Decision Date: 24 February 2025
Summary
The LGSCO identified that East Sussex Healthcare NHS Trust was at fault for failing to refer Mrs Y for rehabilitation support. She and her family may have got confused about the difference between rehabilitation and reablement.
What happened
Mrs X complained for her mother, Mrs Y, regarding Mrs Y’s care provided by East Sussex Healthcare NHS Trust (the Trust).
Mrs Y lived at home with one daily visit from a private carer before she had a fall which led to an admission to hospital in March 2023. The clinical team discharged Mrs Y with pain relief.
Mrs X reported Mrs Y struggled with pain and her mobility post-discharge to the Council, who referred Mrs X to what was called the Joint Community Reablement/Rehabilitation Team.
That service commenced for Mrs Y on the 21st March.
Continuing pain related to Mrs Y’s mobility required readmission on the 24th March.
Following this, she was transferred to a rehabilitation unit for physiotherapy. That team treated Mrs Y as an in-patient and decided the JCR service was no longer suitable due to Mrs Y’s dementia and need for longer-term care services.
In April, an OT completed a home assessment for Mrs Y. This found she could move around with a walking aid but needed support with personal and domestic tasks.
In May, a Council officer completed a Care Act assessment, seeking the views of Mrs X and Mrs Y on Mrs Y’s care. The assessment concluded Mrs Y required longer-term care visits to support her daily living.
On the 11th May the Council officer contacted Mrs X:
“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 any savings above the charging threshold.
Mrs Y was discharged by the Trust on the 22nd May. The discharge summary noted Mrs Y was “deemed medically ready for discharge home with JCR rehab”. This was to be provided by the community therapy team, which was managed by the Trust.
The Trust failed to make a referral to the service, which was ultimately acknowledged within the complaint response.
Mrs Y returned home with two daily care visits. However, Mrs Y later required more support with her mobility; this required extended visits in the morning because of difficulties she had with moving around, which the Care Provider contacted the Council to ask for approval of, on 13 June.
Charging arrangements were discussed the next day between Mrs X and a Council officer. Mrs X said she had been advised Mrs Y’s care would be free for six weeks post-discharge. The Council denied this and advised Mrs Y was paying full cost from the point of [we think, the second] hospital discharge.
Mrs X said Mrs Y would be unable to fund her package of care.
On the 27th June, Mrs Y’s GP referred her to the rehabilitation team, for which she was placed on a waiting list for a physiotherapy review.
In July, the Council contacted Mrs X to arrange a review of Mrs Y’s care needs, but this was deferred due to an ongoing financial assessment for Mrs Y. The Council then confirmed Mrs Y was above threshold and required her to pay the entirety of her care fees.
The rehabilitation team eventually assessed Mrs Y in March 2024. This included provision of a home exercise plan for completion with carers and it arranged ramps for Mrs Y’s property for wheelchair access.
Mrs Y’s family appealed the decision that Mrs X was above threshold. The Council did not uphold the appeal and informed Mrs Y’s family of this decision in October 2023.
What was found
The Trust did acknowledge they failed to refer Mrs Y for rehabilitation at point of discharge and that this service ‘would have been beneficial’ for Mrs Y. However, following triage in July 2023 the therapy team found Mrs Y did not have any urgent therapy needs.
A referral was made on 27th June 2023 over a month after Mrs Y’s discharge. A further delay whilst Mrs Y was on the waiting list for the service meant she was not assessed until March 2024. This was an inappropriate delay which represented fault by the Trust.
The initial reablement service consisted of social care professionals providing support to help people regain confidence with activities of daily living.
The rehabilitation service consisted 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 Council (in response to LGSCO enquiries) explained Mrs Y received free reablement until her rapid readmission to hospital after the first discharge. At this point, her condition was deemed no longer suitable for the service by assessing professions and they instead confirmed she required a long-term care package to meet her needs.
‘JCR’ is a short-term service, normally fewer than six weeks and the one that is free.
The Care and Support (Preventing Needs for Care and Support) Regulations 2014) define “intermediate care and reablement support services” as services which:
- consist of a programme of services, facilities or resources;
- are for a specified period or time; and
- 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.
Home assessments by physio and occupational therapists alongside a Care Act assessment for Mrs Y by a social worker (May 2023), concluded that she required long-term support.
The social worker in her assessment found Mrs Y required support with activities of daily living. These required two daily care visits (alongside the support from the private carer) to assist with these tasks. The care records reflected this position that Mrs Y required a package of long-term care and was not suitable for JCR support.
There was no fault by the Council on this point.
Case records showed that Council officers did provide Mrs X with charging information and clearly eventually established Mrs Y needed to pay for her care from the beginning of her long term package.
There was no fault on the charging information itself, but the LGSCO recognised there was a complex issue in relation to whether Mrs Y’s second property should be disregarded on the financial assessment.
This did delay the financial assessment process, but the delay was not so great as to be considered a fault by the Council.
Within one month the Trust agreed to write and apologise for the failed referral for rehabilitation therapy after Mrs Y was discharged in May 2023 and pay the suggested remedy of £1,036.39 to settle Mrs Y’s outstanding care fees. This payment represented an appropriate and proportionate remedy for the injustice caused by the fault.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
This Guidance from NHS England was mentioned: https://www.england.nhs.uk/wp-content/uploads/2023/09/PRN00761-intermediate-care-framework-rehabilitation-reablement-recovery-following-hospital-discharge.pdf
There was no focus by the Ombudsman here as to whether the first discharge from hospital was premature; and not much on whether the Trust, on the second admission and discharge, had actually articulated that there would be no further attempt at the free reablement.
That might be because reablement tends to be saved for people who have the motivation to regain independence, and people with dementia are often not regarded as being likely to focus.
The delay for the actual rehab service must have negated the whole point of it. The service did not assess Mrs Y until March 2024, almost ten months after her discharge. This was an inappropriate delay and represented fault by the Trust.
The Ombudsman’s investigator did not seem to rate this as a serious fault, saying: there would likely have been a significant delay in any case due to the waiting list for the service. This reflects that the duties owed by the Health Service are not of the same nature as those owed under the Care Act.
We have not come across many examples of what happened here: the discharge by the Trust of Mrs Y’s outstanding care fees of £1,036.39 was an appropriate remedy in this regard.
On discharge from hospital, reablement support services are normally available if the person being discharged is regarded as able to benefit from them. They are time-limited with the aim to reinstate or preserve independence for the individual. They are to be provided through social services, without charge, for up to six weeks for all adults under Reg 4, Care and Support (Preventing Needs for Care and Support) Regulations 2014.
When discharged from her first admission, Mrs Y qualified for and was given this short-term provision. However, her second admission shortly afterwards highlighted she had more complex needs that would require ongoing support. Reablement normally provides support to help oneself regain independence for up to six weeks, which in this scenario would not have provided adequate support for Mrs Y.
The complaint described by Mrs X was that the charging rules were not explained, and she was told that the first six weeks of care would be free. Confusion was generated when the care agency that supported Mrs Y (after she was admitted the second time) told Mrs X that care would be free of charge for the first six weeks. This would have been true if Mrs Y had been provided with more reablement, but due to her long-term needs, this was not the case.
We are not told enough about the charging dispute related to the second property to be able to comment on what we think of the Council’s decision-making in this regard.
What is clear is that Mrs Y should have been referred to as a full cost payer in this report rather than as a self-funder because however much money she owned, a person who lacks capacity to make arrangements for her own care, is entitled to be supported by social services.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s East Sussex County Council (24 003 412) 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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