15. Whether or not an individual is eligible for NHS continuing healthcare funding is a discretionary decision (a decision based on reason, judgement and opinion). It is our role to decide if the IRP made the decision in line with the National Framework. We cannot question discretionary decisions when they have been made without maladministration (fault). So, we can only uphold a complaint about an eligibility decision if there is some specific fault in the way the IRP reached the decision. Such decisions are based on clinical judgements and opinions and we cannot change or alter these.
16. This IRP covers nine years of Mrs I’s care which means we have considered a large amount of evidence. To help show a clear picture of Mrs I’s care needs throughout the period and to show our rationale for our findings, we have given a yearly evidence summary for each domain. We have put the evidence summaries below our analysis of the IRP’s actions and reference it accordingly.
Domain weightings
17. We will firstly explain our decision about the domains Mrs L disputes. The domains set out the care needs a CHC application looks at and the IRP gives a weighting that best describes the level of those needs.
Behaviour
18. Mrs L says care home staff reported her mother had challenging behaviour throughout the whole period. Staff always had to watch her. She used to go into people’s bedrooms and steal things. She would have fights with residents where staff had to intervene. She used to kick staff in the face, swear at them and refuse interventions. Mrs L says her mother used to go missing off the unit and members of the public would bring her back. She did not understand the danger her behaviour caused to herself and others. Mrs L says her mother used to take her clothes off outside. She had lost her inhibitions completely.
19. Mrs L says the carers did everything they should in their remit but her mother needed specialist help.
20. Mrs L says the weighting for this domain should be priority. The descriptor for this weighting is:
21. ‘Challenging’ behaviour of a severity and/or frequency and/or unpredictability that presents an immediate and serious risk to self, others or property. The risks are so serious that they require access to an immediate and skilled response at all times for safe care.’
22. The IRP agreed a high weighting for the behaviour domain for the whole period. The descriptor for this weighting is:
23. ‘‘Challenging’ behaviour of type and/or frequency that poses a predictable risk to self, others or property. The risk assessment indicates that planned interventions are effective in minimising but not always eliminating risks. Compliance is variable but usually responsive to planned interventions.’
24. The IRP report shows it took Mrs L’s and the CCG’s views into account. It concluded that Mrs I’s tendency to defecate in inappropriate places in the early years she was living at the care home was linked to constipation. The records show this to be the case as detailed in year 2005 of the evidence summary (paragraph 31). The records support the IRP’s view that the Senokot (laxative) prescription helped the issue. We can see this issue did not fully resolve but reduced the amount of times Mrs I defecated in inappropriate places.
25. The IRP considered the evidence in the consultant in old age psychiatry’s letters that says Mrs I had some awareness of her behaviour. The consultant thought her dementia and possible frontal lobe involvement could be contributing to her disinhibition, which stopped her from modifying her behaviour appropriately.
26. The IRP considered the additional support the challenging behaviour team gave between 2010 and 2012 and the care plans the home put in place. The report says the other care plans relating to behaviour continued. The IRP acknowledged Mrs I’s behaviour was difficult but this did not stop staff from caring for her. It considered that for Mrs I to have priority level behaviour, it would expect to see that two or three carers needed to accompany at her at all times due to the serious risks posed by her behaviour.
27. We considered the evidence as set out in the evidence summary. We can see Mrs I’s behaviour was challenging for staff to manage. The main issues were that she defecated in inappropriate places, entered other residents’ rooms and stole their possessions, ate food off other residents’ plates, and she had gradual increasing aggression in the later years. We think there is evidence in the care plans that demonstrate staff could predict the risk the behaviour was to Mrs I, others and property. There is evidence of skilled input from the challenging behaviour team to help staff plan interventions. But we have not seen evidence of the need for access to immediate and persistent skilled response, which is part of the criteria for the priority weighting of this domain.
28. We found no failings in the IRP’s weighting of this domain. We can see the IRP’s decision on this domain is supported by the evidence available and it acted in line with the National Framework.
Evidence summary
2004
29. Throughout 2004, Mrs I regularly went into other residents’ bedrooms and defecated in their beds. Staff often found her in other residents’ beds. She was usually compliant when staff encouraged her out of other residents’ bedrooms and helped her find her own room. This issue upset and disturbed the other residents. The care home and its residents kept the other residents’ bedroom doors locked to prevent Mrs I for entering and defecating.
30. Other than this issue, staff reported she seemed settled in the home.
2005
31. Mrs I’s habit of getting into other residents’ beds continued into 2005. She also often refused to get out of bed and was non-compliant with getting dressed. Her behaviour meant she missed meals a couple of times.
32. On 22 February 2005, the consultant in old age psychiatry wrote to Mrs I’s GP. They said that often the faecal soiling can be associated with constipation in people with a cognitive impairment. The consultant suggested Mrs I to take Senokot. This seemed to help the issue but it did not completely resolve it. Although the staff thought she knew what she was doing, the consultant thought her dementia and possible frontal lobe involvement could be contributing to her disinhibition and she may not have been able to modify her behaviour appropriately.
33. On 13 March 2005, the care home changed the care plan to help address Mrs I’s behaviour. The care plan says that staff were to encourage her to stay out of bed in the day but if she wanted to go to bed, to show her where her room was. Staff needed to be aware of when Mrs I went into the wrong room and to show her the name on the door before taking her to her own room. Staff were to accept that Mrs I liked staying in bed but were to offer her food and drink throughout the day. This plan remained in place throughout 2005. In December 2005, she changed rooms to help manage her behaviour.
34. There is one recorded incident on 14 November 2005, where Mrs I was physically aggressive towards other residents.
2006
35. Mrs I continued with her habit of getting into other residents’ beds and staff tried to manage this. Staff recorded that in August 2006, Mrs I had been aggressive with the staff, hitting and nipping them because she did not want to come out of another resident’s room whilst the resident was sleeping.
36. The care plans said staff left Mrs I’s beds unmade to encourage her to stay out of bed in the day. Early in the year, the care plans reflect that this seemed to be working.
37. Mrs I occasionally put her unwanted food on other residents’ plates and used to steal food she wanted from other residents’ plates. When she went into other residents’ rooms, sometimes she would steal their sweets.
38. She regularly defecated in areas other than the toilet.
39. The care plans to manage her going in other residents’ rooms, preventing her from sleeping in the day and defecating on the floor mostly stayed the same throughout this year.
40. In September 2006, Mrs I left the building and walked down the road. Staff from another care home brought her back.
41. Staff recorded Mrs I was abusive towards them in November 2006.
2007
42. Mrs I continued to enter other residents’ bedrooms and get into their beds. Staff regularly worked to try and keep her out of her bed and awake throughout the day so she would sleep at night. She was occasionally incontinent of faeces and urinated in an inappropriate place once.
43. There is a care plan entry on 14 July 2007 where staff were concerned about her refusing to eat at mealtimes. Staff had an intervention in place to try and encourage her to go to the table and eat. Staff needed to monitor her food intake and regularly weigh her to make sure her behaviour was not impacting her physical health.
44. On 14 May 2007, Mrs I refused to finish getting dressed in the morning but eventually did this an hour and a half after starting her morning routine.
45. She left the building on 17 May 2007 but it seems staff found her quickly and she was ok.
46. Care plans mostly stayed the same.
2008
47. Mrs I’s behaviour was consistent with the other years. Care plans stayed the same.
48. In December 2008, she tried to take another resident’s Zimmer frame.
2009
49. The DST completed by a care trust on 30 March 2009 says Mrs I could present with challenging behaviour if somebody said something she did not like or if she did not want to do something she had been asked to do. She liked other people to do things for her and staff described her as stubborn and mischievous. She entered other people’s rooms and would be non-compliant to seek attention. Sometimes she would lie on the floor and poke others as they walked past.
50. There were more records of Mrs I eating other residents’ food at mealtimes. This annoyed the residents and the care plan said staff had to be aware of this to manage the impact on others.
51. She tapped a resident’s face on 12 October 2009 and staff had to intervene to diffuse the situation. Mrs I hit staff on 13 December 2009.
2010
52. Throughout the first few months of 2010, there are entries in the care records saying Mrs I took food from other residents’ plates and she would often go into other residents’ rooms and get in their beds. On 23 March 2010, the records say she tried to steal a resident’s pudding. He held onto the bowl so she grabbed the contents and put them on his head.
53. On 28 March 2010, she hit and kicked a member of staff when they were bathing her.
54. These behaviours continued. On 26 April 2010, the GP made a visit and referred Mrs I to a psychogeriatrician as staff felt her behaviour was becoming more difficult to cope with.
55. On 8 June 2010, the psychogeriatrician wrote to the GP to say her aggressive behaviour was getting worse and staff were finding this more difficult. Staff told the consultant that she would be pleasant for two days and then difficult to manage for five days. In the difficult few days, she would want to spend most of the day in bed, refuse to take medication and refuse to get washed and dressed. She would refuse to eat her own food but steal food off other residents’ plates. She continued to be incontinent and soil in other residents’ beds. The letter notes that one staff member seemed to have a good understanding of the issues and was able to manage Mrs I well. Other staff members were finding it hard to understand and cope with the behaviour. The consultant referred Mrs I to the challenging behaviour team.
56. In August 2010, the home implemented behaviour charts. The challenging behaviour team started to record progress notes. The behaviours continued and staff recorded changes to the care plans as the challenging behaviour team advised them of management techniques. Signs of aggression became more common in the second half of 2010 as staff recorded her trying to hit residents and other staff (16, 18 and 21 September 2010 and 31 December 2010).
2011
57. Mrs I’s behavioural challenges continued throughout this year. She consistently took food from other residents, which annoyed them. The care plans show staff managed this by encouraging her not to do this and this continued throughout the year with no changes to the care plan.
58. She continued to hit other residents, which staff managed by removing her from the situation. The care plan evaluation in November 2011 shows staff knew to watch for signs of Mrs I’s behaviour becoming more aggressive.
59. There were fewer entries where she went into other residents’ rooms and got into their bed than in the previous years. There is a record of her doing this on 1 May 2011. There are fewer entries of her defecating in areas other than the toilet.
2012
60. Mrs I’s behavioural challenges continued throughout the year. She consistently took food from other residents, which annoyed them. The care plans show staff managed this by encouraging her not to do this. Staff could anticipate her mood when she got up for the day and would know if mealtimes would be challenging. When staff were anticipating challenging behaviour at mealtimes, they would give Mrs I a tray table in her armchair to minimise disruption to other residents.
61. Care plans stayed mostly the same throughout the year. There is evidence of Mrs I hitting residents and lashing out at staff, such as on 24 and 27 March, 21 July, 2, 8 and 20 September and 12 December 2012.
62. The care plan in October says Mrs I was resistive to care and would only get ready with help from staff, even though she could do this herself. She needed lots of encouragement from staff. Like the other years, she often wanted to stay in bed all day and would sleep in inappropriate places.
2013
63. The records and care plans show Mrs I’s behaviour continued in a similar way to previous years. There are no reports of a marked worsening in this year.
Cognition
64. Mrs L says her mother had a stroke in 2000. Her condition made her look selfish. She would do things like defecate on the floor but not understand it. She thought the bin was a toilet and staff had to stop her from using it. Mrs L says the IRP did not consider that her mother lacked capacity to make decisions.
65. Mrs L says her mother could not assess risks and carers would have to physically restrain her from doing something dangerous. She says carers would have to complete tasks that carried risks.
66. Mrs L says her mother never knew the time and did not recognise she was in a care home. She seemed to recognise her grandson but did not know his name. She only seemed to recognise Mrs L. She says her mother did not recognise or know the staff and she did not know where her own bedroom was.
67. Mrs L says the weighting for this domain should be severe. The descriptor for this weighting is:
68. ‘Cognitive impairment that may, for example, include, marked short or long-term memory issues, or severe disorientation to time, place or person. The individual is unable to assess basic risks even with supervision, prompting or assistance, and is dependent on others to anticipate their basic needs and to protect them from harm, neglect or health deterioration.’
5 April 2004 – 29 March 2009
69. The IRP agreed a moderate weighting for the cognition domain in this period. The descriptor for this weighting is:
70. ‘Cognitive impairment (which may include some memory issues) that requires some supervision, prompting and/or assistance with basic care needs and daily living activities. Some awareness of needs and basic risks is evident. The individual is usually able to make choices appropriate to needs with assistance. However, the individual has limited ability even with supervision, prompting or assistance to make decisions about some aspects of their lives, which consequently puts them at some risk of harm, neglect or health deterioration.’
71. The IRP considered the CCG’s views that Mrs I could articulate her basic needs such as when she was in pain and when she was hungry. It considered the evidence in the records that says she could understand communication (year 2004 in the evidence summary). It considered evidence that Mrs I could express what she did and did not want to happen. It considered the records that suggested she was not oriented but was mindful of records that said she knew where she was.
72. The IRP considered Mrs L’s submission that she did not think her mother could read and that the psychiatrist’s notes said she was disoriented.
73. The records we saw, as described throughout the evidence summary for this time, show that Mrs I had a cognitive impairment. Staff gave her supervision, prompting and helping her find her room and complete her daily living activities. The social services assessments show she was confused but also understood communication (paragraphs 77 and 88 of the evidence summary). The daily records show Mrs I left the residential home a couple of times (paragraphs 80, 87 and 89 of the evidence summary).
74. The evidence shows Mrs I could make basic choices and she did have a limited ability to make decisions about aspects of her life, such as financial decisions. We saw no evidence in the records to show Mrs I had severe disorientation to time, place or person, which is the criteria for the severe weighting. The consultant in old age psychiatry said she recognised him from the hospital in 2005 (paragraph 82 of the evidence summary) and the care home records show she had some awareness of where she was.
75. We found no failings in the IRP’s weighting of this domain. We can see the IRP’s decision on this domain is supported by the evidence available and it acted in line with the National Framework.
Evidence summary
2004
76. The care plan notes that Mrs I had an assessment in hospital because she became confused and disoriented when she was living independently. She had a period where she lived in the care home temporarily for respite. However she decided she wanted to live there permanently, due to her deteriorating cognition.
77. The care plans show Mrs I experienced disorientation leading to a possible increase in confusion and unsettled behaviour. Staff managed this by using positive reinforcement cues such as time and place and by reassuring her. Staff believed that due to her disorientation, she struggled finding her room.
78. A social services assessment on 9 April 2004 says Mrs I was almost always confused but understood most communication.
79. The daily records show Mrs I wandered into other residents’ bedrooms and got into their beds frequently. She occasionally defecated in other people’s beds.
80. In May 2004, she had a urinary tract infection (UTI), which caused her to be confused and disoriented. Staff reported this improved after a course of antibiotics.
81. On 5 July 2004, Mrs I was reporting wanting to go home and she was looking for her handbag, even though she did not have one. Staff found her outside and brought her back in with no issues. On 9 July 2004, staff reported that she was settled and was oriented most of the time. On 20 December 2004, Mrs I tried to leave the building.
82. There were a few reports of confusion and disorientation but it seems her cognition fluctuated in these areas throughout 2004.
2005
83. In a letter from the consultant in old age psychiatry to Mrs I’s GP on 22 February 2005, it says she recognised the consultant from the hospital. It says she was not fully oriented in place. She seemed to be unaware of the soiling. The consultant suspected the soiling could be associated with constipation and is common in people with a cognitive impairment. The consultant noted that staff believed she was aware she was doing it. But he said that due to her dementia and probably frontal lobe impairment, she was more disinhibited and could not modify her behaviour.
84. The daily records report when Mrs I was confused but not what she did when she was in a confused state. On 23 January 2005, she was looking for her knitting and the dog. She left the care home grounds on 19 June 2005 but complied when staff redirected her back to the home. On 3 July 2005, she asked if she could phone her husband (deceased) to see if he would take her to church. On 9 October 2005, the daily records say she was confused, wandering the home, looking for her coat and shopping bag. On 21 October 2005, she was confused, looking for her daughter to get ready for school and wondering where her husband was.
85. Mrs I continued to get into other peoples’ beds, which frustrated the residents so they kept their doors locked.
2006
86. Mrs I continued to wander into other residents’ rooms and sometimes defecated in their beds. She continued to want to know where her husband was and the daily records show she was confused a lot. On 13 February 2006, she woke up in her armchair feeling agitated because she did not know where she was. On 3 June 2006, her son told her that her brother had died and staff noted that she did not seem to acknowledge it.
87. The care plan review in June 2006 says staff needed to help her find her bedroom. She was independent with feeding at this point and chose to eat in the dining toom. Staff reported that she would initiate conversation with other residents whilst at the dinner table.
88. Mrs I kept wanting to go home and left the care home grounds because she had managed to unlock the doors. She also mentioned wanting to milk the goats in one care home record entry.
2007
89. An assessment for the elderly on 4 January 2020 says Mrs I was sometimes confused but understood most communication. During 2007, Mrs I continued to wander into to other residents’ rooms. And she occasionally defecated in inappropriate places. In August 2007, the care plan evaluation said that staff encouraged Mrs I to use the toilet but sometimes she forgot to pull down her clothes if there were no staff present. Staff worked to make sure Mrs I stayed awake in the day as much as possible.
2008
90. Mrs I continued to be confused and wanted to go home to see her husband. She tried to exit the home on one occasion.
30 March 2009 – 22 August 2013
91. The IRP agreed a high weighting for the cognition domain in this period. The descriptor for this weighting is: 92. ‘Cognitive impairment that could, for example, include frequent short-term memory issues and maybe disorientation to time and place. The individual has awareness of only a limited range of needs and basic risks. Although they may be able to make some choices appropriate to need on a limited range of issues they are unable to consistently do so on most issues, even with supervision, prompting or assistance. The individual finds it difficult even with supervision, prompting or assistance to make decisions about key aspects of their lives, which consequently puts them at high risk of harm, neglect or health deterioration.’
93. The IRP considered the CCG’s assessment that from 30 March 2009, Mrs I needed more help finding her room and that she had some awareness of time but struggled to make key decisions when prompting. It considered the records that say Mrs I liked to read and play bingo.
94. The IRP considered Mrs L’s view that Mrs I could not read, and the psychiatrist said she was not oriented.
95. The records as described in the evidence summary shows a marked change in the care home’s perception of Mrs I’s cognitive ability. The records show the home thought she was becoming less aware of her surroundings in 2009 (paragraphs 96 and 97 in the evidence summary). It described her dementia as having ‘increased’ in 2010 (paragraph 101 in the evidence summary), although the consultant in old age psychiatry viewed her cognition had not declined significantly (paragraph 100 in the evidence summary). It is clear there were fluctuations in her cognition from the records and she had a limited ability to make choices. It appears her ability to make choices did decline in around 2009 as demonstrated by the DST and she could not make decisions about key aspects of her life (paragraph 96 in the evidence summary).
96. We have found no failings in the IRP’s weighting of this domain. We can see the IRP’s decision on this domain is supported by the evidence available and it acted in line with the National Framework.
Evidence summary
2009
97. Mrs I was not oriented at times. A DST from March 2009 said she needed help with orientation to place. She could recognise familiar faces but could not recall names. She could make simple choices but people had to make more complex decisions on her behalf. The records show that Mrs I might have been aware of her needs but she could not act on this.
98. There are reports of her not being as alert as she used to be.
2010
99. The social services risk assessment from 17 March 2010 says Mrs I would be unable to find her way back to the building if she left.
100. The letter from the consultant in old age psychiatry to Mrs I’s GP on 8 July 2010 says Mrs I reported that she had been in the care home for three months when she had actually been there for six years. She told the consultant that she worked on her own and she was half retired. She could not name the home and thought it was in Ireland, even though she later agreed she lived in England. She explained to the consultant that she had been awake the previous night looking after her daughter with meningitis.
101. The consultant said she was disoriented to time and could not name the care home or carers. The consultant said there was no obvious deterioration in her cognitive abilities and the behaviours were much the same as in the past few years. The consultant said she seemed relatively stable.
102. The care home notes from 3 December 2010 say Mrs I’s dementia had increased recently and she had help from the challenging behaviour team. There are records in the care home notes that say she could be disengaged but she managed to take part in some of the activities at the Christmas party.
2011
103. Mrs I continued to have input from the challenging behaviour team, who addressed the variable nature of her cognitive functioning. There is no significant change in the patterns that demonstrate her cognitive ability.
2012
104. Social services assessed Mrs I as not having capacity to make decisions, including financial decisions.
105. She continued to go into other residents’ rooms and staff had to help her get to her own room. The care home said her cognition fluctuated. She was aware of her surroundings and could recognise people. Staff said she could understand simple instructions and thought she chose to ignore people sometimes. The care home records said she could express her likes and dislikes and she could make simple choices.
2013
106. Mrs I’s cognition appeared to be consistent with the previous years.
Psychological and emotional
107. Mrs L says her mother would laugh and cry at inappropriate times. She says her mother had depression, which caused high blood pressure and led to her stroke. She says her confusion caused her a lot of worries and anxieties and caused her to wander round the home.
108. Mrs L says when her mother first went into the care home, she would sit with a bingo card but as time went on, she stopped participating in activities due to her capacity and psychological and emotional issues. Her confusion impacted this.
109. Mrs L says the IRP did not consider her mother’s mental ill health.
110. Mrs L says the weighting for this domain should be high. The descriptor for this weighting is:
111. ‘Mood disturbance, hallucinations or anxiety symptoms, or periods of distress, that have a severe impact on the individual’s health and/or well-being.
OR Due to their psychological or emotional state the individual has withdrawn from any attempts to engage them in care planning, support and/or daily activities.’
5 April 2004 – 29 March 2009
112. The IRP agreed a low weighting for the psychological and emotional domain for this period. The descriptor for this weighting is:
113. ‘Mood disturbance, hallucinations or anxiety symptoms, or periods of distress, which are having an impact on their health and/or well-being but respond to prompts, distraction and/or reassurance.
OR Requires prompts to motivate self towards activity and to engage them in care planning, support, and/or daily activities.’
114. The IRP considered the CCG’s view that Mrs I’s needs in this domain were low until March 2009 when the records start to show she was not responding to prompts. We can see it looked at the records and considered a range of entries about Mrs I’s mood, engagement and interaction with others.
115. The IRP considered Mrs L’s view that her mother’s moods were up and down, she had periods of distress and would cry and go to bed. Mrs L’s view was that her mother’s psychological and emotional wellbeing had a severe impact on her individual health and wellbeing. Mrs L told the IRP her mother was withdrawn from attempts to engage her and that the care plans did not work.
116. We considered what the records say about Mrs I’s psychological and emotional needs. We can see numerous entries which show she was usually in a good mood. Mrs I engaged in activities in the home and went on holiday with care home residents. In June 2006, her GP reduced her fluoxetine dose and monitored her.
117. In 2008, there were record entries where staff found it harder to encourage Mrs I to join in with activities but the daily records show she still took part in some of them. At the start of 2009, the evidence shows Mrs I’s engagement and good moods did continue but the DST social services did at the end of March 2009 says she struggled to respond to reassurance and would lose interest in activities and go to sleep.
118. There are entries in the daily records throughout the period where Mrs I would go to bed and sleep in the daytime and sometimes she would experience low mood.
119. We have not seen evidence that Mrs I’s psychological and emotional state was severely impacting her health and wellbeing at this point. We have also not seen that she had withdrawn from any attempts to engage her in care planning, support and/or daily activities. This is what we would expect to see for an IRP to support a high weighting in this domain.
120. The IRP noted that Mrs I was prescribed fluoxetine in March 2009. The records which show Mrs I took this medication throughout the whole care period so it appears the IRP has got this wrong. We have considered whether this would have impacted its decision, had the IRP got this right. It appears the IRP decided on a low weighting for this part of the period because the records show Mrs I engaged with staff and residents, was regularly in a good mood and participated in a variety of activities. Then we can see the IRP moved the weighting to moderate because of the change in Mrs I’s ability to respond to prompts. We do not see this mistake as a serious failing that could have impacted the IRP’s decision.
121. Although there is one mistake where the IRP incorrectly noted the fluoxetine prescription, the available evidence about Mrs I’s psychological and emotional needs supports the IRP’s rationale, is reflective of the domain descriptor for the weighting of low and is in line with the National Framework. We found no failings in the IRP’s weighting of this domain.
Evidence Summary
2004
122. The daily records show Mrs I liked to play bingo and enjoyed going shopping. She participated in other activities such as singing and quizzes and she participated in activities that helped her reflect on her life. The letter from the consultant in old age psychiatry in August notes that staff thought she was pleasant and enjoyed her sense of humour. The letter shows she had taken an antidepressant but staff could not tell whether this helped or whether other factors had improved her motivation.
123. The care plan in April notes that Mrs I could experience low mood at times where she would feel tearful and weepy and could spend long periods in bed. This care plan stayed in place throughout this year with no changes. The risk assessment from July says Mrs I did experience low mood and was sometimes unmotivated.
124. The social services contact notes reiterate that Mrs I did spend a lot of time in bed but she related well to other residents and had made friends. She liked to go out and she went on a holiday in August with carers.
2005
125. The daily records show Mrs I continued to enjoy bingo and the care home had activities that helped her reflect on her life. She often engaged in other activities such as dominoes and singing and dancing. She liked watching television. The daily records show she was often in a good mood but the letter from the consultant in old age psychiatry said she would often insist on staying in bed. She remained on an antidepressant as the consultant thought there was a mood component as well as personality factors impacting her behaviour.
2006
126. The daily records show Mrs I continued to enjoy bingo and other activities such as watching television and films, seeing family, going in the garden and going shopping. In June 2006, she went to Berwick with other residents and staff for a long weekend in a caravan. The care plans show she did need encouragement to engage, especially as she liked to sleep a lot. The records show she usually appeared to be in a good mood and interacted with other residents. The care plan review in June 2006 mentions that her GP had reduced her antidepressant dose. Staff were to closely monitor her wellbeing.
2007
127. The care home records show Mrs I was usually in a good mood and the daily records show she interacted well with other residents. However the social services record from January 2007 said she had some difficulties establishing good relationships. She liked watching television and films and continued to participate in bingo when she was in the mood. She liked going out in the garden and her family visited regularly. Staff took her shopping quite often and in May, she had a day out with other residents.
128. The care plan review from July 2007 indicates that Mrs I liked to spend a lot of time sleeping but there were no concerns with her emotional wellbeing. Sometimes she chose not to participate in group activities if she was tired.
2008
129. The care home records show Mrs I was usually in a good mood. She liked to go out on the bus and staff would take her shopping. She continued to enjoy bingo and sometimes joined in with other activities. The care plan evaluation from April 2008 said that if she was not in the mood to join in with activities, staff could not encourage her. On 14 September 2008, the daily records say Mrs I became confused and wanted to go to home to her husband. In December 2008, she enjoyed the carol service, parties and social events. The daily records say that she sometimes read magazines and the newspaper.
130. The social services contact notes from 4 December 2008 say Mrs I would interact with the other residents. She slept a lot in the day and staff were monitoring it. There were no concerns about her emotional wellbeing.
January – March 2009
131. The care home records show that Mrs I still enjoyed the bingo, reading magazines and shopping with staff. Social services completed a DST on 30 March 2009 noting that she had a history of depression and her low moods could be prolonged. She struggled to respond to reassurance. Sometimes she would become uninterested and non-compliant and she would sleep a lot during the day.
30 March 2009 – 22 August 2013
132. The IRP agreed a moderate weighting for the psychological and emotional domain for this period. The descriptor for this weighting is:
133. ‘Mood disturbance, hallucinations or anxiety symptoms, or periods of distress, which do not readily respond to prompts, distraction and/or reassurance and have an increasing impact on the individual’s health and/or well-being.
OR Due to their psychological or emotional state the individual has withdrawn from most attempts to engage them in care planning, support and/or daily activities.’
134. The IRP gave a weighting for moderate for this part of the period because there were times Mrs I did not readily respond to prompts and encouragement and she became more solitary.
135. It considered Mrs L’s views that Mrs I often looked like she was participating but was not.
136. The evidence we have seen shows a similar picture to what Mrs I’s psychological and emotional state was before March 2009. The daily records note her regular good moods but we can see her engagement in group activities decreased (paragraph 143 of the evidence summary) and she seemed to need much more encouragement. She liked reading and watching television.
137. Care home staff noted that Mrs I was not alert and did not want to interact with other residents (paragraph 140 in the evidence summary). Sometimes she lacked motivation and this impacted her behaviour (paragraph 146 in the evidence summary).
138. A running theme throughout this time is that staff and health professionals recognised that Mrs I had two moods. She would either be happy and engage or be in a bad mood and withdraw. There was a pattern to this behaviour and staff continued to encourage her on a bad day.
139. We saw no evidence that Mrs I’s psychological and emotional state was severely impacting her health and wellbeing. We can see Mrs I did withdraw form some of the staff’s attempts to engage her in daily activities. However, the criteria for the high weighting is that the individual withdraws from any attempt to engage in care planning, support and/or daily activities. We have not seen evidence that this was the case.
140. We have found no failings in the IRP’s weighting of this domain. We can see the IRP’s decision on this domain is supported by the evidence available and it acted in line with the National Framework.
Evidence summary
April – December 2009
141. The care home records show Mrs I still enjoyed reading books and watching TV. She would go shopping with staff when she was in the mood and she liked to sit in the garden. In October 2009, the care plan evaluation noted that Mrs I’s alert days were rare and she did not want to interact with other residents.
2010
142. Early in the year, the care plan evaluations say staff would encourage Mrs I to join in with activities and do things that stopped her from sleeping all the time. She went out shopping a few times and seemed to still enjoy the bingo and watching television. In July 2010, the care plan evaluation says staff would prompt her to get out of bed.
143. On 8 July 2010, the consultant in old age psychiatry noted that staff described Mrs I as having two moods. She could have a couple of days being bright, appropriate and pleasant and then would have five days of being very difficult to manage. She would want to spend most of the day in bed and refuse to comply with care interventions.
144. The care plan evaluation from August 2010 said that Mrs I was not interested in group activities but would occasionally still read her magazines and go out shopping with staff.
145. The challenging behaviour service started to help in August 2010. They recorded that she had two moods, one where she was disengaged and intolerant and one where she was alert and motivated. The progress notes in September capture her poor mood and lack of engagement.
146. Towards the end of the year, the care home records note that Mrs I had been involved with some of the Christmas activities at the home.
2011
147. The challenging behaviour service formulation session shows Mrs I had a history of depression throughout her life and this could impact her motivation. Her lack of motivation combined with poor impulse control impacted her behaviour. The records show the service identified she needed to be motivated and constructively occupied.
148. The care plan evaluations note she had some involvement in activities and she liked to go out on the bus. The care plans were mostly unchanged. In October 2011, the care plan evaluation says her participation in activities was linked to her mood. It says she was not often in a good mood so was not participating in many activities.
2012
149. The care plan evaluations note that Mrs I needed encouragement to join in with activities. She enjoyed watching TV and would chat if she was in the mood. They note that on a bad day Mrs I would sleep. The care plans were mostly unchanged. The care plan summary from 2 October 2012 says Mrs I could be bright and alert on some days but on others she would be sleepy and withdrawn but staff advised that she had always been this way. Sometimes she chose not to participate in activities but staff continued to encourage her to engage.
2013
150. The care plan evaluations remained unchanged throughout the year. The activities diary noted Mrs I enjoyed trips out, such as when she went out for fish and chips with another resident on 6 October 2013. She read the paper regularly and chatted to other residents. On 1 June 2013, she was in a good mood at the social evening. She played bingo on 19 October 2013. The activities diary notes occasional times she was uninterested or unmotivated.
Communication
151. Mrs L says her mother would talk but she was not communicating. She rarely talked. She could not ask to go to the toilet or for a cup of tea. Her communication never made sense and she could not communicate her needs in any time or in any way. This meant staff had to anticipate her needs.
152. Mrs L says the weighting for this domain should be high. The descriptor for this weighting is:
153. ‘Unable to reliably communicate their needs at any time and in any way, even when all practicable steps to assist them have been taken. The individual has to have most of their needs anticipated because of their inability to communicate them.’
5 April 2004 – 16 October 2010
154. The IRP agreed a low weighting for the communication domain for this period. The descriptor for this weighting is:
155. ‘Needs assistance to communicate their needs. Special effort may be needed to ensure accurate interpretation of needs or additional support may be needed either visually, through touch or with hearing.’
156. The IRP considered the CCG’s view that Mrs I could communicate her needs. It said the care home notes showed this to be the case. It saw that Mrs I could have conversations with others.
157. The IRP considered Mrs L’s views that her mother could not communicate and that there was no evidence of her mother communicating.
158. We considered what the records say about Mrs I’s communication. We can see she regularly talked to residents and staff and she could indicate when she was in pain (paragraphs 172, 174 and 177 in the evidence summary). Occasionally staff had to try to ensure they interpreted what she said correctly.
159. We can see she could articulate her likes and dislikes (paragraphs 168, and 171 in the evidence summary). The consultant in old age psychiatry letters say he had conversations with Mrs I and sometimes she would make things up to compensate for her memory loss (paragraph 178 in the evidence summary).
160. We saw no evidence that Mrs I was unable to communicate her needs reliably at any time and in any way, even when all practicable steps to assist her had been taken. We have not seen evidence in the records of staff having to anticipate most of her needs because of her inability of communicate this. For the IRP to consider a high weighting, we would expect to see evidence of these things.
161. We found no failings in the IRP’s weighting of this domain. We can see the IRP’s decision on this domain is supported by the evidence available and it acted in line with the National Framework..
Evidence summary
2004
162. The Clifton assessment procedures for the elderly on 9 April 2004 say Mrs I communicated in any manner and staff could understand her but this was sometimes difficult. It notes she could see, wore glasses, and could hear without a hearing aid.
163. On 18 August 2004 the letter from the consultant in old age psychiatry says Mrs I told the consultant that she wanted to go home but agreed she could not look after herself and was lonely when living at home previously.
164. The activities diary note that Mrs I chatted to staff and residents. On 20 November 2004, the activities diary notes Mrs I was chatting about photographs whilst she was preparing a life book.
2005
165. On 7 January 2005, the daily records say the optician gave Mrs I an eye test and there were no problems with her sight or glasses.
166. There are numerous entries in the daily records where Mrs I talked to staff and residents, such as on 21 February, 11 April, 16 July, 26 September, and 7 November 2005. These records describe Mrs I as chatting and in a good mood.
167. The letters dated 22 February and 9 June 2005 from the consultant in old age psychiatry to the GP say that she communicated that she was happy at the home but she did not get enough food. She would ask to use the phone or bake and could communicate when she did not feel well.
2006
168. On 12 January 2006, the daily records say the optician was happy with her eyes and there was no change in her sight.
169. The care plan review on 29 June 2006 says Mrs I chose to eat in the dining room where she would initiate conversation with other residents at the table. She could express what she liked and disliked.
170. There are numerous entries in the daily records where Mrs I talked to staff and residents such as on 8 February, 1 October, 22 November and 8 December 2006.
171. On 9 November 2006, Mrs I complained of having a sore right eye. The GP visited because she could not open it.
2007
172. There were no changes to the care plans in this year regarding Mrs I’s communication. The daily records described her as being chatty and she could initiate conversation with other residents. She could communicate what she liked and disliked.
173. On 4 January 2007, the social services assessment says Mrs I could always communicate well enough to make herself easily understood. She complained of a sore right eye on 13 January 2007.
2008
174. On 3 and 14 September 2008, the daily records say Mrs I had problems hearing the television.
175. On 6 October 2008, Mrs I complained of having a painful sore eye, for which her GP prescribed eye drops.
176. The care plans remained unchanged and Mrs I talked to staff and residents.
2009
177. Mrs I’s care plans did not change in this year. She could communicate her needs and people could understand her.
178. She reported earache on 27 May 2009 and the GP visited. The GP records say the GP prescribed something for her ear wax and she had her ears syringed at the surgery. She also had her ears syringed on 30 December 2009. The GP records say that Mrs I’s hearing was normal.
January – October 2010
179. The letter from the consultant in old age psychiatry to the GP on 8 July 2010 notes Mrs I and the consultant spoke about her current situation. The consultant noted that her speech was normal but she made things up to compensate for her memory loss.
180. On 16 August 2010, the challenging behaviour service noted Mrs I would communicate when she was having a good day but not speak at all on a bad day. In her progress notes on 17 October 2010, it says Mrs I did not communicate with anyone except to respond to staff asking if she wanted more drinks.
181. On 22 September 2010, in the behaviour chart Mrs I could communicate that she was still hungry.
17 October 2010 – 22 August 2013
182. The IRP agreed a moderate weighting for the communication domain for this period. The descriptor for this weighting is:
183. ‘Communication about needs is difficult to understand or interpret or the individual is sometimes unable to reliably communicate, even when assisted. Carers or care workers may be able to anticipate needs through non-verbal signs due to familiarity with the individual.’
184. The IRP determined Mrs I’s communication needs increased in October 2010 because the records show her communication reduced.
185. We can see the records show Mrs I could communicate her likes and dislikes. In 2012, the challenging behaviour service noted Mrs I’s moods impacted her communication, which meant staff needed to anticipate some of her needs to protect her from harm. She would chat with others if she was in the right mood and could say when she was in pain (paragraph 193 in the evidence summary).
186. The records show Mrs I could express her likes and dislikes (paragraph 188 in the evidence summary) and that she could identify some of her care needs (paragraph 191 in the evidence summary).
187. We saw no evidence that Mrs I was unable to communicate her needs reliably at any time and in any way, even when staff had taken all practicable steps to assist her. We have not seen evidence in the records of staff having to anticipate most of her needs because of her inability to communicate them. For the IRP to consider a high weighting, we would expect to see evidence of these things.
188. We have found no failings in the IRP’s weighting of this domain. We can see the IRP’s decision on this domain is supported by the evidence available and it acted in line with the National Framework.
Evidence summary
October - December 2010
189. Mrs I’s social services contact notes from 3 December 2010 say that she could express her likes and dislikes.
2011
190. There are no changes to the care plans or patterns of Mrs I’s communication in the care home records.
2012
191. The social services contact notes from 6 March 2012 say that Mrs I could not weigh information to make or communicate decisions.
192. The behaviour team care plan summary on 2 October 2012 says staff felt Mrs I could identify some of her care needs depending on her mood. Sometimes staff needed to anticipate her needs to protect her from harm. It says her speech was clear but varied because sometimes she would refuse to wear her dentures. Depending on her mood, she would chat with others.
193. The activities diary notes that Mrs I engaged with others, such as on 9 September, 11 October, and 24 October 2012.
2013
194. The activities diary shows Mrs I could initiate conversation, such as on 29 January and 8 July 2013. Her willingness to do this seemed to depend on her mood. On 13 May, Mrs I complained of dizziness after a fall.
Nutrition
195. Mrs L says her mother had an eating disorder. She refused food and the interventions that were in place. Her weight went up and down and staff had to break up the food so that she could eat it.
196. Mrs L says staff managed her care well but her needs were marginalised at the IRP. She was not getting the care she needed to keep her nourished and hydrated. This meant she slept a lot.
197. Mrs L says the weighting for this domain should be high throughout the whole period. The IRP agreed this domain had a high weighting from 7 August 2012 to 22 August 2013. The descriptor for the high weighting is:
198. ‘Dysphagia requiring skilled intervention to ensure adequate nutrition/hydration and minimise the risk of choking and aspiration to maintain airway.
OR Subcutaneous fluids that are managed by the individual or specifically trained carers or care workers.
OR Nutritional status “at risk” and may be associated with unintended, significant weight loss.
OR Significant weight loss or gain due to identified eating disorder.
OR Problems relating to a feeding device (for example PEG) that require skilled assessment and review.’
5 April 2004 – 6 August 2012
199. The IRP agreed a low weighting for the nutrition domain in this period. The descriptor for this weighting is:
200. ‘Needs supervision, prompting with meals, or may need feeding and/or a special diet (for example to manage food intolerances/allergies).
OR Able to take food and drink by mouth but requires additional/supplementary feeding.’
201. The IRP considered Mrs L’s views that her mother lost weight every year and needed skilled intervention for adequate hydration. She told the IRP that her mother would sleep for three or four days at a time and would not eat or drink when she did this.
202. The IRP considered the CCG’s views that Mrs I could eat but her weight did fluctuate. The CCG said that Mrs I would refuse to eat and steal food from others, but this was a behavioural issue.
203. There are monthly weight charts in the care records which show some fluctuation in Mrs I’s weight but not in a way that meant she needed enhanced support or monitoring. This is shown throughout the evidence summary. The IRP did not see the care home’s monitoring at this stage as a skilled intervention.
204. The records show Mrs I fed herself independently, had no issues with swallowing her food and she usually had a good appetite. We can see there were behavioural issues, as demonstrated in the evidence summary, which meant staff needed to supervise Mrs I and prompt her with meals. Mrs I did lose more weight in 2012 because she was refusing food more often and this is what prompted the IRP to revise the domain weighting at this point.
205. We have not seen evidence that Mrs I needed skilled intervention due to not being able to swallow. There is no evidence of her needing fluids through a drip. No one involved in Mrs I’s care considered her nutritional status was at risk and she did not lose a significant amount of weight. She did not have a feeding device. For the IRP to consider the high domain, we would expect to see evidence of these things in the records.
206. We have found no failings in the IRP’s weighting of this domain. We can see the IRP’s decision on this domain is supported by the evidence available and it acted in line with the National Framework.
Evidence summary
2004
207. The daily records, social services contact notes and letter from consultant in old age psychiatry show Mrs I had a good diet in this year. The weight charts show an overall weight gain from 8st (stones) 9lb (pounds) to 9st 7lb.
2005
208. The weight charts show Mrs I gained some more weight at the start of this year and weighed 9st 12lb on 3 February 2005. Her weight remained stable and the records indicate an overall weight loss as she weighed 9st 6lb on 21 December 2005. The daily records show she usually had a good diet but occasionally refused to eat and drink. Examples of this are in the daily records on 19 and 22 February 2005. On 30 June 2005, Mrs I choked on her sandwiches and staff had to intervene.
2006
209. Mrs I’s weight charts showed her weight was stable throughout this year. She initially lost some weight (from 9st 6lb in December 2005 to 9st 3lb in May 2006). Overall, in the second half of the year, she gained some weight (highest weight was 9st 10½lb in July 2006) but it remained stable. Her weight was 9st 5lb on 10 December 2006.
210. The daily records report a good diet on most occasions. The social services care plan review on 26 June 2006 says Mrs I was independent with feeding, had a good appetite and could say what she liked and disliked.
2007
211. Mrs I’s weight charts show her weight was stable throughout this year. She initially lost some weight (from 9st 5lb in December 2006 to 9st 1lb in January 2007). After this point she gained weight. She weighed 9st 7lb in December 2007.
212. The care plans show Mrs I refused to eat depending on her mood and staff often needed to encourage her if she was feeling too sleepy to eat. The daily records report she had a good diet throughout the year with occasional refusals to eat her meal.
2008
213. Mrs I’s weight charts and care plan evaluations show she lost weight at the start of this year because she had a chest infection. In January 2008, she weighed 8st 11lb. The weight charts show she slowly gained weight and the care plan evaluations in February and March 2008 show she had regained her appetite and ate a normal diet.
214. The care plan evaluations in June, October and December 2008 note that Mrs I only ate when she wanted to and sometimes this might not have corresponded with mealtimes.
215. Overall, the weight charts show Mrs I gained weight throughout this year (from 8st 11lb in January to 9st 2lb in December). Those involved in her care considered her weight was stable.
2009
216. The care plan evaluations in this year show Mrs I ate when she wanted to and her weight did not vary much. The care plan evaluation from October 2009 notes Mrs I would sometimes refuse to eat her meal and the care plan evaluation from November 2009 says she would often take food from other residents. There is an entry in the daily records on 7 November 2009 which says Mrs I had a poor diet because she left the table during mealtime.
217. A DST from 30 March 2009 notes Mrs I could cut up her own food and feed herself. She had an ordinary diet and could chew and swallow with no problems. It notes her variable appetite depending on her mood but that her weight was normal and stable. She could indicate hunger and thirst and drank adequate fluid. This DST says Mrs I needed supervision with meals.
218. The weight charts show her weight remained stable and stayed around 9st.
2010
219. In May 2010 Mrs I was diagnosed with an overactive thyroid but the care plan evaluation says her appetite and eating habits had not changed. The care plan evaluations note that Mrs I only ate when hungry but she could do this independently and she stole food from other residents’ plates at mealtimes.
220. The challenging behaviour team became involved in Mrs I’s care in June 2010 and offered support relating to her behaviours with food and mealtimes. The behaviour team suggested Mrs I sit with residents who ate slowly, like her, so she did not get up and leave the table when the people who ate quickly had finished.
221. The progress notes and behaviour charts from October 2010 onwards show staff encouraging Mrs I to eat her dinner and implementing strategies to help her remain focussed on eating. In October 2010, the progress note report shows these strategies helped and her food intake had improved.
222. The weight charts show her weight was stable but overall, she lost some weight and weighed 8st 9lb in November 2010.
2011
223. The weight charts show Mrs I’s weight remained stable. She was 9st 2lb in February 2011 and 9st in October 2011.
224. The care plan evaluations show staff continued with the care plan where her challenging behaviour at mealtimes continued.
225. In December 2011, the care plan evaluation says Mrs I continued to refuse meals if she was sleepy but that she would eat them when she was ready.
2012
226. Mrs I’s weight chart shows she lost a small amount of weight between October 2011 (9st) and January 2012 (8st 13lb) but she remained just above 9st until 7 August 2012.
227. The care plan evaluations show Mrs I continued to refuse meals if she was sleepy and staff encouraged her to eat. If she did not eat, staff would save the meal for when she was hungry. Staff also implemented a strategy where they would give her meals on a tray table in the lounge so not to disrupt other residents.
228. After August, Mrs I did start to lose more substantial weight as she refused food more often and the home implemented a food and fluid intake chart in November 2012.
Four key indicators
229. In this section, we looked at whether the explanation the IRP gave for its consideration of the four key indicators is consistent with the evidence for this period and in line with the National Framework. The four key indicators describe the nature, intensity, complexity and unpredictability of an individual’s needs. These descriptions help the IRP consider all the individual’s needs together and help create a picture of the care they need.
Nature
230. In the IRP’s consideration of nature we would expect to see analysis of:
231. ‘the particular characteristics of an individual’s needs (which can include physical, mental health, or psychological needs), and the type of those needs. This also describes the overall effect of those needs on the individual, including the type (‘quality’) of interventions required to manage them.’
232. The IRP said Mrs I needed assistance to manage all of her social and personal care needs such as washing and dressing and needing to be in an environment where she could receive help. This is supported by what we have seen in the care plans and social services records throughout the period.
233. The IRP addressed the nature of each domain. We have looked at how it did this.
Behaviour
234. We can see the IRP commented on the characteristics of Mrs I’s behaviour and the input she and the home had from the challenging behaviour team.
235. The records show Mrs I often slept and soiled in other people’s beds. Later in the period she stole food off other people’s plate and would urinate in places other than the toilet. The letters from the consultant in old age psychiatry to the GP show what these issues were and that she had some awareness she was doing it. Mrs I had told care home staff she did it to annoy them.
236. The IRP noted that social services supported her placement at the care home despite her behaviour as there were no significant difficulties in the delivery of her care.
Cognition
237. We can see the IRP considered Mrs I’s cognitive impairment and the level of decision making she could participate in and how this changed throughout the period. The IRP commented on the prompts and encouragement Mrs I needed for her cognition. The care plans support this and show she could make simple decisions such as what she liked to eat, what she wanted to do and what she wanted to wear. The daily records throughout the period show she had fluctuating disorientation.
238. The IRP commented on a deterioration in her cognitive abilities around March 2009, where staff recorded she had difficulty making decisions. The records are supportive of this. The letter from the GP to the consultant in old age psychiatry on 5 May 2010 say that Mrs I had been experiencing a general cognitive decline.
239. The consultant in old age psychiatry commented on Mrs I’s cognition being stable and she presented in a similar way as in past consultations.
240. The care plan summary on 2 October 2012 says Mrs I needed staff to help her find her room. It says her cognition fluctuated and she could understand simple instructions from staff. She could express her likes and dislikes and make simple choices.
Psychological and emotional
241. The IRP commented on Mrs I’s general psychological and emotional state as being sociable and enjoying interaction with staff. It noted she took antidepressants which had a good effect.
242. The daily records show Mrs I liked to talk to residents and staff and she could initiate and participate in conversation. The social services assessment at the start of the period in 2004 notes that Mrs I could establish good relationships with others. Early in the period, Mrs I participated in activities at the home.
243. The IRP notes Mrs I’s anxiety had increased towards the end of March 2009. The DST from 31 March 2009 describes Mrs I’s mood. It says she sometimes did not respond to reassurance and would become disinterested and non-compliant. It commented on her tendency to sleep a lot in the day. It says she liked to sit and read books and magazines and watch television. It appeared to be her lethargy that contributed to her withdrawal from social situations. But there are numerous entries in the daily records after this point in March that show Mrs I enjoyed chatting with residents.
Communication
244. The IRP said Mrs I could communicate about her needs and she could indicate when she did and did not want to do something. The IRP noted that professionals could discuss Mrs I’s care needs with her. The IRP said this changed around October 2010.
245. The evidence shows times when the consultant in old age psychiatry talked to Mrs I about why she was in the care home and she indicated she wanted to stay there because she would not be able to care for herself at her own home.
246. The daily records show Mrs I was often talkative with staff and residents. The care plan review from 26 June 2006 says Mrs I could initiate conversation. This care plan review remained unchanged throughout the period. She could also say when she was in pain, such as when she complained of having a sore right eye in November 2006, January 2007 and October 2008.
247. The progress note report from 17 October 2010 notes that Mrs I was not communicating and the social services contact notes from 3 December say she could express her likes and dislikes. The records do show more entries relating to a decline in Mrs I’s ability to communicate from 2010 as she could not make and communicate decisions in 2012.
Mobility
248. The IRP says Mrs I was independently mobile for most of the period under review but that she had a fall in November 2011.
249. This is supported by what we have seen in the records.
Nutrition
250. The IRP said that Mrs I maintained a stable weight until August 2012 and then it dropped from then onwards. We have looked at the weight charts, which show this is the case. At this point staff started to monitor Mrs I’s food and fluid intake and completed charts for this.
251. The records show Mrs I could feed independently and did not have any advanced nutritional needs. The daily records and care plans show staff needed to encourage her to eat her meals and put strategies in place to manage her behaviours around mealtimes to ensure she got a proper diet.
Continence
252. The IRP noted that Mrs I became doubly incontinent gradually throughout the period.
253. The records show she used to defecate in other residents’ beds and other inappropriate places. When she entered the home in 2004, the care plan says that the incontinence was related to her memory and behaviour issues. The care plans show staff had to prompt Mrs I to use the toilet and the continence adviser advised a toileting programme which the care plans say she did not respond positively to. Mrs I needed incontinence pads but sometimes refused to wear them.
254. The records show Mrs I’s incontinence increased and the challenging behaviour team became involved in 2010. The team considered her incontinence to be impacted by her behavioural issues.
255. She became more reliant on staff to assist her with her continence needs in 2012.
Skin
256. The IRP says Mrs I did not have any serious problems with her skin during the review period but that care home staff need to monitor her regularly because of her tendency to develop a rash.
257. The IRP commented on the gout Mrs I had in both her feet over the years. It said her skin remained intact.
258. The records show Mrs I needed cream for rashes but that her skin remained intact. In December 2012, the records show Mrs I’s left foot was swollen and the GP records note this was possibly gout. The GP’s consideration of gout continues throughout 2013. Mrs I also had a fall in 2012 when she sustained some injuries and bruising. The records note that her skin remained intact.
Breathing
259. The IRP noted there were no episodes of difficult breathing for Mrs I. This is supported by the evidence in the records. It noted her chest infection in 2008.
Drug therapies and medication
260. The IRP noted that there were no major difficulties with medication for Mrs I. It commented on her non-concordance with taking medication in March 2009.
261. The records show Mrs I took regular medication for depression, constipation, raised cholesterol and antiplatelet medication. She needed supervision but the records do not show there were any problems between 2004 and 2008.
262. In 2009 Mrs I stored some medication in her mouth and refused to swallow it. This meant care home staff needed to ensure she swallowed her medication. She occasionally refused to take her medication. In 2013, care home staff administered her medication covertly after a period of non-concordance.
263. The care plans show she could express when she was in pain.
Summary of the nature of needs
264. The IRP concluded the nature of Mrs I’s needs did not indicate that she had a primary health need. It said the care interventions she needed were not over and above what a local authority could give, along with community based services, such as the GP, the consultant in old age psychiatry, the challenging behaviour team and district nurses. The local authority reviewed Mrs I’s care and could appropriately meet her needs.
265. The IRP’s consideration of the nature of Mrs I’s needs is consistent with what we have seen in the records. We found no failings on this part of the complaint. We can see it acted in line with the National Framework.
Intensity
266. Mrs L says her mother’s needs did combine to create more intense needs. She was at risk constantly because care home staff always had to find her. She says all her mother’s needs interacted.
267. The records say staff had to be vigilant because she was deemed to be at high risk in the home.
268. Mrs L says her mother could not manage daily living activities herself.
269. Mrs L says her mother’s psychological and emotional needs impacted her behaviour. She says her behaviour did not change and was not correctable because she had a cognitive impairment. Her behaviour often interrupted her interventions and she often refused interventions. Her non-compliance greatly lengthened her interventions.
270. Mrs L says her mother did not know when she was hungry and when she was not. She did not have the mental capacity to know she needed help mobilising.
271. In the IRP’s consideration of intensity we would expect to see analysis of:
272. ‘both the extent (‘quantity’) and severity (degree) of the needs and the support required to meet them, including the need for sustained/ongoing care (‘continuity’).’
273. The IRP acknowledged Mrs I had a range of care needs but it did not see that the totality of those needs combined to create a quantity or intensity of need which would indicate a primary health need.
274. The IRP’s view was that Mrs I did not need constant attention from the care staff, nor continual care or monitoring. This appears to be supported by the evidence. The records show one to two staff members were meeting Mrs I’s needs through the interventions in place in the care plans. The records do not show she had constant attention and intervention from staff.
275. The IRP considered the collective severity of Mrs I’s needs and the response care home staff needed to give to meet her needs. Its view was that she needed help from a carer for everyday tasks and she needed ongoing care and support to meet her needs for safety, comfort, welfare and personal care needs.
276. We can see there were behavioural challenges where staff needed to be alert to Mrs I’s whereabouts. The IRP commented on the input from the challenging behaviour team and her eventual discharge from the team. We cannot see evidence that Mrs I needed constant monitoring for her behaviour but that the care home gave support and care to meet her daily living needs. We can see her cognition impacted her behaviour, as demonstrated by the letters from the consultant in old age psychiatry. But we cannot see her behaviour was so intense that staff could not deliver care.
277. We saw no evidence that Mrs I’s mobility and nutritional needs were severe to the extent they needed enhanced and sustained oversight.
278. We can see the IRP considered the amount of needs Mrs I had and how severe her needs were. The IRP’s consideration of the intensity of Mrs I’s needs is consistent with what we have seen in the records. We have found no failings on this part of the complaint. We can see it acted in line with the National Framework.
Complexity
279. Mrs L says her mother needed 24-hour monitoring because she would get into trouble otherwise. She kept escaping and defecating in the bin. Mrs L says this indicates that she needed higher skilled carers to monitor her and she needed more than just help and support with daily living.
280. Mrs L says her mother constantly declined care and carers did not have the right level of skill to deal with her.
281. In the IRP’s consideration of complexity we would expect to see analysis of:
282. ‘how the needs present and interact to increase the skill needed to monitor the symptoms, treat the condition(s) and/or manage the care. This can arise with a single condition or can also include the presence of multiple conditions or the interactions between two or more conditions.’
283. The IRP identified interaction between the domains, such as cognition and behaviour, but it did not think these interactions made her care needs more complex.
284. We can see the IRP acknowledged Mrs I’s challenging behaviour and why she behaved in the ways she did. It looked at the care she had from the care home and from the challenging behaviour team and determined this was not complex.
285. The records support Mrs L’s understanding that her mother needed monitoring throughout the day because of her challenging behaviour. But we saw no evidence that she needed carers with a higher level of skill to help manage the care. We have not seen evidence to show us the carers did not have the right level of skill to care for Mrs I. The challenging behaviour team and consultant in old age psychiatry, which are part of community health and social care, did support staff in forming interventions and care plans that helped meet Mrs I’s needs. The IRP considered this.
286. We can see Mrs I’s behaviour did impact her diet because she sometimes refused to eat. This necessitated a food and drink chart in 2012. We have not seen evidence that this interaction lead to a complexity in her health care provision.
287. The IRP’s consideration of the complexity of Mrs I’s needs is therefore consistent with what we have seen in the records. We have found no failings on this part of the complaint. We can see it acted in line with the National Framework.
Unpredictability
288. Mrs L says her mother needed more support than she had. A carer told Mrs L that she knew when her mother was going to lash out when she was sat at the dining table but her behaviour was such a problem throughout the day that carers generally could not foresee challenges reliably. Mrs L says the records will show staff could not manage her behaviour.
289. Mrs L says her mother’s referral to the challenging behaviour team helped staff understand how they could manage her needs but she should have had more staff helping to manage this need.
290. Mrs L says that because of the unpredictability of her mother’s needs, the care plans changed every week, especially her continence care plan.
291. In the IRP’s consideration of unpredictability we would expect to see analysis of:
292. ‘the degree to which needs fluctuate, creating challenges in managing them. It also relates to the level of risk to the person’s health if adequate and timely care is not provided. Someone with an unpredictable healthcare need is likely to have either a fluctuating, or unstable or rapidly deteriorating condition.’
293. The IRP’s view was that Mrs I’s needs did not fluctuate to create challenges in managing them or a need to adjust the levels of support in the care period. It considered Mrs I’s referral to the challenging behaviour team and viewed this as something to help the care home staff become aware of the triggers of her challenging behaviour. It did not view this referral as evidence of unpredictable behaviour but evidence that staff were working to best manage the needs that Mrs I presented with.
294. We can see this is what the evidence in the records shows. Mrs I’s behaviour challenges were known and documented in the care plans. Staff knew the signs to look for. For example, the care plan evaluation from November 2011 says Mrs I would raise her arms up and down and blow through her tongue. This was a warning sign that she was about to pinch food from another resident.
295. The IRP considered the content of the care plans and daily entries to see if there was any evidence of unpredictable and fluctuating needs. We have seen that care home staff reviewed the plans regularly. They were consistent and did not change much throughout the period. We can see staff updated the plans to include the interventions the challenging behaviour team wanted them to try. We can also see Mrs I’s continence was a known issue. Although staff could not know when she would be incontinent, they knew it was a care need and had consistent care plans in place to manage this.
296. The IRP considered the local authority reviews. We have looked at these and they remain consistent throughout the care period with no changes that reflect fluctuations in Mrs I’s needs.
297. The IRP acknowledged Mrs I needed timely care, monitoring and supervision but said that her needs were not unpredictable.
298. The IRP’s consideration of the unpredictability of Mrs I’s needs is consistent with what we have seen in the records. We have found no failings on this part of the complaint. We can see it acted in line with the National Framework.
Conclusion
299. In this report we have set out our final decision about Mrs L’s complaint. We have thoroughly and impartially investigated the complaint and drawn conclusions from careful consideration of the evidence.
300. We have not seen any evidence NHS England’s IRP did anything wrong and we do not uphold this complaint.