Decision Date: 13 August 2024
Summary
Mr W complained that he’d been led to believe that his mother’s care would be free as she would be placed in a care home on a ‘discharge to assess’ basis and that that meant free care for up to 6 weeks. The LGSCO found some minimal fault in communications but clarified that that is not the case. We look at whether that is in fact the full picture.
What happened
Mr W’s mother, Mrs A, was in hospital in January 2023. The hospital flagged to social services that she may have a need for care and support. The assigned social worker spoke to Mr W and he said he did not feel his mother’s needs could be met at home, and he was looking into nursing homes near his father in York, so they could visit her when visiting him.
The social worker had recorded asking Mr W if his mother had savings and that Mr W had said he wasn’t sure. The record showed the social worker had explained to him that if his mother had more than £23250 she would need to pay for her own care.
Mr W told the social worker he had been told his mother could be discharged to an NHS bed. The notes say the social worker told him the only NHS beds available were not near his father’s address. Mr W explained his interest in being able to visit both, regularly.
The social worker visited Mrs A in hospital to assess her mental capacity in March 2023. It also sent assessments to two care homes which had available beds.
Mr W chased up the progress on discharge a few days later, saying “When we spoke, we discussed the opportunity and importance of when my mother is placed to ‘Discharge to Assessment’, that this is undertaken in York…”
The care home the Council was considering told the Council that Mr W believed the ‘funding plan’ was “d2a” and asked the Council if this was correct.
The records suggested that the Council did not respond to either about whether the placement was going to come under the discharge to assess scheme.
The Council agreed a weekly rate with the home, and Mrs A was discharged to its care.
When the Council contacted Mr W about a financial assessment his position was that the placement was not chargeable for six weeks and at that point the Council clarified that this was not their view.
Mr W complained that although Mrs A had above-threshold capital, he had been led to believe the initial six weeks of care were free.
The Council clarified that there was no policy whereby anyone was automatically entitled to six weeks care, free of charge.
Four weeks after Mrs A moved into the care home she died.
The bill issued to Mr W was for a period of just under five weeks. Billing started from the date Mrs A was initially intended to be discharged, rather than her actual discharge date which was five days later.
The Council knew Mrs A had potential care needs and that a financial assessment would be needed, as of January 2023. Mrs A passed away in May 2023, and the financial assessment had still not been done by that time.
What was found
The delay in carrying out an assessment is a fault. Had this been done in a timely manner, the Council could have confirmed that Mrs A would be self-funding her care.
The Council had given Mr W a reasonable explanation of the funding situation regarding the threshold.
Notes from a call on 25 February stated that Mr W had said a doctor had told him that Mrs A could be discharged to an NHS bed. During that same call, the Council said NHS D2A beds were not available in York. Mr W said Mrs A would need to go to a care home in York, knowing this was the position.
There are no direct records of the Council telling Mr W that the first six weeks of care would be free. Nor was there any such indication on the Council’s website.
Mr W’s point was that the Council had involved itself in agreeing care fees with the care home, even though Mrs A was going to have to fund the care herself. The investigator thought that this was an indicator that he in fact knew that Mrs A had capital over the threshold.
[We think it is consistent with the system requiring the Council to do the commissioning and not merely the funding if a person lacks capacity, no matter how well off they are. It is not inconsistent with him having been got the impression from hospital staff that his mother might get what’s called NHS INTERIM funding – if only someone had checklisted her for qualifying for CHC – which given her death within 4 weeks of hospital discharge, does not seem beyond the realms of the possible!]
The Council should have taken the opportunity to explain the D2A scheme to him, when he repeatedly made reference to it; but he was referencing the D2A scheme without specifically mentioning free care.
The Council could not know that he was referencing its scheme under a false understanding that his mother’s initial care would be free. Crucially, the Council did not ever say that it would be free.
[But the NHS Framework does, and reablement is free, even if one is not positively checklisted – IF one is ripe for reablement!]
The Council was not at fault for applying the charges but there was likely an error in the date from which the care fees should be charged.
The Council agreed to apologise and correct the bill, but more significantly to review why the financial assessment was not carried out sooner in this matter and take steps to ensure the issues would not be repeated in future and share the evidence with the LGSCO.
Points to note for councils, professionals, people using services and their carers, advocacy groups, members of the public
The national Discharge to Assess scheme may not mention free care but the shocking thing about this report is that the D2A scheme needs to operate under the broader legal framework for NHS and Council functions. The status of a person, when they are medically optimised for discharge (FIT for discharge in shorthand), is that until it is decided that they are NOT, they are potentially a person qualifying for CHC, in which case, after a positive Checklist exercise, they should be getting an interim NHS bed pending the organisation of a Decision Support Tool exercise or some other NHS funded interim service such as rehabilitation; or they are not potentially a CHC qualifier, in which case they are potentially entitled to reablement from the local authority, free for up to 6 weeks.
Alternatively, the patient might be assessed to be entitled to long-term care straight away, in which case their savings will be relevant as to who organises that unless they lack mental capacity (likely to be the case here, given the reference to the Mental Capacity Assessment) and if they have more than £23250 they will be a self-funder and not merely a full cost payer.
Para 106. NHS Continuing Healthcare Framework, says this:
In order to ensure that unnecessary stays on acute wards are avoided, there should be consideration of whether the provision of further NHS-funded services is appropriate. This might include therapy and/or rehabilitation, if that could make a difference to the potential of the individual in the following few weeks or months. It might also include intermediate care or an interim package of support, preferably in an individual’s own home. In such situations, assessment of eligibility for NHS Continuing Healthcare, if still required, should be undertaken when an accurate assessment of ongoing needs can be made. The interim services should continue until it has been decided whether or not the individual has a need for NHS Continuing Healthcare (refer to paragraph 107). There must be no gap in the provision of appropriate support to meet the individual’s needs. It is important that there are clear local protocols setting out where responsibility for meeting an individual’s needs lies, including who is responsible for funding their care and support.
In addition, ICBs and their partner organisations should ensure appropriate processes and pathways exist for individuals who may have a need for NHS Continuing Healthcare, for example:
…
(b) a decision is made to provide interim NHS-funded services to support the individual after discharge. This may allow individuals to reach a better point of recovery and rehabilitation in the community before their longer-term needs are assessed. In such a case, before the interim NHS-funded services come to an end, screening, if required, for NHS Continuing Healthcare should take place through use of the Checklist and, where appropriate, the full MDT process using the DST (i.e. an assessment of eligibility);
…
(d) a ‘positive’ Checklist is completed in an acute hospital and interim NHS-funded services are put in place to support the individual after discharge until it is either determined that they no longer require a full assessment (because a further Checklist has been completed which is now negative) or a full assessment of eligibility for NHS Continuing Healthcare is completed;
103. ICBs should ensure that local protocols are developed between themselves, other NHS bodies, local authorities and other relevant partners. These should set out each organisation’s role and how responsibilities are to be exercised in relation to hospital discharge, including any arrangements for intermediate, reablement, rehabilitation or sub-acute care and arrangements for long-term care assessments including NHS Continuing Healthcare. In particular, ICBs should ensure (i.e. through contractual arrangements) that discharge policies with all providers are clear. Where appropriate, the ICB may wish to make provisions in its contract with the provider. There should be processes in place to identify those individuals for whom it is appropriate to undertake a screening for NHS Continuing Healthcare using the Checklist and, where the Checklist is positive, for a full assessment of eligibility to be undertaken at the appropriate time and place.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s North Yorkshire Council (24 001 841) report.
If you are affected by the issues in this report, please consider asking a free, one-off question, anonymously, at a level of principle, here. Our experts’ response will give you an opinion which may then help you and the broader community, when posted.
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