Decision Date: 23rd July 2020
Mr F complained on behalf of his mother, Mrs G.
Mrs G had been receiving privately funded care at home.
In October 2017 she suffered a fall and was admitted to hospital with a fractured arm.
On the 9th October Mrs G was admitted to the rehabilitation unit for treatment, as she was unable to mobilise with a trolley or frame. No CHC checklist process was carried out at this time.
The Trust carried out a ‘mini mental state’ examination, which Mrs G scored 9 out of 10. Therefore there were no recorded concerns about her mental capacity.
Mrs G followed a physiotherapy programme and was also assessed periodically by the OT team.
On the 7th November she met with a social worker to discuss discharge plans. Mrs G said she did not want to go home because she didn’t think she would manage, and instead wanted to go to a care home with a view of potentially staying there permanently. (She had previously stayed at that care home for respite care). She told the social worker that she wanted to source her care privately, and that if she did eventually decide she wanted to return home, she would reinstate her private care home package.
The social worker highlighted to Mrs G that if her savings fell below the threshold, she would need an assessment if she wanted to stay in the home permanently.
The next day Mr F had a discussion with the care home about options, and a discharge meeting to discuss further options was held with Mr F on the 11th of November.
On 13 November, a multi-disciplinary team meeting decided Mrs G was medically fit for discharge. The care home assessed Mrs G, and she was transferred there on 16 November.
Mr F complained to the Trust and Council. He felt Mrs G’s discharge to the care home was rushed, that the correct assessments were not done, there was a lack of support and information provided, and the family had not sufficiently been involved. He also complained that a CHC checklist was not done while Mrs G was in the rehabilitation unit. Mr F received responses from both but remained unsatisfied with the responses and complained to the LGO.
What was found
Although Mr F felt that Mrs G’s discharged was rushed, the evidence showed that Mrs G had been assessed appropriately by both the physiotherapy and OT teams. No outstanding needs were highlighted in the discharge summary, therefore there was no fault in discharging her to the care home.
The LGO highlighted that Mrs G had been deemed to have capacity and had stated that she wanted to privately fund her care. Therefore, there was no need to undertake an assessment.
Regarding involvement of the family, the LGO found that the Trust had sufficiently involved Mr F. It held numerous meetings with Mr F updating him on Mrs G’s progress and held appropriate discussions with him about the discharge planning.
However, the LGO found that there was a breakdown of communication between the social care team and Mr F. The social worker did not liaise with Mr F because it understood that Mr F was talking to ward staff about discharge planning. This was fault. The Council accepted that it ‘would have been helpful if the social worker had updated Mr F’.
The LGO highlighted that guidance from the Health and Care Professions Council (HCPC) states “You must communicate properly and effectively with service users and other practitioners”. It determined that there was an injustice to Mr F, because if he had been involved or informed about discussions with the social worker, he is likely to have had more information and understanding regarding discharge planning.
Finally, both the Council and Trust acknowledged that a CHC checklist was not completed until the day after Mrs G was discharged. This was fault. It should have been completed in the rehabilitation unit with Mrs G and Mr F present. This caused an injustice to Mr F, as he was left with some uncertainty, and it is likely he would have been better informed had he been present when the checklist was completed prior to Mrs G being discharged.
The LGO recommended that both the Council and Trust write to Mr F to apologise for the failure in completing the CHC checklist, and failure in discharge planning.
Public Law Legal Points for the public (and discharge co-ordinators) complaints staff and anyone interested in discharge to assess (D2A) during the pandemic or otherwise
The facts giving rise to the complaint occurred WELL before the pandemic as the report makes clear. At that point, the hospital discharge guidance that everyone was obliged to follow was in the Care Act and various regulations and guidance which sat uncomfortably with the NHS Framework for Continuing NHS Healthcare.
That Framework was update in October 2018 and big changes were made to the central role to be played in allocating STATUS to people before their discharge, of the process known as Checklisting for CHC.
The regulations had long since made it clear that even if a person is fit for discharge, medically speaking, that does not mean the NHS’s duty is OVER; not until that has been properly determined in cases where CHC status is a possibility can it be said that the NHS has finished the job it started in the acute phase of hospitalisation. Checklisting was critically important as a screening tool, to sort out those people who MIGHT qualify (a positive outcome based on a low threshold of scored descriptors seeking to identify profiles of need that might constitute primary health need) from those who would most probably not (negative result).
The notion of the CCG paying for a step down bed or an interim bed when that crucial assessment could be done, in a non-acute setting, and then ultimately in the best possible environment for the person’s recuperation, was current even in 2017 for people with a positive checklist (the council paying for reablement for those with a negative checklist).
The 2018 changes made checklisting more the exception than the rule, unfortunately, which has created a perfect fog for all as to their rights. The issue is that people don’t understand the difference between an assessment of needs (of course that doesn’t have to be by a social worker, if the NHS is continuing to be responsible, and is not done under the Care Act) – on the one hand – and assessment of STATUS on the other – on which funding depends, for the longer term.
This mess has now become the gold standard and blueprint for Discharge To Assess (D2A) policy, pre pandemic, during the first lockdown and now, under the second phase of special Covid funding for NHS underwriting of the next stage of care after hospital (regardless of setting) for up to 6 weeks and thereafter by default, ongoing, if assessment (of status) has not occurred.
In our experience, no council’s advice and information materials or hospital discharge notes from the CCG or Hospital Trust are adequate to make sure people know who is responsible for what, and why, and under what. Forgive us for thinking that that is kind of important and not something that deserves to be left out of Matt Hancock’s White Paper on innovation and integration!
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The full Local Government Ombudsman report of Suffolk County Council’s actions can be found here