The Commissioner has developed a guide on hospital discharge for older people and their families, which provides a range of helpful information about what older people should expect when they are ready to leave hospital.
The guide includes information about people’s rights, as well as contact details for organisations that can provide help and support.
Ready to go: Helpful information about what to expect when you’re ready to leave hospital
Medically fit for discharge means that you’ve been assessed as no longer needing medical treatment in hospital, and that you’re ready to be discharged.
You may be able to go straight home or, if it’s likely that you’ll need some support before you can return home, you may be moved to a ‘step down’ facility.
This could be a different ward, hospital or perhaps a care home where you may receive a period of rehabilitation. The aim of rehabilitation will be to help you regain as much strength as possible so that you can return home if possible.
You should be allocated a named Care Coordinator – this could be a ward manager, a nurse or another health or social care professional. They may be known by a different title to Care Coordinator, but it will be part of their job to help guide you through the discharge process.
Be sure to ask who your Care Coordinator is and for a copy of their contact details if they aren’t automatically given to you. They will act as your point of contact, including for your family and friends, and can keep you updated on your discharge plans.
This depends on what you need to be able to do when you get home, and whether you need any rehabilitation before you can do it.
Following a stay in hospital, you may need some help to build up your strength again or to re-learn some of the skills needed to live independently, such as increasing your confidence in safely moving around your home or with daily-living tasks like preparing meals and washing.
The hospital staff should discuss and agree with you whether you need any rehabilitation and what your rehabilitation goals are.
The aim of rehabilitation is to increase your independence to be able to do things for yourself at home or in your usual environment, to reduce your need to depend on others to provide care for you.
Rehabilitation often starts when you are still in hospital and continues after you leave. You may receive support from a range of health professionals, including physiotherapists, occupational therapists or speech therapists who can help with both speech and swallowing difficulties.
Rehabilitation is time-limited and is not a form of ongoing, long-term care. You have a right to receive up to 6 weeks free rehabilitation if you are assessed as needing it.
If you come to the end of your rehabilitation and still need support to do the things you want to do, or need someone else to do them for you, you have the option of accessing home care (carers visiting you at home) through your local authority or, should you choose, directly through a home care provider.
Your Care Coordinator or other professionals involved in your care will discuss this with you. Alternatively, you can contact the Older People’s Commissioner for Wales (see details on Useful Contacts page).
There is no set time in law about how long you will be expected to wait for a social worker to be appointed to you and, similarly, for your needs to be assessed. However, you should not be expected to wait an unreasonable amount of time (but there is no set time for what is considered reasonable and it will vary depending on the situation).
If you feel that you’re waiting too long, you can make a complaint to your local authority social services department. If you need to raise a concern about an NHS or social care service, you can talk to Llais (see details on Useful Contacts page) whose independent complaints advocates can support you to make a complaint. Llais is an independent statutory body, set up by the Welsh Government to give the people of Wales much more say in the planning and delivery of their health and social care services.
You should keep in contact with your Care Coordinator to ask for an update on the likely waiting times. You can also contact your local authority social services department to ask them for an update on likely wait times. The hospital staff (NHS) and the social services staff (local authority) should be working closely together but this isn’t always the case. To find out how to contact your local authority social services team, see details on Useful Contacts page.
Once your social worker has been appointed, be sure to ask for their name and a copy of their contact details if they aren’t automatically given to you. They will be your main point of contact in arranging any care and support you may need to help you return home. Your Care Coordinator or other professionals involved in your care will discuss this with you. Alternatively, you can contact the Older People’s Commissioner for Wales (see details on Useful Contacts page).
Currently, there is a shortage of home care workers which may mean that if you have been assessed as needing home care (carers visiting you at home), you may need to temporarily move to a care home whilst you wait for your care team to become available. Whilst this is not the normal process, some people are experiencing this due to the shortage of trained staff to provide home care (carers visiting you at home).
Once a social worker is assigned to you, they will need to assess your care and support needs – this is known in law as a Care and Support Assessment. The aim of this assessment is to establish what your needs are. You have a right to a Care and Support Assessment if it appears that you may need help to return home. Your Care Coordinator or other professionals involved in your care will discuss this with you. Alternatively, you can contact the Older People’s Commissioner for Wales (see details on Useful Contacts page).
When the assessment is being undertaken, you have the right to have your views and wishes (or those of your family, friends, and/or suitable representatives (including an advocate)) heard. If you need help to participate in the assessment process, you may have the right to an Independent Professional Advocate and you should ask your social worker about whether an advocate would be appropriate as they will need to make a referral for you. You have a right to a copy of your Care and Support Assessment – ask for a copy if you’re not automatically given one.
When your Care and Support Assessment has been completed, a Care and Support Plan will be created. This sets out how your assessed needs are to be met i.e. what services will be provided, how they will meet your needs, when they will be provided, and who will provide them. For example, someone’s needs might be met through home care (carers visiting you at home), moving to a care home or perhaps help with shopping.
You have the right to have your views and wishes heard during the creation of your Care and Support Plan. For example, if you want to have your needs met through moving into a care home, your social worker or the person creating your plan must listen to your views and take them into consideration. You also have the right for your independence to be promoted as much as is possible e.g you should be supported to use the bathroom rather than being required to use incontinence products. If you are not automatically given a copy of your Care and Support Plan, you can ask for a copy as you have a right to have this.
If you’re not happy with your Care and Support Plan (i.e. you don’t think it provides a sufficient level of care to meet your needs), you can make a complaint to your local authority social services department (there is no appeals process, only a complaints process). To contact your local authority social services team, see details on the Commissioner’s Useful Contacts page. Alternatively, contact the Commissioner.
Instead of the local authority arranging care and support services for you, they can arrange to give you money so that you can pay for care, support, or equipment yourself. This is called ‘Direct Payment’ and is meant to give you more choice, control and independence.
You can work with the local authority to decide how your care and support needs will be met using direct payments. You can then decide who provides that support and control how, where and when it is delivered.
Adults of any age with an eligible care and support need can receive direct payments.
Your social worker should talk through direct payments as an option and discuss how they could work for you as part of your care and support plan.
If you choose to receive direct payments, you will agree with your local authority how the money will be used to meet your assessed needs.
There are some cases where an individual may not be eligible for direct payments.
There is currently a shortage of home care workers, which means that some people wait for a long time for home care (carers visiting you at home). However, that does not necessarily mean that you should have to go to live in a care home permanently instead.
The local authority has a legal duty to promote your independence and to take into account your views and wishes when meeting your care and support needs.
You might have to move into a care home on a temporary basis while you wait for home care to become available, but you should be able to return home if it’s what you want (and it’s what your family wants and it’s found to be in your best interest if you lack the mental capacity to make this decision yourself).
If your care and support needs are going to be met through home care (carers visiting you at home, also called domiciliary care), you may have to wait for a home care team to become available.
There may be a delay while the Local Authority tries to find a provider with the capacity to take on another client. It’s hard to say how long this will be in each area of Wales and it depends also on the level of care that you need.
You cannot wait in hospital for your care and support needs to be met. It is likely that you would have already been transferred to a ‘step down’ facility to recover or to receive rehabilitation before having your care and support needs assessed.
You may be able to remain here to wait for your care to be put in place or your may need to move to a care home temporarily.
You cannot choose which care home to stay at temporarily whilst you wait for your care and support needs to be met but your Care Coordinator and/or your social worker should take into account your needs and wishes (such as the location of the care home to allow your friends and family to visit).
Your local authority has a legal duty to meet your assessed care and support needs following an assessment and if you have been waiting longer than you expect for the care and support you require, you can make a complaint to your local authority Social Services department.
You should keep in contact with your social worker and ask for regular updates on what they are doing to try to find a package of care for you.
Don’t be afraid to keep contacting them to ask for an update. If you are waiting in a temporary care home placement for home care (carers visiting you at home) or to move to a permanent care home, you may want to ask your social worker for an action plan with approximate timescales to give you a better idea on when you can expect to receive the care and support you need.
If you are concerned about the length of time you are waiting for home care, you can contact the Older People’s Commissioner for Wales (see details on Useful Contacts page).
The amount you will have to pay towards your care will depend on how much income and savings you have. You will need to have a Financial Assessment which is carried out by your local authority to assess how much you will have to pay. Some people will not have to pay anything towards their care if they are on a low income.
Payments towards your home care (carers visiting you at home) is capped at £100 per week so you will not pay more than this.
If you have more than £50,000 in savings or capital assets (this may include the value of your home if no one else is living at your home) then you will usually have to pay the care home fees in full.
Further information on financial assessments, including your right to refuse an assessment and fully fund your own care, is available in our Factsheet 6: Paying for Care. Alternatively, you can contact the Older People’s Commissioner for Wales for a hard copy of this factsheet.
If you are concerned about your financial situation or would discuss your benefits and entitlements, please contact the Older People’s Commissioner for Wales (see details on Useful Contacts page).
Mental capacity refers to the ability of a person to make decisions for themselves. Some people, such as an older person living with dementia, may lack the mental capacity to make certain decisions for themselves or they may experience fluctuating mental capacity.
In these circumstances, a meeting will need to take place to decide what is in their best interest and to consider the older person’s wishes. It is important to make your needs and wishes known and to think about who you would wish to act on your behalf should you lack mental capacity or experience fluctuating capacity. For more information, please see the Commissioner’s easy guide to Lasting Powers of Attorney (LPA). Alternatively, you can contact the Commissioner for a hard copy of this factsheet.
Sometimes, an older person who lacks mental capacity will want to return home but it is assessed that it is not in their best interest to do so, and that their needs would be better met in a care home. Sending someone to live in a care home against their wishes is depriving them of their liberty. Therefore, legal authorisation is needed known as Deprivation of Liberty Safeguards (DoLS).
As part of this process, a meeting will need to take place to decide what is in the older person’s ‘best interest’. The older person has a right to be part of this discussion and have their views and wishes heard (or have their views put forward by their family, friends, and/ or suitable representatives (including an advocate)). For there to be a Best Interest Assessment (BIA), there has to first be an assessment of a person’s mental capacity – it cannot be assumed that just because an older person has dementia that they do not have the mental capacity to make decisions about certain areas of their lives. You have the right to have a copy of the mental capacity assessment (normally undertaken by a doctor) and you have a right to a copy of the outcome of a Best Interest Assessment.
If an older person or their family disagrees with the outcome of the BIA, they have the right to challenge the decision. In
such instances, you can ask the Care Coordinator or the social worker for an Independent Mental Capacity Advocate (IMCA) as they can help. If you need help to do this, you can contact the Commissioner (see details in Useful Contacts page).
You should be able to visit your loved one when they are in hospital. Visits are often particularly important to people who are more vulnerable, such as people living with dementia.
Older people who need help or encouragement to undertake tasks such as eating and drinking and patients who have limited or fluctuating mental capacity should be allowed to have a person visit them.
If you are denied access to your loved one and you feel that they should be allowed visitors because they are vulnerable, you can raise your concerns to the Patient Advice and Liaison Service (PALS) within the hospital (see details in Useful Contacts page). Alternatively, you can contact the Older People’s Commissioner for Wales (see details on Useful Contacts page).
You should not feel pressured in any way to provide care and support for your loved one. However, should you choose to provide care on a temporary basis to enable your loved one to leave hospital more quickly, your rights should not be affected. The right to a Care and Support Assessment remains as does their right to have their assessed needs met through a Care and Support Plan.
If you are going to provide care and support on a temporary basis, you should ask your social worker for written confirmation of the likely length of time you are expected to provide care. You should ask for information on whom to contact if your situation changes or you are struggling to meet your loved one’s care and support needs.
As an unpaid carer, you also have a right to a Carer’s Assessment. Additionally, if a Care and Support Assessment has taken place, you may be able to receive a Direct Payment which is a payment to allow a person to buy in their own care and support instead of receiving services.
You can ask your social worker for more information on Direct Payments or you can contact the Older People’s Commissioner for Wales (see details on Useful Contacts page).
Llais: Your voice in health and social care
3rd Floor, 33 - 35 Cathedral Road, Cardiff, CF11 9HB
029 2023 5558
Older People’s Commissioner for Wales: Advice and Assistance Service
Mount Stuart Square, Cardiff, CF10 5FL
03442 640 670
Ground Floor, Mariners House, Trident Court, East Moors Road, Cardiff, CF24 5TD
0300 303 44 98 (charged at local rate)
Aneurin Bevan University Health Board:
• 01633 493753 / ABB.PALS@wales.nhs.uk
Betsi Cadwaladr University Health Board:
• 03000 851234 / BCU.PALS@wales.nhs.uk
Cardiff & Vale University Health Board:
• 029 2074 4095 / 029 2074 3301 / email@example.com
Cwm Taf Morgannwg Health Board:
• Bridgend PALS: 01656 754194 / CTM.BridgendPALS@wales.nhs.uk
• Merthyr PALS: 01685 724468 / CTM.MerthyrCynon.PALS@ wales.nhs.uk
• Rhondda PALS: 01656 754194 / CTM.RhonddaTaffEly.PALS@wales.nhs.uk
Hywel Dda Health Board:
• 0300 0200 159 / firstname.lastname@example.org
Blaenau Gwent County Borough Council
• 01495 315700
Bridgend County Borough Council
• 01656 642279
Caerphilly County Borough Council
• 0808 100 2500
• 029 2023 4234
Carmarthenshire County Council
• 0300 333 2222
Ceredigion County Council
• 01545 574000
Conwy County Borough Council
• 0300 456 1111
Denbighshire County Council
• 0300 4561000
Flintshire County Council
• 03000 858858
• 01758 704 099 (Llŷn Area)
• 01286 679 099 (Caernarfon Area)
• 01248 363 240 (Bangor Area),
• 01766 510 300 (Eifionydd and Meirionnydd North)
• 01341 424572 (South Meirionnydd Area)
Isle of Anglesey County Council
• 01248 752 752
Merthyr Tydfil County Borough Council
• 01685 725000
Monmouthshire County Council
• 01600 773041 (Monmouth/Usk/Raglan)
• 01873 735885 (Abergavenny)
• 01291 635666 (Chepstow/Caldicot)
Neath Port Talbot County Borough Council
• 01639 685717
Newport City Council
• 01633 656656
Pembrokeshire County Council
• 01437 764551
Powys County Council
• 0345 602 7050
Rhondda Cynon Taf County Borough Council
• 01443 425003
City and County of Swansea
• 01792 636519
The Vale of Glamorgan County Borough Council
• 01446 700111
Torfaen County Borough Council
• 01495 762200
Wrexham County Borough Council
• 01978 292066
Advocate – A person who will help you express your views and wishes. This can be a family or friend or a professional, known as an independent professional advocate.
Care & Support Assessment – An assessment of your need for social care. The assessment will be undertaken by a social worker.
Care Coordinator – A Care Coordinator is the person responsible for coordinating your discharge from hospital and will be your main contact. They may be known by a different title to Care Coordinator. They could be a ward manager, a nurse or another health or social care professional.
Domiciliary care – Carers visiting you in your own home (also known Home care – Carers visiting you in your own home (also known as domiciliary care).
Independent Mental Capacity Advocate (IMCA) – An independent professional person can advise you of your rights and help put forward your views if you do not have the mental capacity to make decisions for yourself. An IMCA can also provide support to your family or friends who are advocating on your behalf.
Lasting Power of Attorney (LPA) – This is a legal document that lets you appoint one or more people (known as ‘attorneys’) to help you make decisions or to make decisions on your behalf if you have an accident or an illness and cannot make your own decisions (you ‘lack mental capacity’).
Medically fit for discharge –You no longer need medical treatment in hospital and you’re ready to be discharged.
Mental capacity – This refers to your ability to make decisions for yourself.
Rehabilitation – Also known as ‘reablement’, this is a service provided on a short-term basis, often following a stay in hospital, because you have been assessed as having the capability to regain some or all of your ability to carry out daily living tasks.
Social Worker – A professional who will assess and coordinate your social care. They often work for the local authority but there may be social workers based in the hospital too.
Step-down care – This might be a specific hospital ward or community facility (such as a community hospital or a care home) where you may go if you no longer need medical care but you still may need some care during the period of recovery and rehabilitation.
Support Assessment – An assessment of a carer’s needs (usually a family or friend who is providing unpaid care). The assessment will be undertaken by a social worker.