When a loved one is in hospital, it is natural to want them home as soon as possible. But the period immediately after discharge can be daunting. Your family member may be weaker than before, less steady on their feet, or in need of support they did not require previously. Understanding the discharge process, the support available, and how to arrange care at home can make a real difference to their recovery.
This guide explains what happens when someone is discharged from hospital in Wales, what reablement and domiciliary care options are available, and how families in Denbighshire, Conwy, and Wrexham can access the right support.
The Hospital Discharge Process in Wales
Hospital discharge in Wales is guided by national policy designed to ensure people leave hospital safely and with appropriate support in place. Hospitals have discharge coordinators and social workers whose job is to plan the transition from hospital to home.
The discharge process typically involves:
- Clinical readiness: The medical team decides when the patient is well enough to leave hospital. This is a clinical decision based on the person’s health, not on bed availability.
- Discharge planning: A multi-disciplinary team — which may include doctors, nurses, physiotherapists, occupational therapists, and social workers — will assess what support the person needs at home.
- Family involvement: You should be involved in the planning process. If you are not being kept informed, ask to speak to the discharge coordinator or ward sister. You have the right to be part of the conversation.
- Arranging support: If the person needs care at home, this may be arranged through the local authority, through a reablement service, or privately.
What Is a Delayed Transfer of Care?
Sometimes, a patient is medically fit to leave hospital but cannot be discharged because the support they need at home is not yet in place. This is known as a delayed transfer of care (sometimes called “bed blocking” in the media). It is a significant issue across Wales and the wider UK, and it underlines the importance of having adequate domiciliary care capacity in the community.
If your loved one’s discharge is being delayed because of a shortage of care packages, you may wish to explore arranging care privately to speed up the process. At Accredilink, we can often arrange domiciliary care more quickly than a local authority care package, as we have care workers and emergency care responders ready to deploy.
Reablement: Short-Term Support to Get Back on Your Feet
In Wales, many people leaving hospital are offered a reablement service before long-term care is considered. Reablement is a short-term programme, typically lasting up to six weeks, designed to help people regain their independence and confidence after illness, surgery, or a fall.
Reablement is different from ongoing domiciliary care. The focus is on rehabilitation rather than doing things for the person. A reablement team will work with your loved one to:
- Rebuild mobility and physical strength
- Regain confidence with daily tasks such as washing, dressing, and preparing meals
- Practise using any new equipment or aids provided by occupational therapy
- Work towards agreed goals, such as being able to walk to the kitchen independently
Reablement is provided free of charge in Wales for up to six weeks. It is usually delivered by the local authority’s own reablement team or by a commissioned care provider. If your loved one is offered reablement, it is well worth accepting — research consistently shows that effective reablement reduces long-term care needs and helps people stay independent for longer.
At the end of the reablement period, the person’s needs are reassessed. Some people recover fully and need no further care. Others may need ongoing domiciliary care, which is then arranged through the usual assessment and funding process.
What Support Is Available After Hospital?
Depending on your loved one’s needs, a range of support may be put in place following hospital discharge.
Domiciliary Care
If your loved one needs ongoing help at home — with personal care, medication, meals, or mobility — domiciliary care is the most common form of support. This can range from one or two short visits a day to multiple visits or even live-in care for those with more complex needs.
Sit-In Services
For people who are not safe to be left alone for extended periods, a sit-in service provides a care worker who stays with them for several hours at a time. This is particularly useful in the early days after discharge when the person may be at higher risk of falls or confusion.
Emergency Care Response
The days and weeks after a hospital discharge are a period of heightened risk. Falls, medication issues, and sudden deterioration can happen. At Accredilink, we have emergency care responders on shift who can attend quickly if something goes wrong. This provides an important safety net during the vulnerable post-discharge period.
District Nursing and Community Health Teams
If your loved one has ongoing health needs — such as wound care, catheter management, or injections — district nurses can visit at home. The hospital should arrange this as part of the discharge plan. Community physiotherapy and occupational therapy may also be available.
Equipment and Adaptations
An occupational therapist may recommend equipment to make the home safer, such as grab rails, a raised toilet seat, a perching stool, or a hospital-style bed. In Wales, many of these items are provided free of charge through the local authority or NHS. The hospital OT should arrange for essential equipment to be in place before discharge.
How Domiciliary Care Helps Recovery
Recovering at home, in familiar surroundings, is generally better for a person’s wellbeing and outcomes than staying in hospital longer than necessary. But it only works if the right support is in place. Here is how domiciliary care contributes to a safe and successful recovery:
- Medication management: After a hospital stay, medication regimes often change. A care worker can provide prompts and ensure new prescriptions are followed correctly.
- Nutrition: Proper nutrition is essential for recovery. Care workers can prepare nutritious meals and encourage adequate fluid intake.
- Mobility support: Gentle encouragement to move, along with safe assistance, helps prevent the deconditioning that comes from prolonged immobility.
- Emotional support: Coming home from hospital can be an anxious time. A caring, regular presence provides reassurance and companionship.
- Observation: Care workers see the person regularly and can spot early warning signs of deterioration, infection, or complications, allowing intervention before a crisis develops.
- Communication with family: Families often worry intensely during the post-discharge period. Regular updates from the care team provide peace of mind.
What Families Can Do to Prepare
If your loved one is in hospital and likely to need care when they come home, there are practical steps you can take to prepare:
- Engage early with discharge planning: Ask to be included in the multi-disciplinary team discussions. Do not wait until discharge day to start thinking about care.
- Make the home safe: Clear clutter, ensure good lighting, check that pathways are clear, and remove loose rugs or trip hazards.
- Stock up on essentials: Make sure there is food in the house, medications are collected from the pharmacy, and clean bedding is ready.
- Research care providers: If you may need to arrange care privately or are considering topping up local authority provision, start looking at providers now. Check CIW registration and read inspection reports.
- Ask about funding: Speak to the hospital social worker about financial assessments, direct payments, and other funding options. Our guide to care funding in Wales covers this in detail.
- Plan for the first 48 hours: The first two days at home are often the most challenging. If possible, arrange for a family member to be present alongside the care team during this transition.
What If You Are Not Happy with the Discharge?
If you feel that your loved one is being discharged too soon, or without adequate support in place, you have the right to raise concerns. Speak to the ward sister, consultant, or the hospital’s Patient Advice and Liaison Service (PALS). In Wales, you can also contact the local Community Health Council, which acts as an independent patients’ watchdog.
It is important to know that a discharge cannot be delayed simply because a family disagrees — the clinical team makes the final medical decision. However, if care support is not in place, you should insist that this is resolved before discharge proceeds.
How Accredilink Can Help
At Accredilink Community Response Taskforce, we regularly support families navigating the transition from hospital to home. We serve Denbighshire, Conwy, and Wrexham, and our team can often begin care at short notice to prevent discharge delays.
Our services include personal care and daily living support, sit-in services for those who should not be left alone, emergency care response for rapid support, and palliative care for those with more serious conditions. We are regulated by Care Inspectorate Wales, and our care workers are trained, vetted, and committed to providing compassionate, professional care.
If your loved one is approaching hospital discharge and you are unsure what comes next, get in touch. We can talk through the options and help you put the right support in place for a safe return home.