Continuing care needs assessment

I’m very new so Pleeease be gentle!
My mum had a severe stroke 5mths ago and is now waiting to be discharged from hospital. She has a high level of care needs and we are hoping she will get full funding for a nursing home based on her level of need.
I’ve looked at the topic on here but tbh it made me feel completely overwhelmed! So if anyone can help I would appreciate it so much
Firstly do we need to insist the health needs assessment is done and appealed if necessary before she is discharged? Or are we OK to have it done when she comes out?
Who pays in the meantime if there’s a gap?
Any top tips for ensuring its awarded if a case is ‘borderline’??

Many thanks in advance
It all feels v stressful!


Hi Jane.

Some links for you which will make things clearer :

HOSPITAL DISCHARGES ( By the book or NO discharge ! ) :

Being discharged from hospital - NHS

( Care plan and future care are all part of that. )

REABLEMENT CARE ( Should it be offered ) :

Care after illness or hospital discharge (reablement) - NHS

CHC / NHS CONTINUING HEALTHCARE ( A deduction from your posting ? )
( Colour coded for ease of reference. )

Quite a bit to digest within those three threads … feel free to bounce anything off us here on this forum.

This is a very difficult time, I’ve been there, I’ve been bullied by the hospital trying to get their bed back.
Chris has given you links to all the details, here’s my layman’s introduction.

My top tips would be to
NOT SIGN ANYTHING AT ALL. Not for Social Services, the hospital, or the nursing home.

Does mum have mental capacity? Has she given you Power of Attorney. If not, sort this out as soon as possible. Make sure that mum is not being bullied either, tell them to deal with you, not mum, if she is frail.
If mum can possibly afford it, I’d recommend using a solicitor so that there can be no challenges later.

Does mum own her house?
Does she have over £23,000 in savings? (Yes/No)

These are the two critical questions regarding residential care. I’’ explain further depending on your answer.

Hi Jane,

I don’t want to worry you, but I was in the same situation. I had a lovely phone call telling me Mum was on her way to a Nursing Home 10 miles from me. Mum was put in a tiny little room with no light and a tiny TV. Paid for by the NHS for 6 weeks…

Don’t dither, just do what is best for your Mum…

Does she still have mental capacity? Has she had a mental capacity evaluation or not? If so what was the outcome? Refuse to sign anything.

What do you mean by borderline? Sort out power of attorney issues now before it is too late. Get a lawyer who can help you if the fees are not too much. Who owns the property?

Hi everyone

Many many thanks for your replies.
Mum doesn’t have mental capacity and myself and my brother have power of attorney for health and finances.
She has part share in a property with my but no real savings.
She needs 24 hr care. My dad wanted home care but they said it’s too much for him. So we are now looking at nursing homes. This feels v painful and we have only found one we vaguely like. That has a waiting list
Anymore advice great fully received

Also where we live there’s some sort of 6-8week joint working agreement. Where someone is discharged to nursing home and all fees paid for this time whilst continuing care needs assessment and financial assessment is done
Maybe this happens everywhere?
If I can only find say 3 nursing homes we like and they all have waiting lists where do we stand in terms of just refusing discharge until a space becomes available?
Also what do I need a solicitor for?
And what should I not sign?
What may they ask us to sign?

The nursing home or NHS may ask you to sign to agree to pay fees after the six weeks are up, or “top up” fees.
As you have a part share of a property, it should be disregarded for charging purposes.
As mum lacks mental capacity I would suggest that you or your brother decide who is going to take the lead in this. As you have found the forum, I’d suggest it was you, because we can help you through what is going to be a very stressful time.
You should only be looking at homes for the “Elderly Mentally Infirm” which assure you they can deal with everything that crops up healthwise, until mum dies. Yes, I know, very sad, but that is the reality. You want this to be mum’s last ever move. It might be possible for dad to move in as he gets older too, or he could live in a different part of the same home. Again, difficult to discuss.

Look at the Care Quality Commission website and find the six nearest homes to mum and dad’s home, or yours, or somewhere in between. Go and visit each. Only do one a day, and make notes about each one. Don’t just look at the fixtures and fittings, think about how friendly the staff are to the residents, and to you. Do they seem happy in their work? Does the home smell OK? Sadly there will always be some “nasty niffs” when people are very ill. Pay particular attention to food issues. Is there a menu for the day, is there a choice? What help do they give residents who cannot help themselves?
The home MUST be within reasonable travelling distance, so you and dad can visit as much as you want.
Now make a cuppa, then Google NHS Continuing Healthcare Framework. It’s about 165 pages if I remember rightly, this is where the proximity of the home is detailed.

If you have looked at all the homes local to you, and there is a waiting list, then the hospital will have to wait to get their bed back.


The POA is the first step. Insist on attending every single meeting. Have you toured or visited local care homes or not? The fact you have only partial share, should not be a concern. Since she does not have mental capacity, all decisions must be made by you or your brother.
With care homes, research is crucial. Start with the Care Quality Commission site or look at Prepare a list of questions to ask. Remember it is a lot like looking at schools really. Get a behind a scenes tour. Are the staff professional and kind? Is the home clean? What do families think? That sort of thing. Make notes too during your visit. Use a notebook and bring a pen. Read articles about the care home as well.