Risk of ‘poor or potentially illegal’ practice in care home discharge plan, warns ADASS

Director body raises concerns about people making permanent moves into residential care following hospital discharge without informed consent, on back of £200m government scheme for NHS to block-book care home beds

Nurse helping woman rehabilitate in care home
Photo: Rido/Adobe Stock

Government plans for the NHS to discharge people from hospitals into care homes may result in “poor or potentially illegal” practice, through people being moving into residential care without their informed consent.

That was the warning from the Association of Directors of Adult Social Services (ADASS), in response to the Department of Health and Social Care (DHSC) plan to give the NHS £200m to block-book step down beds in care homes to which to discharge some of the 14,000 people who are medically fit to leave hospital but cannot.

The funding can be used to pay for a new or extended package of social care, plus associated clinical advice and services to support rehabilitation, for up to four weeks, during which time assessments should be made of the person’s ongoing needs, according to guidance issued last week by NHS England.

NHS trusts are required to take steps to involve people and their carers in discharge decisions when they likely have ongoing care and support needs, under the Care Act 2014, while separate DHSC discharge guidance specifies that it should “respect an individual’s choices and provide them with the maximum choice and control possible from suitable and available options”.

This also states that, should a person’s preferred place of discharge is not available, “an available alternative or alternatives appropriate for their short-term recovery needs should be offered, while they await availability of their preferred choice”. Where a person may lack the mental capacity to make relevant decisions, professionals should carry out a capacity assessment as part of the discharge process and make a best interests decision if they are found to lack relevant capacity.

However, following criticisms of the plans from sector leaders following their announcemnt last week, ADASS chief executive Cathie Williams raised concerns about decision making should people end up spending longer than four weeks in the care home they were discharged to.

Risk of ‘poor or potentially illegal practice’

“Our concern is that there may be practice that is poor or even potentially illegal,” she said. “None of us can be required to live somewhere without exercising a choice unless we’ve broken the law or there are safeguards under the Mental Health Act or DoLS [Deprivation of Liberty Safeguards]. The concern is that people will in effect be forced into making a permanent move to a home without giving informed consent.”

In a statement to Parliament last week, health and social care secretary Steve Barclay said he had asked NHS England to ensure that people discharged to care homes received “wrap-around care…so that it is the shortest-possible stay on their journey home and into domiciliary care”.

However, Williams said the prospect of people ending up stuck in care homes was increased by staff shortages and a lack of NHS community services to aid rehabilitation.

“Rehabilitation can work in a residential setting but it needs to be in a focused unit with the right staffing. We have real concerns that those staff aren’t there. As a result people will in effect be forced into making a permanent move into a home which they haven’t fully considered.”

Funding reserved for ‘bedded’ services

The NHS England guidance made clear that the £200m funding may only be used to fund “bedded step down capacity”, rather than care at home, despite ADASS saying last week that use of the funding “should be guided by the ‘home first’ principle, rather than the default being that people are discharged into care homes”.

Williams said: “There are potentially poor outcomes for people as individuals [from being discharged to care homes]. Also, at the end of the four weeks, if people can’t get home, either they, as private individuals, or the council or NHS will incur very significant costs. This may help for three or four weeks but there’s likely to be another delay for care after that.”

The NHS England guidance issued last week states that ICBs may not use the £200m to fund post-discharge care after the four weeks are up. On the “rare occasion” where people remain in care homes pending assessment of their ongoing needs, they should be funded according to agreed local arrangements between councils and ICBs, it adds. Where these do not exist, ICBs should fund care for people awaiting an NHS continuing care or funded nursing care assessment, with councils resourcing services when people are awaiting a Care Act needs assessment.

The £200m fund, which will last until the end of March 2023, is designed to supplement existing resources for post-discharge care, including an extra £500m provided by the DHSC for this winter, which is being split between councils and ICBs.

NHS urged to work with councils 

Amid ADASS and Local Government Association concerns about the impact on the local care market of ICBs commissioning care home beds alongside local authorities, the NHS England guidance says: “ICBs must work with local authorities to ensure that an appropriate, locally benchmarked, rate is paid for care funded through these arrangements, with rates set at a level that does not lead to local inflation in the cost of care.”

It also says that ICBs must make procurement decisions with the full involvement of councils in their areas and may make use of existing pooled budget arrangements – under section 75 of the NHS Act 2006 – to deploy the all or part of the new funding.

The DHSC’s focus on funding post-discharge care, both through the £500m and £200m packages and in the directing of some of the additional social care resource for 2023-25, reflects concerns that the high number of people stuck in hospitals is causing backlogs throughout the NHS, particularly in accident & emergency departments.

However, with about 500,000 people awaiting a social care needs assessment or care package, Williams said the focus on discharge was neglecting people’s needs in the community and risked being self-defeating.

Criticism of discharge focus

“Our concern is that with the focus on discharge above everything else,” she added. “We can see from ADASS  surveys that directors of adult social care are prioritising their resources to support hospital discharge or to respond to referrals where there are concerns about abuse or neglect.

“By focusing resources on these priorities, the resources available for assessment and planning of people in the community are necessarily reduced – and as a result  the numbers waiting for assessment and care are rising. A proportion of those waiting at home will inevitably deteriorate and end up in hospital, making things worse for them and the health and care system.”

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4 Responses to Risk of ‘poor or potentially illegal’ practice in care home discharge plan, warns ADASS

  1. Chris Sterry January 17, 2023 at 5:39 pm #

    This all so true and I welcome the Association of Directors of Adult Social Services (ADASS) now speaking out, but this should have been done much earlier for this crisis is nothing new, but is so much more than it has been.

    The crisis with the funding of Social Care goes back years, even well before 2010 when the dreaded Tory austerity cuts were introduced. It was so clear then and well before that social care could not continue as it needs to with totally insufficient funding it was receiving and the Austerity cuts, followed by COVID and now the cost of living inflations are making it even more necessary for so much more funding. It is surprising that Social Care has continued to be there, which it has in a very seriously depleted form on the backs of the totally insufficiently paid care workers.

    Due to the extremely low pay in the care profession, less and less people are prepared to enter the profession for a meagre remuneration, when much more can be earned in other areas with so much less responsibilities required.

    Then with the Tory so inappropriate immigration policies this then drastically cut the numbers of persons wishing to come to the UK to enter the care profession on either a full-time or even part-time basis. Then there are the totally inappropriate Terms and Conditions available, again totally insufficient travel expenses, no proper sick pay arrangements and no recognition for working Bank Holidays and in some instances even holiday entitlement, but there are many other difficulties.

    This has led to a serious deficiency in staffing and even more so now, so these small amounts of Government funding at this late stage will do so little to achieve. it is not £millions required, but many £billions, at least £12billion.

    If this Government and all previous Government had been really concerned about social care then these current situations would not be here, but all these Governments viewed social care has being insignificant, if they even viewed social care at all.

    We are all now and the NHS suffering greatly for all this current and all past Governments great insufficient concerns and there will be so much more suffering for those who are in the greatest need of care, for deaths will and are occurring due to all these lack of concerns by all Governments.

    Every area of the NHS is suffering not just hospital beds, just as social care has been suffering for years without any real concerns.

    For the NHS to have any real chance of survival then social care has to be fully, sufficiently funded and not just for now, but the required funding has to be sustained, otherwise these crises will just reoccur and in a greater extent to that currently.

    Wake up Government for once in its life and break the habit of a lifetime and do all that is required for both social care and the NHS for both depends on it for any forms of survival.

    Care workers are very much misaligned and deserve so much more respect from all quarters of the UK, especially this Government.

    • Susan Elliott January 19, 2023 at 10:20 am #

      You talk about adequate funding . Government funding shouldn’t be going to pay private social care provider companies who are inadequately governed and regulated and very frequently associated with abuse of our vulnerable elderly.

      I’ve just removed my father from a Residential home due to abuse. He was there for 8 months and paid £33,000. for the After only 6 weeks he acquired a pressure ulcer on his big toe which apparently went unnoticed by staff. All care and NHS staff involved in his care failed in their safeguarding duties.
      I could list the other issues but don’t have the time.

      When we took Dad home last week we noticed 2 dressings that we knew nothing about.
      One was covering a large, stinking abscess and the other an infected pressure ulcer.
      According to the GP he’d not had any antibiotic treatment for either.

      More beds in the residential homes won’t solve the NHS problems . It’s ludicrous that they won’t fund domiciliary care as for people who only need a short period of less intense rehabilitation to allow them to become independent or mostly independent their home is the best place.

      One has to strongly consider the risk of institution acquired infection. Infection control practice in card homes is generally poor( excluding during COVID)
      They need to be more rigorously and effectively regulated.
      The CQC inspections and reports aren’t fit for purpose .
      Service users and their families don’t have enough information available to them to be able to make informed decisions regarding whether their £50,000 a year plus will be well spent.

      • Anne E. January 20, 2023 at 7:42 pm #

        So sorry to hear of what happened to your father and I hope he recovers from the appalling abuse he has suffered. Sadly, others must be experiencing this in placements across the country. I hope that you are able to take some kind of legal action against the residential home, which I presume is a private home and from the income of which the owner awards him or herself huge profits. i hope too that you have forwarded the information to your MP and included photographs.

        I have just read an account of political prisoners during the occupation of France during WW2. It contains descriptions of how, in concentration camps, prisoners would die from untreated sores and ulcers – along with other horrific treatment. It is so shocking to read of a vulnerable elderly person suffering in the same way, in our country today.

        It was never a good solution to allow the private sector to have responsibility for the care of vulnerable people.

        Care staff currently receive inadequate remuneration and may be poorly trained . Homes are understaffed. It is hard for relatives to have oversight and carry out full physical checks. In any case, some residents are without family and even if a system of independent visitors existed this would not allow for intimate checks such as would be necessary to reveal physical abuse and neglect as described above.

        I agree with Chris Sterry.

        Surely both or all political parties should be able to agree a way forward which must realistically include the imposition of higher taxes. Given the current major crisis – lives are being lost – and the situation will worsen – common sense would dictate pooling ideas and finding a consensus amongst parties.

        How is it possible for the relevant government ministers to sleep at night?

  2. Jill Honeybun January 18, 2023 at 7:56 pm #

    In some cases, there may be family members willing to care for loved ones, but cannot afford to do this because Carers Allowance amounts to under £70 a week. DWP say that caring is a “choice” and not equivalent to full time work, family carers are classed as “economically inactive”. However, anyone else caring for the same person doing the same work – but working for a care agency, gets a guaranteed minimum wage, sick pay, holiday pay and pension. This is so unfair on family carers, without any of these rights. Surely, when there is such a dire shortage of anyone to care for the elderly wanting to go home, those who care for someone should be on an equal financial footing? In theory under the Care Act,the elderly needing help can be given Direct Payments which can then be used to pay whoever they like to meet their needs, including friends and family. Local authorities are blocking payments to family carers. NHS Continuing Healthcare also has, in theory, a similar possibility of Direct Payments. However cash strapped Health Authorities make it almost impossible to get CHC.