) says reablement services should:
• offer the person information they need about their care and support in a range of formats, including in writing;
• agree goals with the person, document them and give a copy to the person;
• regularly review people’s goals with them and adjust the period of reablement depending on the progress they are making towards their goals;
• before the person finishes reablement, give them information about how they can refer themselves back to the service should they need it; and
• have a clear plan for when the service ends, with a contingency plan should anything go wrong.

What happened

43. The Council started providing Mr X’s reablement service in the afternoon of the day he was discharged from hospital to Property 1, 10 November 2021. It assessed his reablement needs and worked with Mr X to set his reablement goals the following day. It reviewed Mr X’s progress four times in November.
44. The available records say that by 1 December, Mr X could manage his personal hygiene, food and drink needs and often refused offers of help with these from the reablement workers who visited him. While he wanted to be able to have a shower, he could not do this in Property 1 because the property owner refused to allow adaptations. Instead, he washed himself while sitting on a stool.
45. The Council concluded on 1 December that Mr X had met his reablement goals. On 2 December, it noted Mr X had declined all offers of support and was independent. It said that the showering goal cannot be achieved in Property 1, but that Mr X could be re-referred to reablement when he moved somewhere suitable for shower equipment. The Council formally stopped Mr X’s reablement service on 7 December. Mr X was unhappy with this and complained the Council stopped reablement prematurely.

Was there fault causing injustice?

46. The Council acted in accordance with guidance when it assessed Mr X’s reablement needs, set his reablement goals and reviewed his progress. The Council’s records also show it properly considered the reasons for and consequences of ending Mr X's reablement service. I have therefore found no fault in the way the Council reached its decision to end Mr X’s reablement service in December 2021.
47. There is evidence the Council discussed reablement needs, goals and progress with Mr X in accordance with the guidance. It also gave Mr X leaflets with general information about its reablement services. However, the Council has not provided any evidence it gave Mr X written information about his goals, the service ending and contingency plans. This was fault, which meant Mr X had to rely on and recall verbal information. Having clear written information may have managed Mr X’s expectations about the limitations of the reablement service.
48. Since the events Mr X complains about happened, the Council has improved the computer system it uses so it now reminds staff to send written information to people using its reablement services. I have recommended a remedy for Mr X at the end of this statement.

D – Inaccurate information to a housing department

49. Mr X considers the Council incorrectly told a neighbouring council’s housing department that he could stand in a shower cubicle.
50. The evidence I have seen indicates that, before Mr X moved into Property 1:
• the Council’s occupational therapy department assessed Property 1 and produced a report in September 2021. This said the shower in Property 1 could only be used by somebody able to stand in it independently;
• the Trust issued a discharge notice stating Mr X needed to sit to wash; and
• the neighbouring council was aware of this information.
51. In December 2021, about a month after Mr X moved into Property 1, the Council had a discussion with the neighbouring council. The conversation included the views that Mr X had difficulty standing but could manage to use an adapted shower. However, the shower in Property 1 could not be adapted.
52. There is nothing in the evidence I have seen to show the Council or the Trust told the neighbouring council that Mr X could stand in a shower cubicle without adaptations and without difficulty. I have therefore found no fault in this part of the complaint.

E – delays in complaint handling

53. Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 say that:
• NHS organisations and councils should have clear procedures to deal with complaints, and investigate and resolve them quickly and efficiently;
• where a complaint is about more than one organisation, they must cooperate with each other when handling the complaint and provide a joint response; and
• in most cases, organisations must acknowledge complaints within three working days of receiving them. They can do so orally or in writing.
54. Regulations do not say how long a complaint investigation should take. But they do say an expected timescale must be explained at the start, usually in discussion with the complainant. If the complainant does not want to discuss this, the responsible body must decide the timescales and confirm them to the complainant in writing. The body must keep the complainant informed of progress during the investigation ‘as far as reasonably practicable’. If the responsible body has not provided its response after six months (or after a longer period agreed with the complainant), it must write to the complainant to explain why. (Regs 13 and 14, Local Authority Social Services and National Health Service Complaints (England) Regulations 2009)

The Trust’s complaint handling

55. The Trust has a complaints policy which is in line with the Regulations.
56. On 18 January 2022, Mr X contacted his MP with his concerns about a lack of physiotherapy. The MP contacted the Trust, which replied within a week. This was within the timescale set out in the Trust’s complaints policy and not fault.

The Council’s complaint handling

57. The Council has an adult social care complaints policy which says:
• people should direct their complaints to its customer care team;
• the Council should acknowledge all complaints in writing within three working days of receipt;
• where a complaint relates to a health body, the Councill will get consent from the complainant before forwarding the information for investigation;
• where a complaint relates to both health and social care services, every effort will be made to provide a joint response. If this is not possible or would cause delays, the Council will inform the complainant as soon as possible;
• the Council will do an initial assessment of the complaint before contacting the complainant to discuss their desired outcome and a timeframe for a response. The Council’s usual response timescale is 25 working days, but it can extend this for more complex cases; and
• if the complainant tells the Council they are dissatisfied with its response, the Council can signpost them to the Ombudsman or provide further responses, including a written response following a senior manager review. The Council aims to complete this within three months of the senior manager receiving the review request.
58. On 1 December 2021, Mr X told the Council’s reablement team that he wanted to complain. The reablement team signposted him to the Council’s complaints procedure.
59. On 21 January 2022, Mr X emailed a senior manager at the Council with concerns about the delay in occupational therapy equipment for Property 1. Following discussion with the reablement team, the Council decided to ask its customer care team to treat Mr X’s email as a formal complaint on 26 January. The council contacted Mr X the following day. It sent Mr X a formal acknowledgement letter on 31 January. This was longer than the three working days set out in the Council’s policy. However, the Council acknowledged the complaint in writing within three working days of its customer care team receiving it. This was in accordance with its complaints policy.
60. The Council sent its response on 23 February. This was within the Council’s 25 working day timescale.
61. Mr X was dissatisfied with the response of 23 February and asked for a review by a senior manager. The Council acknowledged this on the following day. It wrote to him on 28 February saying it would respond formally within 25 working days. This met the timescales in its policy.
62. The Council responded to Mr X within 25 days, on 15 March, to say most of the issues he remained concerned about were the responsibility of other organisations. It provided the organisations’ contact details should Mr X want to contact them individually. It also offered to refer Mr X’s complaints to the other organisations if he provided consent. It did not refer Mr X to the Ombudsman. Mr X replied on the same day to say he was dissatisfied with this response. He did not provide consent for the Council to share information with other organisations.
63. On 21 March, the Council wrote to Mr X again asking him what outcomes he wanted to resolve the complaint. It also explained how the other organisations were involved in the matters he complained about and provided a further consent form. Mr X replied confirming he wanted a financial remedy and providing consent for the Council to share information with the Trust’s hospital.
64. On 28 March, the Council confirmed it would carry out a senior manager review of Mr X’s complaint. It said it would respond within three months. The Council obtained input from the Trust and issued its final response to Mr X on 30 May 2022. This was within the timescale set out in the Council’s letter of 28 March. The Council’s letter told Mr X he could complain to the Ombudsman if he remained dissatisfied.
65. The Council’s complaints policy conforms to the Regulations. Overall, the Council responded to Mr X within the timescales set out in its policy and without fault.

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Agreed actions

66. The Trust will send Mr X a meaningful written apology and pay him £250 in recognition of the distress, worry, uncertainty and inconvenience caused by the faults we have identified. It will do this within one month of the date of our final decision.
67. We recognise the Council has already apologised to Mr X for the delay in referring him for physiotherapy and offered him £150 in recognition of the problems this caused him. However, we have identified further fault and injustice as part of this investigation and therefore consider this is not an adequate remedy. The Council has agreed to apologise to Mr X for the faults identified in this decision and their impact on him. It will also pay him £500 in total (incorporating the £150 already offered) in recognition of the overall impact of the faults we have identified. This includes uncertainty, inconvenience, lost opportunity to access a more convenient and dignified way to maintain personal hygiene, and delay in accessing physiotherapy. It will do this within one month of the date of our final decision.
68. Many of the faults we have identified happened while special hospital discharge guidance was in place because of COVID-19. That guidance has since changed. The Council has already improved its system to ensure staff are reminded to send written information about reablement. We have therefore not recommended service improvements related to hospital discharge or written information about reablement.

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Final decision

69. We uphold some of Mr X’s complaints about hospital discharge, reablement and referrals for therapy. We do not uphold Mr X’s complaints about the Council’s complaint handling or the information it provided to another council. The Council and Trust have accepted our recommendations, so we have completed our investigation and closed this complaint.

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Investigator's decision on behalf of the Ombudsman