Urgent question about care plan

HI all,

My elderly relative (87) is about to be dischared from hospital to a transitional place, to see whether she can be helped to regain her mobility so we can know whether she can come home.

I have two questions.

First, are we entitled to a copy of the care plan? I think we are (we have Lasting Power of Attorney (both kinds) and my relative is suffering from dementia/delirium). I’ve asked for it but was told that they weren’t sure we were allowed to have it.

Second, how long is my relative allowed at the rehab place? I was told the plan was 2-3 weeks, but in each of those weeks they have qualified Occupational Therapists/Physios going in only twice, so even with 3 weeks she would only have 6 opportunities to be helped by a qualified person after having spent two months in a bed in hospital. They tried to tell me the care assistants would help her every day, but the care assistants are not qualified to help an immobile person who is bedbound to regain their mobility, even if they had time to try (and of course they don’t).

I don’t feel 2-3 weeks is long enough, bearing in mind this will be her last chance to be given an opportunity to be fit to go home, and I believe they’re entitled to up to six weeks. However, and from what I’ve been told, on the current plan it’s likely that they will ring me after 2/3 weeks to say she hasn’t made progress and so will have to go long term to a nursing home.

If you can help please do. They’re trying to get hold of me to speak on the phone and I would very much like to have the asnwers to these questions before we speak again.

Many thanks if you can help.

Copy of care plan - yes you can. Talk to PALS at the hospital.

For your second question. Sorry I am not able to locate a link or document at this moment.

Thank you very much indeed - very much appreciated.

Best, GS

As you have Power of Attorney INSIST that you are fully involved.
I have found the best way to get what I want out of a hospital is to make an immediate formal complaint to the CEO. Ask to speak to his office and you’ll get the PA as a rule. When they know the “boss” is involved and can see possible promotion at risk, they usually “remember” what the proper procedure is. Also insist that they do an NHS Continuing Healthcare Checklist. This should involve you and the team looking after her.
What do YOU want to happen? If you can be clear in your own mind, then that helps negotiations.

Is it fair to send her to somewhere for “rehab” (in other words the first hospital gets their bed back - their only concern) only for her to fail at the second. Would it be kinder for them to arrange Continuing Healthcare and a nursing home placement immediately?

Yes, absolutely you should be able to view the care plan.

Any care assessment should consider what family support may be available when back in a home setting so it’s natural that you should also be able to view it.

In relation to your next question, decisions are usually taken to a) avoid a hospital readmission and b) support people in their own home for as long as possible.

Its sounds like your relative is still within the care of the NHS framework. Their aim is to get people out of hospital (more costly) into stepdown, rehabilitative care with a view to getting them home. At that point, your relative is more likely to become the responsibility of the local council and be eligible for social care. This will at first be delivered as reablement care. Often provided by the council themselves for upto 6 weeks, the purpose of reablement is to maximise a person’s recovery to the point where they can manage at home independently. There is no charge for reablement support. If ongoing care is still needed then a domiciliary care package will be arranged which you may have to contribute financially to.
As domiciliary care is generally a more cost effective way to care for people and they generally stay better for longer in their own surroundings then subsequently a residential care placement would only be opted for when care at home is no longer possible.

If someone is totally immobile, then going back home really isn’t a practical solution.
Carers 4 times a day for half an hour still leaves 22 hours a day without any care!!
So what will the toiletting solution be?
Peeing and pooing in a nappy, sitting in her own mess until the next carer visit I’m afraid.
This was my mum’s deciding issue in going into residential care.