Scotland - care home. Who has the legal 'say'

[flourpot]

Looking for a bit of advice as I'm in a situation where I have POA for a relative and I disagree with the discharge team at hospital.

Relative is 93, has no capacity, no idea what's going on and lives upstairs flat. I think it would be dangerous to send her home.

Brief phone call today indicated the team think home with carers is acceptable

I did not realise that when the decision needed to be made about a care home it might not be my decision.

I'm struggling to find out whether my POA means I can disagree with the team at the hospital or if I have to accept their choice.

Any ideas?

@flourpot

Your frustration is completely understandable - there is a huge gap in policy especially for complex cases. I had no idea either until SM ended up in hospital.

The problem is that organising appropriate long term care takes time but from the hospital POV once a patient is "medically fit for discharge," out the door they go. It becomes a "social care" issue. Which i find mind boggling because dementia is a progressive brain disease affecting cognitive function and physical health. And you're in that no man's land between these two policies.

It's clear from what you say that your relative needs 24 hour care / supervision as does my SM. We've also been offered carers 4 times a day but the expectation is that my Dad will do the rest. In the two weeks prior to admission my SM was awake for stretches of up to 60 hours, rampaging round the house etc and resisting care because of her distractions.

Her paranoid delusions have included serious allegations about my Dad, she had been uncharacteristically aggressive to him and me yet she is described as pleasantly confused.

Her right to autonomy means she can make "unwise decisions".

There has also been guilt tripping as although her delirium may last for months our resistance to her returning home is implied as a factor in delaying her potential recovery. There are two vulnerable elderly people at risk from this policy in my case and I will stall any discharge home as long as I can.

The uncertainty is the worst part of it and feeling unheard.

I really really feel for you x

@Bonbon21

If she is to be 'discharged home' then the OT should be making a home visit to assess what the home is like and what 'aids' will be required..

I told the woman on the phone today the carpet still needs cleaning as it has been soiled as she hasn't managed toileting

Bear with me on this...
Without a home visit they cannot carry out a risk assessment for the discharge.
If she can mobilise with a zimmer or similar at all then I would suggest if she has been able to go to the toilet in hospital ' with assistance', then who will assist her when she is in the house alone and decides to head to the loo?
... at this point she becomes a 'falls risk'.. and it therefore becomes ' an unsafe discharge'.

Well she got a zimmer in hospital so as a new thing it is more likely to cause a fall. It's more likely to make her think she can go outside so she will fall downstairs with it. She has a Zimmer and a nurse to toilet in hospital

If she is recognising that she is in hospital, then she will not recognise she is at home and the stairs are lethal in those circumstances as she will be incapable of assessing any danger in using them... especially if she is also coping with a zimmer/ walkkng aid.

They don't seem to agree but I am making notes and what you say is very helpful thank you

Make sure you get the names of everyone you speak to... and make it clear that you will not forget them.

I didn't even think of this

The route you need to go down involves explaining the risks to the hospital and how she would be at risk of significant harm. You need to ask them how they’ve considered safeguarding be cause you believe she would be at risk of harm even if she spent 1 day at home.

Leave aside the PoA because, this alone, cannot force them into arranging interim care.

If you feel the risks are too high (and based on what you’ve said, it sounds like you’re right), focus on these.

I am not in Scotland but perhaps someone else can advise if you have hospital discharge nurses /
coordinators?

Try to put aside the long term plan and reiterate to them that you want it recorded that she object to her returning home. Be really clear and give examples. “Jane fell down the stairs and broke her hip and wrist. She has declined in cognition since then and she forgets she cannot use the stairs so she will try.” “Jane gets up approx 3 times a night and wanders around, she goes into the garden. She does not recognise her surroundings.” “Jane has set fire to her toaster and microwave.” “Jane does not understand hot and cold taps, she has burnt her hands multiple times.” “Jane smokes and forgets to put out the cigarette.” “Jane has had 10 falls in the last 6 months. From this, she had paramedics every time and was admitted to hospital on 3 occasions due to the nature of her injuries.”

Hope this helps!

Sorry you have no right to insist she is admitted to a community hospital. The professionals decide if she can have a place.

I know in Scotland the person with POA can be overridden but I do not know the mechanism. I only know of a case where the family wanted their mother to go home with carers, and the POA was over ruled and she was sent to a care home with her home being sold to pay for it.

But there is a severe shortage of carers so it is very doubtful they can organise this quickly. They might decide this should happen, it actually happening is a different story.

I'm a mental capacity lead for a hospital and advise on these situations pretty frequently. My home area is England but the law in Scotland is very similar.
Your POA makes you the decision maker. That is the entire point of the role - your relative chose you as someone they trusted to make such decisions on their behalf when they could no longer do so.
You can only make a decision from the options that are available - it sounds like there are the funds for a care home so that is certainly one option, as is going home with a full package of support.
You do have to make the decision in you relatives best interest.. as pp's have said, that isn't as simple as choosing the 'safest' option, it also nedds to factor in emotional wellbeing and past/present expressed wishes. I'd recommend hearing the views of professionals and what support might be available to your relative at home (it may not change your mind but your legal role demands that you carefully consider all the options).
I'd provide them with evidence of your PoA and, in writing, ask them to confirm your authority to make the decision.
You don't say what your relatives current expressed wishes are ( I accept that they have been assessed as lacking capacity but that does not negate the fact they still have views, wishes and preferences). Be aware it is likely that, if your relative strongly objects to a move into a care home, then it will end up with the court being asked to make a final decision and the judge will want to hear your reasoning. That's not to put you off, I'm just saying that it's important to be clear about how you've come to that 'best interests' conclusion.
Good luck!

I just want to thank everyone again. I am going to read through the whole thread in the morning and take some notes as there is a lot of helpful stuff here. I feel like I have been arguing when people are trying to help but i am just trying to work out how to prevent a dangerous situation for my loved one. I'm sorry I do appreciate everyone's help (except the poster who suggested death by stairs was preferable) and I am truly grateful

What you are reporting is not normal practice.

As poa you should be at a case conference and you should be called upon to make decisions.

I've never attended a case conference where a relative has not been allowed to come unless the patient was at risk from the relative.

The OT should be informing their recommendations based on assessment. It would always be the norm to try at home with a poc if no poc in place previously unless there are significant concerns that this won't work. Or if informal care has assimilated a care package.

@Checkmymoves

You don't say what your relatives current expressed wishes are ( I accept that they have been assessed as lacking capacity but that does not negate the fact they still have views, wishes and preferences). Be aware it is likely that, if your relative strongly objects to a move into a care home, then it will end up with the court being asked to make a final decision and the judge will want to hear your reasoning.

She doesn't understand anything. She can't object she wouldn't even know what a care home was

We were able to stall due to the lack of carers. DF and DSM lived in a rural village and even before he went into hospital the carers he needed weren't available (DSM was paying a neighbour to help with bedtime). Carers refused to service their village due to time constraints.
DF was initially taken into hospital in one of the cities. Once he was medically stable, he was transferred to a community hospital nearer home. I attended a case meeting on my own (DSM was on a much needed holiday) and was I bullied into agreeing that DF be discharged home despite the necessary care not being in place (DSM has a back injury which means that she couldn't do the lifting that was needed). I had limited contact with SW, OT etc due to covid restrictions and living 70 miles away; DSM went through everyone when she came home (her work was linked to SW so she knows the system) and DF's discharge was delayed.

@flourpot

Bless you, I bet you're exhausted. It is a huge amount to take in and navigate, and when you're trying to keep your loved one safe the legal and policy issues seem like such a blunt tool.

If you can step away for a bit and get some rest you'll be able to regroup in the morning x

Just take care of yourself as much as you can and I hope you get some rest xxx

As POA you can absolutely decide where your relative gets discharged to. What you CAN'T do is insist they keep her in hospital once the option they have deemed suitable is arranged. You are absolutely within your rights to arrange a care home, but you can't insist she stays in hospital while you choose a care home and wait for a space if they deem that she is suitable for discharge to her own home with a package of care, once that package of care is available.

Playing devils advocate here, but why should the NHS pay for what are actually social care needs and not health care needs? Beyond that, as well as considering the risks of sending a patient home, they also have to consider the risks of keeping the patient in hospital - and there absolutely are risks to keeping a patient in hospital once they are medically fit for discharge - loss of mobility, but most likely, contracting a hospital acquired infection, or Flu/COVID/any of the other viruses that are floating around at this time of year - any of which could kill a vulnerable, frail, elderly patient. These are a real risk - the NHS doesn't have the resources to isolate everyone and someone who is entirely asymptomatic, could be incubating, and therefore be infectious from one of these viruses and could pass it on to your relative.

I went through the exact same thing with my Mum. I actually cared for her at home for the few days it took to arrange a suitable care home

The board above the bed is for information for any staff working with the person so they know what level of support they require.
She may be zimmer and supervision in hospital due to unfamiliar environment or distance required to walk to the toilet.
Physio may have assessed as supervision in hospital but independent at home.

That's worth clarifying.

Aldo has she previously fallen down the stairs or is this an anticipated risk?

@halfshutknife

She ended up in hospital becsue she fell at home and was lying for hours. Not on the stairs but that is a real risk now her cognitive impairment has dropped dramatically. If it's a risk in hospital it's a bigger risk at home/.

She also fell in hospital before they managed to decide she needed assistance. She had been there for 4 days

My experience is in Scotland with my mum. The discharge team wanted her discharged quickly with a care package. The reality is very different to what the discharge team want. Even getting a hospital bed delivered to her house took a while, and securing carers took even longer. So whatever the decision things are unlikely to move as fast as the discharge team want.

@Jadebanditchillipepper

Playing devils advocate here, but why should the NHS pay for what are actually social care needs and not health care needs?

There is actually an interim stage which is either community hospital or a different care home until a permanent arrangement is made. I feel she needs further assessment and I think she should have it or the NHS will be paying a lot more when she ends up back in hospital due to another fall or something dangerous happening

Not accurate. A home visit would not be carried out for all patients to make a risk assessment. They should however complete a comprehensive assessment which includes families concerns.

@halfshutknife

Not accurate. A home visit would not be carried out for all patients to make a risk assessment.

Really? I assumed it would be done.

So they won't see the extent of how bad things have been or realise she can't actually get in the house

This is reassuring, it could buy me some time to start dealing with practical arrangements

OP is the issue that you want her in the community hospital as an interim measure while you sort out a care home? Because if it is then you do not have the right to make that decision. They are saying she can go home with carers. If you want something else to happen you have to organise and pay for the alternative.

There is no legislation that says she needs to go home unless she’s already had carers in, legally she can move from hospital to community hospital to care home. They prefer to send people home with care because it’s cheaper but they can discharge her to a care facility.

You’re going to need to stand your ground. While she may be clinically ready for discharge, that discharge needs to be safe. The home should be assessed by OT and social work and a care plan agreed before discharge - there will be a hospital social worker who should be responsible for assessing her safe discharge, this isn’t a medical assessment and is separate from the question of whether there’s a clinical need. Ask to speak with the hospital social worker and speak to your local adult care social work team because they’ll take over after discharge.

The final decision should be an agreement between the medical team, social care team, AHPs and social work and you. There’s a legal duty on social work to seek and consider your views, so you need to speak to them.

In terms of funding, the local authority should cover the first few weeks (12 I think) before you’d start having to self fund - this is the bit they’ll be trying to avoid.

It’s appalling but stand your ground and explore their risk assessment fully (ie what makes them think she can mobilise safely, what evidence do they have that she could feed herself, what evidence do they have that she could use a safety alert), basically make them explain their assessment rather than you telling them it’s not safe. Ask for a copy of her care plan and go through it with a fine tooth comb, asking for a clear explanation of each part and what they have in place to keep her safe. Make them do the work of explaining to you, write it all down.

If the person you’re speaking to can’t or won’t, tell them to find you someone who can. Keep punting it up the ladder both in hospital and social work.

In the meantime look for nursing homes/care facilities that have space, there may be a waiting list but it may be possible to negotiate recuperation at a community hospital while waiting for a place. Them not actually discussing it with you isn’t good enough, and is their way of avoiding a difficult conversation - put all of your concerns in writing to the discharge team, social work department (write to the Head of Service if need be), make reference to the 3 point criteria for Adult Support & Protection which your relative definitely meets and ask that they provide a written response to each of your concerns. Written each in a numbered list.

Its time consuming, emotionally heavy work, but if you make enough noise, in writing, citing adult protection, you’ll get a response.

I fully understand stairs pose a risk. I hate 4 in a block internal stairs as they are essentially pointless.

Are they of the opinion that the fall was caused by illness? This hoping that if illness treated this is unlikely to happen again?

It sounds like you're dealing with a very inexperienced team who either aren't considering the risks or aren't very good at telling you why they've made their recommendations.

I'd be interested to know what hospital your relative is in. I recall a fairly similar story on here some time back and D&G was the hospital in question.

Nope. If you imagine a caseload of 9 patients at every time and an environmental visit taking around 3 hours, it won't be feasible.

Many situations they are required but in most they aren't.

You tell them the carpet is soiled and the house isn't currently habitable as a result then no one needs to attend and confirm that.

I do not know what hospital your relative is in. But my experience with my mum was that the hospital social worker said to me that the medics often want a quick discharge, but she likes to take the time to make sure everything is in place. It will depend on the individual though.

Okay. The rest of my post still applies. You are the decision maker here not professionals, and no discharge planning meetings should take place without your input. Your PoA gives you the authority to make welfare decisions on behalf of your relative and this is a welfare decision. Again, ask them, in writing, to confirm your understanding that this is the case.

The relevant legislation is the Adults with Incapacity Act (Scotland) 2000 . Attornies are covered in this section: https://www.legislation.gov.uk/asp/2000/4/part/2

NRTFT but have been in your situation. The home visits were 15 minutes x 4 a day. We all took it in turns to go round but she just wasn’t safe. What worked for us - the local authority will have a vulnerable adults safeguarding policy with a governing committee. Email them and say there is a vulnerable adult at risk, phone social services daily to report it. Pass the responsibility to them while keeping a sneaky eye on your relative.

As PA you can’t control the medical discharge but you can control what happens next. I honestly think any medical professional will agree that your relative needs a care home and we were able to turn this round in a week after we visited care homes. If your relative objects (unlikely as sounds like capacity issue) then the doctor may have to section your relative (as a last resort). There would then be a court appointed representative to look into it but honestly I think the docs will agree a care home is best. PM me if you need help. Sorry this is happening 💐