Date of decision: 07 July 2025
Summary
This was a complaint about serious failings in a Trafford Council‑commissioned care package for an elderly woman discharged from intermediate care. Errors in information sharing, equipment training and handling by both the Council and NHS Trust caused risk of injury, financial loss, and lasting uncertainty.
What happened
In July 2022, an elderly woman, Mrs Y, who had previously suffered a stroke (leaving right‑side weakness and speech impairment) entered hospital after falling and breaking her arm. In summer 2022, she was moved to Ascot House (an intermediate care facility run by Manchester University NHS Foundation Trust) for rehabilitation.
On 9 August, a physiotherapist at Ascot House assessed her and recommended use of a Ross return transfer aid. On 11 August, the physiotherapist trialled use of the Ross return with a belt, providing greater support. On 12 August, an occupational therapist assessed her as needing two people for washing, dressing and bathing, with the Ross return and belt for transfers. On the same date, the physiotherapist noted she was not pulling herself up but passively waiting to be lifted. On 17 August, she completed sit‑stand exercises but reported knee tenderness. By 22 August, she was declining sit‑stand due to pain in her right knee. On 24 August, carers at Ascot House reported difficulty using the Ross return; she required assistance of two people but later managed transfers. On 25 August, she transferred well.
On 30 August, the physiotherapist and occupational therapist produced an activities of daily living report for the Council (probably to support Care Act assessment). It recorded she needed a wheelchair, transfers using Ross return and belt with assistance of two, and support with medication. Ascot House contacted her family and said discharge home would be arranged by social services.
In early September, the Council’s social worker completed a “stabilise and make safe” (SAMS) short‑term reablement package request. This recorded that she needed four daily visits with assistance of two carers for transfers, personal care and medication. It was envisaged as an intensive service which was free, but expected to last for 3 weeks.
The SAMS request omitted important details: it did not state the need for a belt with a Ross return, nor her right‑side weakness, nor her speech difficulties. Delta Care agreed to take the package.
On 9 September, the social worker held a discharge meeting with the family, who accepted Delta Care. On 15 September, the woman was discharged home. Ascot House’s records that day described her as very poor, on standing with the Ross return and belt, only able to move sideways with assistance of two. The physiotherapist and occupational therapist undertook a home visit and found transfers a little more difficult on discharge than normal, and Mrs Y was not assisting with standing as much as normal.
Later that day, Mrs Y’s son‑in‑law reported the carers did not know how to use the Ross return. Delta Care recorded that the belt slipped during a transfer, leaving her unwilling to continue. The social worker contacted Delta Care, which said carers had failed to tighten the belt; it claimed staff were trained but were adjusting to different handling.
The social worker spoke to their manager, who advised they could not change care providers immediately. The family asked about a private provider, who the family had identified and could start immediately if the Council would pay its own rate and the family would top up. But the social worker said this was not possible. The social worker explained the woman could refuse support, which the Council had to respect. The social worker told Mrs Y’s daughter Mrs X that the family could pay a private carer over the weekend at Mrs Y’s cost.
By teatime on 15 September, carers struggled with transfers. Notes recorded Mrs Y was helped to the commode and back to the chair: ‘used stand aid to lift but was really difficult. Finally managed to use it and get to commode….explained she needed a mechanical lift as she can’t lift herself. Rang on call to let them know.’ Mrs X (the daughter) telephoned the social worker and said she had to assist the care workers with Mrs Y’s transfer. She said Mrs Y might need to go into respite if the issues could not be resolved. Mrs X emailed the Council late on 15 September detailing concerns, including painful legs, inconsistent carers, poor communication, dangerous equipment use, and suggesting respite if issues persisted. She wrote again the next morning and said staff were struggling to use the belt properly to enable safe use of the Ross return.
On 16 September, a Delta Care manager assessed and found her in too much pain to stand. The GP declined an emergency visit ‘as it was 2pm on a Friday’.
The only other option was an ambulance as ‘this lady cannot be moved out of the chair she is in safely without being in pain and screaming out’. Delta Care informed the social worker Mrs Y could not weight bear on her leg as she was in too much pain and needed a hoist. The son‑in‑law called an ambulance, saying her leg pain was caused by rough handling with the Ross return. The social worker raised a safeguarding concern.
She was readmitted to hospital. The Council’s records noted the hospital should complete a reassessment for equipment and decide on a discharge pathway. By late September 2022, the hospital team considered her fit for discharge with support, but she could not go home due to redecorating. Mrs X said she had arranged this for an 8-week period, to address damp in the property. The notes recorded Mrs Y would then need support from adult social care for an assessment to ensure she had care workers on her return home. In October 2022, she was self‑funded into respite care in a care home.
In December 2022, her daughter requested a continuing healthcare (CHC) assessment through the GP, which never progressed. In February 2023, the daughter contacted the Council again, as funds were depleting, requesting help for permanent placement and CHC screening. In March 2023, the Council conducted a needs assessment, finding she wanted to remain in 24‑hour care. The Council approved ongoing care‑home placement, noting her funds would fall below the threshold in April 2024.
The CHC referral was made. In May 2023, a multidisciplinary panel found her ineligible, confirmed to the family in June 2023.
On safeguarding, the Council initiated enquiries in September 2022, planning a multidisciplinary meeting. Meetings were delayed twice due to missing information. It finally met in December 2022, confirming the safeguarding concern was substantiated but the risk was removed once Delta Care ceased involvement. Delta Care was told to report unsafe discharge, retrain staff on the reablement purpose of the SAMS input and equipment, and notify CQC. Safeguarding minutes were incorrectly issued; corrected versions were not sent until February 2023.
On complaints, the daughter complained in early 2023. Due to the nature of the compliant the Council decided to appoint an independent investigating officer who met with Mrs X in mid March. The report was produced in August and sent in September. An adjudication was prepared, but in October the Council said health services had not been involved and reopened the complaint jointly with the Trust. The Trust later said it had provided input, but its response was omitted from the Council’s letter. The Ombudsman did not see a copy of the Trust’s response to the Council. The internal Investigating Officer completed an addendum report which they said considered information provided by the Trafford Local Care Organisation and the Head of Personalised Care (Trafford) NHS Greater Manchester.
The final adjudication in May 2024 by the Council did not uphold Mrs X’s complaints about not exploring a long-term package of care; about the information the commissioning team shared with care providers; that Delta Care was commissioned; the lack of a risk assessment before the care package started; or delay in carrying out a CHC assessment. But it partially upheld aspects, apologising for safeguarding minutes delays and for a misleading stance taken about not assessing her until she was below threshold. The Council considered that the fact that no information was provided to the care provider about Mrs Y’s medication and that she was on blood thinners, or that care workers were not properly trained to use the equipment or about communication between Ascot House and Delta Care, was the responsibility of the health team.
It awarded £850 for complaint handling failures.
In June 2024, the daughter complained to the Trust, which responded that some issues were for the Council and that the matters had been ‘made historical’ by the fact that the Council had already reported.
The Trust said Ascot House had completed its proper handover as part of the activities of daily living report. It said the handover to the care agency was the responsibility of the adult social services assessor. It was for the Council to ensure carers were trained on equipment use. It acknowledged lessons about joint discharge protocols, which were implemented from April 2023.
When the Ombudsman pursued an explanation, the Council said despite its best efforts, collaboration with the Trust was largely unsuccessful due to ‘differing professional opinions of the complaint parameters’.
The Ombudsman found collaborative working between the Council and Trust remained poor.
By mid‑2024, the Council introduced new adult social care practice standards and complaint protocols, and meetings with the Trust used the woman’s case to improve discharge processes.
What was found
The Ombudsman found the Council properly used a SAMS approach for reablement but at fault for failing to include key details in the SAMS commissioning request; for failure to review the woman’s suitability to use the Ross return for nearly three weeks before discharge; for failure to ensure commissioned care staff were competent with equipment; for delay in issuing safeguarding minutes; and for misleading advice and delay in conducting a needs assessment despite a legal duty under Care Act 2014. The Council also mishandled complaints by failing to coordinate with the NHS Trust under the 2009 Complaints Regulations duty to cooperate. Both organisations failed to provide a single coordinated response.
The Trust was at fault for inadequate joint working on discharge and complaint handling.
Given the inadequate detail in the request for a provider, Delta’s care workers were not fully aware of Mrs Y’s needs or her communication difficulties, and this affected her ability to use the Ross return and impacted the care worker’s ability to communicate effectively with her.
These faults caused distress, pain, loss of confidence in care, long‑lasting uncertainty over what would have happened with proper care, frustration, financial loss in ongoing care fees, and wasted time in the complaint process.
The Ombudsman required apologies and further payments: £300 to the daughter (£150 each from the Council and Trust) and £500 to the elderly woman (£250 each), to acknowledge distress, frustration and uncertainty. Trafford Council was directed to evidence discharge process improvements. The Trust was directed to issue a briefing note to staff emphasising the importance of joint complaint handling.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
The report (for both the Parliamentary and local government ombudsmen) refers to the statutory guidance on Hospital discharge which was last updated in January 2024. The updated guidance includes detail on the duty to co-operate between NHS bodies and local authorities, and the involvement of families and carers.
Guidance under the Care Act and established community care law, including case law such as R (KM) v Cambridgeshire and R (McDonald) v Kensington and Chelsea, confirm that assessments must examine all aspects of wellbeing, risk and outcomes, and that safe and effective equipment use is part of the council’s duty to secure proper care. The absence of timely reviews, poor handover documentation and lack of equipment training do not meet these standards and would amount to breach of statutory duty in legal proceedings.
Readers will be intrigued to discover that there is no action in negligence against a council that it is possible to launch in England, on the basis that the duty to meet needs does not amount to a duty of care in negligence and there is no common law equivalent, as there is with medical staff.
The duty to conduct safeguarding investigations under section 42 requires timeliness, thorough record-keeping and transparency. Persistent delays or sharing incomplete or incorrect minutes undermine individual safety and violate dignity and legal expectations. How no fault was found in the safeguarding investigation, given the inadequate provision of information to Delta, by the SAMS team, we simply do not understand.
Equally odd, to our eye, is the notion that failure to assess Mrs Y on account of her assets caused her no financial injustice. If a person is above threshold, and arrangements are made at the Council rate, they are likely to be lower than the rate for a private contract. But perhaps the damp work which prevented her from returning home was treated as the operative decision by the family…
We think a 3-month delay in arranging a CHC assessment is undue delay, but the investigator did not apply so demanding an expectation. If she had only been checklisted, it would have had to have been within 28 days under the National Framework.
Effective complaint coordination between social care and health bodies is a statutory obligation. Failure to cooperate as required by the Local Authority Social Services and NHS Complaints Regulations 2009 risks overlapping, incomplete or missed remedies—and prolongs distress to vulnerable individuals and families.
Councils and professionals must ensure robust discharge planning and risk assessment, including full sharing of health and support needs and medication details. Gaps in discharge practice repeatedly cause avoidable harm. People using services and their carers should expect clear communication, timely assessments, safe equipment provision, and coordinated complaint responses regardless of funding status. Advocacy groups and professionals should challenge any council or provider failing to meet the letter and spirit of the Care Act and community care law. Defensible, person-centred assessments and seamless partnership approaches are not optional; failure in these areas is not only poor practice but risks statutory breach, judicial review and continuing injustice.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Trafford Council (23 013 641) Ascot House (23 013 641b) reports.
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