What to do while they are still in hospital

This is the window. Discharge dates are often confirmed a day or two ahead, and there is no right to stay in a hospital bed while a preferred care home has no vacancy — so the families who still have a choice on the day are the ones who did this bit early. Nothing here commits you to anything, and none of it is wasted if they come home with support instead.

1. This week, on the ward

• Get the discharge coordinator's name and a direct number — and say you would like to be part of the discharge planning. Since 2022 trusts have had a duty to involve the patient and their carer, so that is a right, not a favour.
• Ask whether the council's hospital social work team is involved yet, and get that name too.
• Ask which discharge route they are planning and why — home with no support, home with short-term reablement, a short stay in a rehab bed, or a care home.
• Ask to be told when a date is being CONSIDERED, not once it is set.
• Ask for the council's free needs assessment to be started now, rather than after discharge.
• Ask for a carer's assessment in your own name at the same time — it is yours, separate, and also free.
• Ask whether an occupational therapist will do a home visit or access check before discharge.
• Ask whether a Continuing Healthcare checklist has been done. Anyone can ask; it is free and not means-tested.

2. Equipment — ask about lead times

This is the thing families are never warned about, and the commonest cause of a discharge that does not work.

• Small aids — a frame, a raised toilet seat, a perching stool, grab rails — usually days.
• A hospital bed, a hoist or a ramp — longer, and someone has to order it. Ask who has, and when it is due.
• A stairlift or level-access shower goes through a Disabled Facilities Grant: months, not weeks.
• Minor aids and adaptations costing £1,000 or less must be provided free.
• Ask what the plan is for the gap between the discharge date and the equipment date.

3. The house — things you can do without anyone’s permission

• A key safe by the door, with the code given to the ward and to any care agency — carers cannot let themselves in without one.
• The way in: the step or threshold, and whether the path takes a frame or a wheelchair.
• Could a bed go downstairs? Where is the nearest loo, and what is the plan at night?
• A chair with arms, at a height they can stand up from — a low soft sofa is one of the commonest reasons home does not work.
• A second stair rail, a rail by the front door, a rail by the loo.
• Rugs, trailing leads and hallway clutter out of the way.
• A working phone within reach of the bed or chair, a lamp beside it, a night light on the route to the loo.
• Heating on, milk and food in, something easy for the first night. Spare keys sorted.
• Clothes and shoes taken IN to the ward for going home.

4. Paperwork and money, lined up early

Lasting Power of Attorney, both kinds — health and welfare, and property and financial affairs. It can only be made while the person has the capacity to make it, capacity is decision-specific and often improves in the weeks after a stroke, and registration takes weeks. That is exactly why families start it while someone is still on the ward. Without one, the route later is a Court of Protection deputyship, which is slower and costlier; a DWP appointee is the smaller, faster version and covers benefits only.

One folder now. The financial assessment comes later but always wants the same papers — bank statements, pension and benefit letters, savings, property. Gathering them this week turns an afternoon later into ten minutes. Above £23,250 in capital someone pays the full cost of their care; below £14,250 only income is counted.

Benefits, honestly. Attendance Allowance is not means-tested and savings are irrelevant — but it normally requires having needed help for six months (fast-tracked only under the terminal-illness rules), so straight after a sudden stroke it is a diary note rather than a this-week job. Where it is alreadyin payment it is suspended after 28 days in hospital and restarts on discharge, and the DWP needs telling both times. Under State Pension age the equivalent is Personal Independence Payment. Carer’s Allowance exists for whoever is doing the caring, with an earnings limit.

If a permanent care home ever does come up — the value of the person’s home is disregarded for the first 12 weeks of a permanent placement the council arranges, and a deferred payment agreement lets fees be secured against the house rather than the house being sold. Both are worth knowing before anything is signed, which is why they belong in this week rather than that one. How paying for care works. Nothing is signed on the ward.

5. Look early — three or four, not one

There is no right to stay in a hospital bed waiting for a preferred home to have a vacancy. If the first choice is full on the day, somewhere interim is offered instead. A shortlist of one is a single point of failure; three or four you would genuinely accept is the mechanism that keeps the choice with you. Ten is a way of never deciding.

• See what is registered near where they would be going — every service with its CQC rating in CQC’s own words and the date it was published. Save the ones worth seeing to your shortlist so you can compare them, and share that list with whoever is deciding with you.
• Ring and ask for the manager: “My mum's in hospital and we're preparing for discharge — could we come and look round this week?” Homes are used to that call.
• Go once by appointment, and if you can, once unannounced — late afternoon, a mealtime, or a weekend, when staffing is thinnest.
• Ask: how many staff are on at night; how sickness is covered; how many staff have been there over a year.
• Ask: do they take council-funded and CHC-funded residents; the fee and what it does not include; whether a top-up would be sought.
• Ask: do they do short stays and respite; would they hold a room, and for how long; the trial period and the notice.
• Ask: what happens when someone's needs change; do they take people straight from hospital, and how soon could they come and assess.
• Notice: are people up and dressed; is anyone talking WITH residents rather than about them; do staff use names; the smell; what is actually happening at three in the afternoon.
• Check the CQC rating AND its publication date — an old rating is a different thing from a current one.
• Write it down as you go. Nobody's memory survives a discharge phone call.

If it is care at home rather than a care home, shortlist agencies the same way — what to ask an agency covers minimum visit length, whether the same carers come each time, whether they cover the postcode, and whether they can start at short notice from a hospital discharge.

6. Have ready for the day

• The discharge coordinator's name and number. The hospital social work team's. The council's adult social care number and any case reference.
• The shortlist, with each place's number and who you spoke to.
• NHS number, GP surgery, medicines list, allergies.
• Who holds Lasting Power of Attorney, or that it is in progress.
• The key safe code, and who has keys.
• Transport home arranged, and who is there for the first night.
• A plan for the take-home medicines — usually the last thing to arrive and the commonest cause of a long wait on the day.
• The written discharge plan — ask for it before they leave.
• The number to ring if it does not work, including out of hours.
• ONE named person in the family as the single point of contact, so the ward is not ringing three people.

7. What you can push back on

Fair to push back on, plainly and without apology:

• Being asked to choose a home the same day from a list. You can ask for time — and ask that any short-notice move is recorded IN WRITING as interim while you carry on with your own choice.
• Being told someone must pay before a financial assessment or a Continuing Healthcare checklist has happened.
• Being asked for a top-up when you did not choose a home more expensive than the council's rate — no top-up is payable on an interim placement made because a preferred home had no vacancy.
• Being told the family will provide the care. Nobody can be signed up as a carer without being asked.
• Leaving with no written plan.
• Being refused a needs assessment, or a carer's assessment.

Not a right, and fairer to say so plainly: staying in a hospital bed until a preferred home has a vacancy. Which is exactly why three or four places beats one favourite.

Who to go to, in order:the nurse in charge, then the ward manager or matron, then the discharge coordinator’s manager, then the council’s hospital social work team manager, then the hospital’s PALS, then the trust’s formal complaints process — and finally the Parliamentary and Health Service Ombudsman for the NHS side, or the Local Government and Social Care Ombudsman for the council side. Put anything that matters in writing, even two lines. “Can we have that in writing, please?” is the single most useful sentence a family has on a ward.

8. Help that already exists, and is free

• Home from Hospital and settle-in services — the British Red Cross runs one in many areas, as do some Age UK branches: the lift home, heating on, milk in, a check-in over the first few days. Ask the ward or the council whether one runs locally.
• Stroke Association helpline 0303 3033 100.
• Carers UK 0808 808 7777.
• Age UK Advice Line 0800 678 1602.
• Beacon — free independent advice on NHS Continuing Healthcare.

General information about how discharge works in England, not advice about any particular person. What care someone needs is established by the council’s free needs assessment, and clinical questions belong with the ward team or the GP. Arrangements vary between councils and NHS trusts. We hold no fees, vacancies or waiting lists — those are worth asking about directly.