Where To Find Trusted Information

GOV.UK hospital discharge guidance: the national rules for hospitals and councils.

GOV.UK discharge leaflet for patients: a short leaflet on what to expect.

Surrey County Council: leaving hospital in Surrey.

Healthwatch Surrey: independent feedback and advice about local services.

Alzheimer's Society: information on dementia and hospital stays.

Dementia UK: Admiral Nurse support for family carers.

Parliamentary and Health Service Ombudsman: if a complaint can't be resolved locally.

Remember

Going home from hospital is not the end of the journey.

It is the beginning of the next stage.

Most families find small issues in the first week, and that doesn't mean anyone has failed.

Take things one day at a time, and ask for help when you need it.

Care, Costs And Support After Discharge

Short-term support is only the beginning. If your loved one is likely to need ongoing help, a Care Needs Assessment with Surrey County Council is the next step. Our Funding Dementia Care guide explains what's available, including NHS Continuing Healthcare and which help is means-tested.

If a care home is likely, our guide to choosing the right care home can help you ask the right questions. And if you're not sure who to call first, our Dementia Support in Surrey guide explains who does what.

The First Week At Home

Trust your instincts. If something doesn't feel right, don't ignore it simply because your loved one has been discharged. Seek advice if:

They become much more confused.
They're unable to manage safely at home.
They refuse food or drink.
Their condition suddenly worsens.
You're worried about their safety.

Contact the GP or NHS 111 for urgent advice, and call 999 in an emergency. You know your loved one better than anyone, and your concerns matter.

What Is Hospital Discharge, And Why Is It Different With Dementia?

Hospital discharge is the planning that happens once someone no longer needs acute hospital care. It should be a planned process that helps your loved one move safely to the next stage, whether that's home, a temporary rehabilitation bed or a care home.

With dementia, that move can be harder. Unfamiliar surroundings, disrupted routines and difficulty remembering instructions can all make leaving hospital more confusing. Families often hold the missing information, such as what is normal for them, what they can and can't manage, and what helps when they're anxious.

Since July 2022, NHS trusts have had a legal duty to involve patients and carers in discharge planning. You have every right to be part of the conversation.

Need More Personal Support?

Hospital discharge can feel rushed and overwhelming, especially when dementia is involved. If you'd like independent help to understand the plan, prepare your home or coordinate support, our Hospital Discharge Support service is here for you.

We are completely independent and take no commissions from care providers. We don't make clinical or council decisions, but we can help you ask the right questions and approach each conversation with confidence.

Start The Conversation

If you have genuine concerns, speak up early. Explain clearly why you're worried and ask what support can be put in place.

Start with the nurse in charge or the discharge coordinator. If you're still not reassured, ask to speak to the ward manager or the hospital's Patient Advice and Liaison Service (PALS). Decisions about discharge involve clinical judgement, but families should be listened to and included in planning.

If you're the carer, you can also ask for a Carer's Assessment. If you hold a Lasting Power of Attorney for health and welfare, tell the ward team and bring a copy. Our Lasting Power of Attorney guide explains why that matters at moments like this.

What If The Discharge Plan Doesn't Feel Safe?

Families in Surrey commonly use hospitals such as Royal Surrey County Hospital (Guildford), East Surrey Hospital (Redhill), Epsom Hospital, St Helier Hospital, St Peter's Hospital (Chertsey), Frimley Park Hospital and Kingston Hospital, and for families on the south London borders, Croydon University Hospital. Each works with Surrey County Council's Adult Social Care and local community teams.

A few things are worth knowing locally.

Short-term support at home. If the hospital team think you'd benefit, they can refer you for support at home through discharge to assess. Surrey County Council says this short-term care is free.

The Butterfly Scheme. If your loved one has dementia, ask the ward about the Butterfly Scheme, which helps staff recognise and support people with memory difficulties.

Equipment and technology. Surrey Connected Care includes motion sensors, falls detectors and alarm pendants, which can help someone stay safe at home.

Local advice. Age UK Surrey offers advice on leaving hospital, and Surrey County Council explains the process on its hospital visits and discharge page. Its Adult Social Care information and advice line is 0300 200 1005 (Monday to Friday, 9am to 5pm).

Hospital Discharge In Surrey

One of the most useful things you can do is slow the process down just enough to understand what happens next. Before leaving, try to find out:

Why was your loved one admitted, and what treatment have they had?
Which discharge pathway is planned, and who is coordinating it?
Have any medications changed, and do you have a clear, up-to-date list?
Is any new care or equipment being arranged, and when does it actually start?
Are there follow-up appointments, and who should you contact if you're worried?
Who will check in on them during the first few days?

If something isn't clear, ask for it to be explained in plain English. You should never feel embarrassed about asking someone to explain medical language.

If your loved one seems more confused than usual in hospital, tell the staff what is normal for them. Sudden or worsening confusion can be a sign of delirium, which is common in older people in hospital and is often treatable, so it's worth raising rather than assuming the dementia has suddenly progressed.

What To Ask Before Your Loved One Leaves Hospital

Sometimes families spend so much time preparing for the hospital that they forget to prepare the house. Before returning home, think about:

Is there enough food, and is the home warm and safe?
Are walking aids, a commode or other equipment in place if needed?
Are medications organised, ideally with a simple system such as a dosette box?
Is someone staying with them for the first few days?
Have any new care arrangements actually started?

Even small preparations can make a big difference.

Is Home Ready?

Most hospitals (should) now use an approach called discharge to assess, often alongside Home First. The idea is that people leave as soon as they no longer need acute hospital care, and the assessment of their longer-term needs happens afterwards, once they've had time to recover, usually at home or in a community setting.

Plans are organised into four routes, called pathways:

Pathway 0: home with no new or increased formal support, or restarting care that was already in place.

Pathway 1: home with new or increased support, such as short-term care visits while recovery continues.

Pathway 2: a community bed with dedicated recovery support, such as rehabilitation.

Pathway 3: usually a care home, for people likely to need ongoing 24-hour care.

A transfer of care hub helps coordinate this, and some people are given a case manager. National guidance also says people should leave hospital as early in the day as possible, ideally before 5pm, as agreed with you and any care providers. Read the national guidance on GOV.UK

How Does Hospital Discharge Work In England?

Welcome

Leaving hospital often feels like a milestone. Families are usually relieved that their loved one is well enough to go home, but it's also common to feel anxious about what happens next.

"Are they really ready to come home? And will we cope?"

When someone has dementia, hospital can be confusing and unsettling, and going home can bring challenges that weren't obvious before the admission.

The good news is that a safe discharge isn't about getting everything perfect. It's about making sure the right information, support and planning are in place before you leave the ward.

This guide explains how hospital discharge works in England, what to expect in Surrey, the questions worth asking and how to prepare for the first days at home.

The Care Lens Tip:

Ask, "Which pathway is the plan, and who is coordinating it?" It's a simple question that tells you what support to expect, and it often prompts the team to explain the plan properly.

The Care Lens Tip:

Hospital staff should want people to leave safely, not quickly at any cost. If you're unsure about the discharge plan, it's okay to keep asking questions until you understand it.

What Happens, What To Ask, And How To Prepare For A Safe Journey Home

Reading time: Approximately 15 minutes

Hospital Discharge With Dementia guide

Frequently Asked Questions

This guide has been written by The Care Lens using practical experience alongside established guidance from organisations such as the NHS, Alzheimer’s Society, Dementia UK and NICE. Every family is different, so this guide is intended to support—not replace—professional medical or legal advice where appropriate.

The Care Lens Tip

The first few days at home often tell you far more than the hospital stay did. Watch carefully, take notes, and don't worry if new questions arise. They often do.

What is hospital discharge for someone with dementia?
It's the planning and process for leaving hospital once acute care is no longer needed. For someone with dementia, it should include a plan for support at home or elsewhere, and you as a family member or carer should be involved in it.

What is discharge to assess?
It's the approach most hospitals now use. People leave hospital as soon as they no longer need acute care, and the assessment of their longer-term needs happens afterwards, at home or in a community setting, once they've had time to recover.

Can a hospital discharge someone with dementia without a care plan?
Hospitals should plan discharge with you, and NHS trusts have a legal duty to involve patients and carers. Under discharge to assess, longer-term assessments may happen after discharge, but there should still be a plan for immediate support. If you aren't sure what it is, ask, and raise it with the ward manager or PALS if you aren't satisfied.

Can I refuse discharge if I don't think it's safe?
Discharge decisions involve clinical judgement, so families can't simply veto them, but you should be listened to. Explain your concerns as early as possible and ask what support can be put in place. Options might include extra community support, rehabilitation or short-term care.

Can someone with dementia discharge themselves from hospital?
Adults who have the mental capacity to make that decision can choose to leave hospital, even against medical advice, though it's always best to speak to the ward team first. If someone with dementia can't make the decision themselves, it should be made in their best interests with those close to them involved, not by the family alone.

Who pays for care after hospital discharge?
Short-term support arranged through discharge to assess is usually free for a limited time. Longer-term care may be funded by the NHS (Continuing Healthcare), by the council after a means-tested assessment, or by the family. Our Funding Dementia Care guide explains each route.

Will someone visit after discharge?
It depends on the discharge plan. Some people receive follow-up from community nurses, therapists, GPs or care providers, while others don't need regular visits. Before leaving hospital, ask who is expected to be involved and when.

What paperwork should we keep?
Keep discharge summaries, medication lists, appointment letters and any contact details you've been given together in one place. They can be very useful if you need advice later.

Remember

Don't be alarmed if your loved one seems more tired than usual. Hospital stays can affect confidence, mobility, sleep and appetite.

Some people appear more confused for a short time after coming home before gradually settling back into familiar routines. Others may need more support than they did before the admission.

Try not to compare today with yesterday. Instead, look for gradual improvement over the coming days and weeks.