When the person you care for is first admitted into hospital, you may feel overwhelmed with the initial information. Always ask for clarification.  

Many hospitals have a Carers Passport Scheme which can help the hospital understand your needs, please see the links below: 

Southport and Ormskirk Hospital

Liverpool University Hospital

If the person you care for lacks capacity then “Best Interest” Meetings are arranged.  

This is when a patient lacks mental capacity to make important decisions about their care or treatment. During these meetings, a multidisciplinary team comes together to make a decision for the patient’s best interest.  

As a carer, you should be included in this meeting to represent the person you care for and make known any limitations or needs when caring for the person who is being discussed.  

If you have lasting power of attorney for their health, final decisions will be yours to make. 

Each hospital has its own discharge policy – this can be requested from the ward manager or Patient Advice and Liaison Service. The discharge planning should begin as soon as the person you care for is admitted. 

A hospital discharge plan should include: 

• The name of the member of staff at the hospital who’s responsible for checking you’re discharged properly 
• Arrangements for an assessment of your care needs, if necessary 
• Details of any support, help, equipment or adaptations which are to be set up at your home before discharge, and information about who is responsible for providing these (with an idea of timescales) 
• Details of any contacts to be made to the community health services, such as GP, district nurse or social worker 

A patient can ask for a copy of the discharge plan, and so can a carer or representative with the patient’s permission. 

The new discharge process known as ‘Discharge to Assess’ recognises people have different needs once they no longer need care in an acute hospital. Staying longer than necessary is not good for a person’s recovery or wellbeing.  

Staff are asked to arrange discharge on the day the doctor agrees they no longer need hospital care. The person cannot stay in hospital if they choose not to accept the care offered to them. 

This process identifies four types of patients. Those who:  

1. Need minimal help on discharge 
2. Would benefit from short term support to recover further at home, before assessing their long-term care needs
3. Would benefit from short term support to recover further in a residential setting, before assessing their long-term needs 
4. Are unlikely to benefit from short term support and need ongoing nursing care, most probably in a nursing home. 

Ward staff manage discharge of patients needing only minimal help, for example with transport home or someone to switch on heating. They can provide information on organisations who can help, for a few weeks, with tasks such as shopping or a referral to Sefton CVS hospital discharge service 

The person you care for may have potential for further recovery when their need for hospital care finishes. They may benefit from support to maximise their recovery before staff assess their long-term. If so, staff will discuss with you and the person you care for what this might mean and appoint a case manager. The case manager arranges to discharge them to a more suitable location, any settle-in support they need, and for a health professional to visit them and you.  

If the person you care for has needs that are too great to return to their own home, they may be discharged to a residential setting such as a community hospital or care home. Support, over and above what they were receiving prior to their hospital stay, is free of charge for up to four weeks. Staff are expected to assess their longer-term care needs within this time. If the person you care for is unlikely to benefit from further support Ward staff will discuss their long-term needs with them and you and any other family as appropriate.  

• If the person you care for lacks capacity to make decisions about treatment and care and has registered a LPA for health and wellbeing, and you as the carer are an attorney, then staff should fully involve you, so that you can make decisions on their behalf. 
   
• If you are not the registered attorney, staff must make a ‘best interests’ decision on the person’s behalf, and should consult with you as a carer before doing this. Staff should give you information at every step of this process. 
  
  
• An assessment on the ward should be carried out to see if the person you care for is medically fit to be discharged from hospital.  
  
  
• A discharge assessment should be carried out to see if they need support once discharged from hospital. This may require a visit from the occupation therapist to cared for’s home. 
  
  
• As a carer you should be asked by one of the clinical team or the discharge team, if you are willing and able to carry on caring for this person. If you are not able to do so then they need to listen to you and adjust the discharge plan with both your and the person you care for’s agreement and consent. This is in line with the Care Act 2014.  
  
  
• A Carer’s Assessment should be offered via a referral to Sefton Carers Centre to see whether you as a carer need support once the person you care for is discharged to their final place of care.  
  
  
• A written care and support plan (called a ’Care Plan’) should be given to the person you care for, which outlines the support required and how this will be provided.  Any extra help is arranged. For example, a visit from the district nurse or paid home help.  
  
  
• If required an Occupational Therapist will carry out a home visit or talk to you about any equipment or adaptations needed.  
  
  
• Any equipment is fitted and delivered. For example, a raised toilet seat, chair raisers, hospital bed. Home adaptions are also made. For example, grab rails in the bathroom and/or on any stairs. 

• Am I registered as the main carer/ next of kin on the hospital records? 

• When is the review meeting?  

• When will I receive a copy of the Care Plan?  

• Has the person I care for been assessed by an Occupational Therapist or Physiotherapist?  

• Could the patient recover further, if offered formal support or more rehab?  

• I am willing to care at home but do not have the correct equipment or any equipment.
• Who do I need to talk to?  

• What is the Discharge to Assess (D2A) process? 

• Is the person I care for eligible for the free four weeks paid care worker support?  

• If the person I care for needs to go into a care home or nursing home how will this be funded?  

• Is the person I care for eligible for Continuing Health Care funding?  

• Who is the member of staff who I need to talk to about discharge?  

• Will I receive a discharge plan or letter? 

Sefton Carers Centre has a limited number of wheelchairs which can be hired free of charge from Sefton Carers Centre for a limited time periods to support carers registered with ourselves. 

Terms: 

• Carers must be registered with Sefton Carers Centre  

• Loan is free for a limited time period, maximum period of 2 weeks 

• The wheelchair must be collected and returned to Sefton Carers Centre    

To find out more information contact us here or call us on 0151 288 6060 

Carers UK

NHS Hospital Discharge

Government Guidance