16. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. If what happened fell far short of what should have happened, we call this a failing. When we see indications of a failing, we next look at whether that failing had a negative impact on the person in question. If we think it did, we will go on to consider what, if anything, the organisation has done to try to put things right.
17. Having done this, we have seen no indication that anything went wrong when NHSE made its decision.
Domains
Mobility
18. Mr R disputes the IRP’s finding in the mobility domain. He considers that his wife’s needs were severe.
19. The descriptor for severe is:
‘Completely immobile and/or clinical condition such that, in either case, on movement or transfer there is a high risk of serious physical harm and where the positioning is critical.’
20. Mr R says his wife was completely immobile and there was no risk of falls as she could not stand up. She would lean to one side, and unless positioned properly in the chair, could slide out of a sitting position. She spent all her time in the chair, apart from when she was in bed and had to be hoisted.
21. The IRP agreed with the CCG that Mrs R had high needs in this domain.
22. The descriptor for high is:
‘Completely unable to weight bear and is unable to assist or cooperate with transfers and/or repositioning.
OR Due to risk of physical harm or loss of muscle tone or pain on movement needs careful positioning and is unable to cooperate.
OR At a high risk of falls (as evidenced in a falls history and risk assessment).
OR Involuntary spasms or contractures placing the individual or others at risk.’
23. The IRP said Mrs R was unable to weight bear and needed a hoist for all transfers. The stroke had left her at risk of falling from her chair. She also suffered from osteoarthritis (painful and stiff joints) and contracture of her leg, which caused pain and discomfort during transfers. Mrs R needed the support of two staff for all movement and handling. The IRP said this was in line with the descriptor for a high level of need.
24. The IRP said Mrs R was not 'completely immobile' in clinical terms. She had some limited movement in her upper body and was able to, for example, swallow unaided, or try and hit staff with her arm when anxious. Mrs R did not have a clinical condition such that, on routine movement or transfer, there was the threat of serious physical harm or injury. She therefore did not meet the terms in the descriptor for a severe level of need. The physical condition, and the highly specialised forms of care and support needed for a severe level of need was not shown.
25. Our adviser said the clinical evidence supports the IRP’s reasoning in this domain.
26. We can see the IRP considered the evidence presented in the domain of mobility including the information the family supplied. In the IRP report, it gave a thorough description of why the domain was in line with the high descriptor.
27. We can see the evidence in the CCG file gives a clear description of the deterioration in Mrs R’s mobility following a fall, and the interaction between the domain of mobility and her dementia. It describes Mrs R’s needs in this domain as:
• immobile • needing two carers and the use of a hoist • disorientated.
28. We can see the daily care records show Mrs R:
• experiences pain on movement • has a left sided weakness and contractures • was using a T Cushion, but later that it was advised to discontinue its use as she could not tolerate it • needed bed rails and covers as she was at risk of falling out of bed • needed two carers plus a hoist for transfers - she was frightened of the hoist and became very anxious • needed a recliner chair • had monthly manual handling assessments and there was no change between 16 November 2018 and 16 March 2019 • had a constant high risk of falls (risk: 15) between 16 November 2018 and 16 March 2019.
29. The GP records show Mrs R was prescribed medication to improve bone strength and medication to relieve muscle spasm. This included:
• alendronic acid and theical D3 (bone strength and uptake of calcium) • baclofen (muscular spasm)
30. The descriptor for the high weighting describes Mrs R’s presentation regarding mobility.
31. When we weigh up all the information, in the records of her daily needs we cannot see strong evidence that Mrs R was completely immobile or that her positioning was critical to avoid serious harm throughout the review period. These are the factors that would indicate a severe weighting.
32. We can see no evidence of any falls or any relevant incident forms completed. We can also see the IRP explored the definition of the severe level of need in the report and took time to explain why this did not apply in Mrs R’s case.
33. We are satisfied there is no indication of a failing here as the rationale for the IRP’s decision on this domain is supported by the evidence available. It has acted in line with the National Framework.
Communication
34. Mr R disputes the IRP’s finding in the communication domain. He considers that his wife’s needs were moderate to high.
35. The descriptor for moderate is:
‘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.’
36. The descriptor for high is:
‘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.’
37. Mr R says his wife was unable to reliably communicate. In December 2018, she could verbally speak but she had no idea of what she was talking about. She could not make any decisions. The impression was that this was someone completely normal in her speech or words individually. She did not understand anything and could get upset, and not give a proper answer to any questions.
38. Mr R says his wife would make noises, instead of saying she was in pain. When she was moved this would make her angry and she would throw things around.
39. The IRP agreed with the CCG that Mrs R had moderate needs in this domain.
40. The IRP said Mrs R could verbalise, although her conversation was increasingly confused and unreliable. She could make some limited needs known through non-verbal cues and body language, for example if she was in pain. The IRP said this presentation was consistent with a moderate level of need. It was not correct to describe Mrs R at that time as unable to communicate any of her needs in any way, so a high level of need was not shown.
41. Our adviser said the clinical evidence supports the IRP’s reasoning in this domain.
42. We can see the IRP considered the evidence presented in the domain of communication including the information the family supplied. In the IRP report it gave a detailed description of why, the domain score of moderate, was appropriate.
43. We can see the daily records care plan includes the following:
• Use clear, short sentences • Sit by [Mrs R] and make good eye contact • Give reassurance • Give clear instructions as to what is going to happen • Be patient and await a response and consent to carry on
44. The daily records show:
• 13 November 2018 - ‘[Mrs R] has had a good day today; she has been in the lounge enjoying a chit chat with other residents’ • 24 November 2018 – ‘[Mrs R] says that she has had a lovely day today especially when her husband visited’
45. Mr R believes his wife was unable to reliably communicate. She could not make any decisions and did not understand anything. When we weigh up all the information, we cannot see strong evidence in the records to support this. The care home records show Mrs R needed repetition of instructions to ensure that she understood them. She noticed facial expressions and used non-verbal body language to make some of her needs known.
46. We acknowledge that Mrs R needed carers to interpret her communication and that her communication was not always dependable. We can see carers needed to have a good rapport and knowledge of Mrs R so that they could anticipate her needs, and this is covered in the moderate domain.
47. We are satisfied there is no indication of a failing here as the rationale for the IRP’s decision in this domain is supported by the evidence available. It has acted in line with the National Framework.
Psychological and emotional
48. Mr R disputes the IRP’s finding in the psychological and emotional domain. He considers that his wife’s needs were high.
49. The descriptor for high is:
‘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.’
50. Mr R says when his wife moved into the care home, she was not interested in anything. Before the assessment in December 2018, she was taken out of the lounge because she was disruptive and abusive. She was put in a separate room because of her reaction to other residents. She could not explain what she was doing but something in her head told her what was happening. She would get upset and take it out on other residents. She would make a fuss, cry, shout, and withdrew from any effort to join with care planning, singing, exercises, or when people came into the home. She had no interest in daily activities or the garden.
51. The IRP disagreed with the CCG that Mrs R had low needs in this domain. The IRP felt her needs were moderate.
52. The descriptor for moderate is:
‘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.’
53. The IRP said Mrs R had times when she was anxious or distressed, often, but not always related to times of transfer or movement. Her mood could change significantly, and her family described how it was difficult to calm or reassure her. She would often ask to go home and made some statements about wanting to end her life.
54. The IRP considered that these traits, and the difficulty in reassuring Mrs R, pointed to a moderate rather than a low level of need. However, the IRP did not find evidence of any major implications for other aspects of her welfare. The anxiety about movement and handling was due to issues of pain and discomfort. Reluctance to eat is a common feature of an individual with severely impaired cognition. It was likely that the latter was also the main reason for her lack of engagement with any social interaction or daily activities at the care home. The IRP was satisfied that there was no evidence to show a high level of need for this domain.
55. Our adviser said the clinical evidence supports the IRP’s reasoning in this domain.
56. We can see the IRP considered the evidence presented in the psychological and emotional domain, including the information the family supplied. In the IRP report, it gave a full description of why the domain scored as a moderate level of need.
57. We can see that due to Mrs R’s dementia she would, at times, become agitated and stressed and that she did not always respond to reassurance. There is also evidence to suggest that her displays of agitation and stress were also a way for her to communicate her needs.
58. We can see the daily records include:
• 3 November 2018, 8.41pm – [Mrs R] was shouting in the lounge that people were going to come in and shoot everyone in the head. She was reassured but did not respond. The carer then noticed that the programme on the TV was about World War 2 as soon as the channel was changed Mrs R became calm again • 3 November 2018, 8.57pm - Mrs R started shouting again that someone was coming to harm her. She was reassured but she started hitting herself on the forehead saying that she would rather hurt herself than someone else do it. She said that she wanted to die and that she loved and missed her husband. She was offered a phone call to speak to him, but she did not want to disturb him.
• 21 November 2018 – ‘[Mrs R] has been in the lounge today; she enjoyed a visit from her husband this afternoon’ • 22 November 2018 – ‘[Mrs R] has had a good day today. She has enjoyed the activities in the lounge’ • 28 November 2018 – ‘[Mrs R] has had a good day today, she joined in with armchair aerobics which she enjoyed and later on her husband came to visit which made her very happy’.
59. Mr R believes his wife was disruptive and abusive. She was put in a separate room because of her reaction to other residents. She could not explain what she was doing. She had no interest in daily activities or the garden.
60. When we weigh up all the information, we cannot see strong evidence in the records that Mrs R’s mood disturbance, or periods of distress, had a severe impact on her health and wellbeing. These are the factors that would indicate a high weighting in this domain.
61. She would become disruptive, which was a sign of her impaired dementia condition, and would shout out. But this would not signify a high level of need.
62. We are satisfied there is no indication of a failing here as the rationale for the IRP’s decision in this domain is supported by the evidence available. It has acted in line with the National Framework.
Behaviour
63. Mr R disputes the IRP’s finding in the behaviour domain. He considers that his wife’s needs were high or severe.
64. The descriptor for high is:
‘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.’
65. The descriptor for severe is:
‘Challenging behaviour of severity and/or frequency that poses a significant risk to self, others or property. The risk assessment identifies that the behaviour(s) require(s) a prompt and skilled response that might be outside the range of planned interventions.’
66. Mr R says his wife’s behaviour was unpredictable. Her moods changed rapidly, and it was unknown what triggered the change. When he was at the home before the assessment, his wife would throw food at him. Staff warned her if she did not behave herself when hoisted she would be kicked out as she would lash out at carers. Mr R says he would hold his wife back or take her food away when she was restrained, and he managed the behaviour himself. She would self-harm and said she wanted to end her life and wanted to go home. Mr R says his wife tried various medications to moderate her behaviour. Any movement triggered a violent reaction.
67. The IRP agreed with the CCG that Mrs R had moderate needs in this domain.
68. The descriptor for moderate is:
‘Challenging behaviour that follows a predictable pattern. The risk assessment indicates a pattern of behaviour that can be managed by skilled carers or care workers who are able to maintain a level of behaviour that does not pose a risk to self, others or property. The individual is nearly always compliant with care.’
69. The IRP said Mrs R was anxious and unsettled at times, particularly associated with movement and transfers. She also had on occasion displayed some challenging behaviours, which included hitting out at staff, or throwing food. This was linked to times of anxiety. The care plan recommended an Antecedents, Behaviour, Consequences (ABC) monitoring chart be completed but this did not start around the time of the CHC assessment. An ABC monitoring chart is used as a tool for the assessment and formulation of problem behaviours. The times when Mrs R might present some challenging behaviour was known and acknowledged in the care plan and could therefore be considered as predictable.
70. The IRP said the evidence about her personal care needs show that all necessary care was carried out suitably. Mrs R could be considered as generally compliant with personal and hygiene care. No actual risk to herself or others was realised. This presentation was consistent with a moderate level of need in this domain.
71. Our adviser said the clinical evidence supports the IRP’s reasoning in this domain.
72. We can see the IRP considered the evidence presented in the domain of behaviour including the information the family supplied. In the IRP report, it gave give a comprehensive description of why the domain scored a level of moderate.
73. We can see the daily records care plan includes:
• Record all incidents on an ABC chart • Mrs R’s anxiety leads to the outbursts, but she does not mean harm • Carers should have patience and good explanations • Carers should recognise that Mrs R has fluctuating capacity
74. Mr R says his wife’s behaviour was unpredictable. Her mood changed quickly, and she would lash out at carers. She would self-harm and was tried with various medications to tone down her behaviour. When we weigh up all the information, we cannot see strong evidence that Mrs R was aggressive or abusive in her behaviour and that she caused injury, distress, or harm to others, nor did she damage any property. There were no ABC charts within the evidence. She was not prescribed mood stabilising medication and a behavioural care plan was in place.
75. There are some incidents where Mrs R was more challenging than at other times. We can see the daily care records show there were no barriers to care and Mrs R was normally responsive to reassurance.
76. We are satisfied there is no indication of a failing here as the rationale for the IRP’s decision in this domain is supported by the evidence available. It has acted in line with the National Framework.
Consideration of four key indicators
Nature
77. Mr R disputes how the IRP considered the nature indicator, which was used to determine whether his wife’s needs were primarily for health.
78. Mr R says his wife was not settled as she always wanted to go somewhere else. Her weight was not stable. The nurse assessor noted her weight was 65.6kg, but Mr R says it was well over 70kg when he later checked with the care home manager after being concerned with his wife’s size. His wife was up and down in weight.
79. The IRP said because of her stroke in 2015, and symptoms of dementia, Mrs R was cognitively impaired. She became confused and disorientated, with short and long-term memory loss. Mrs R was therefore reliant on her carers to anticipate and prompt her needs and help in all the activities of daily living. The IRP agreed with the CCG that the behaviours followed a pattern linked to anxiety when faced with manual handling, use of the hoist, or while being encouraged to eat. As such, the behaviours were known about, predictable, and referred to in care plans.
80. The IRP said Mrs R needed regular reassurance and encouragement from staff, due to her declining mental capacity, and for emotional or psychological reasons. The IRP said Mrs R was compliant with personal care. All personal and hygiene care was completed satisfactorily.
81. The IRP said Mrs R needed the support of two staff, using physical aids, to carry out all transfers, handling, and positioning. Her weight was stable by that time. The routine for her diet was straightforward, though she could be a reluctant eater and needed lots of supervision and encouragement.
82. Mrs R was doubly incontinent, but this was managed straightforwardly through pads. Through her earlier drop in weight, the loss of mobility, and double incontinence; her skin was at a high risk of breakdown and pressure area damage. Her skin was described as intact at the time of the DST, supported by the monitoring and preventative measures in place. She continued to suffer from oedema (fluid retention in the body) to both legs, and there were limited breathing problems described.
83. There were no recent or current episodes of altered states of consciousness (ASC). She needed a safe and supervised environment due to her inability to care for herself. She needed suitable care and monitoring over a 24-hour period.
84. The IRP found no evidence that Mrs R needed any form of regular nursing oversight. There was no evidence her carers needed regular support of NHS community services around this time or needed additional skills beyond standard care practices available within a residential care home. The IRP agreed that all her care was being delivered by care staff who were familiar with the needs of older people with dementia and associated mental and physical frailties.
85. The IRP said Mrs R had a range of social care and health care needs. She needed to be looked after in an environment where ongoing attention could be given to ensure all her needs were met. The IRP decided that the nature of Mrs R's care needs indicated that she did not have a primary health need following the CHC assessment and DST, completed 12 December 2018.
86. Our adviser said the clinical evidence supports the IRP’s rationale for the nature indicator.
87. When the IRP considers the nature indicator, in line with the National Framework, we would expect it to ‘describe the particular characteristics of an individual’s needs. These can include physical, mental health or psychological needs, as well as the overall effect of those needs on the individual, including the type (‘quality’) of interventions required to manage them’.
88. We can see the IRP looked at the right things and presented a full picture of how Mrs R’s needs were met. We know Mr R disagrees with some of the detail. We have looked at what the clinical evidence tells us.
89. We can see the records, including those of his wife’s daily care, support the IRP’s picture of her needs. For example, they support that his wife needed supervision and prompting with her eating, hygiene, and repositioning.
90. The IRP described the nature of her condition well. The description is detailed and considered the way in which Mrs R’s needs were met, and how they changed due to her condition of vascular dementia. It is clear she had many care needs, as Mr R says.
91. We can see there is evidence in the care plans to suggest her care could be provided routinely by the care staff. She did not need intervention from specialist teams. The staff did not need any special or additional skills to meet her needs, or occasional unsettled behaviour. The records presented were clear enough for the IRP to make the decision. There was no clinical evidence to show needs of a nature associated with a primary health need.
92. We are satisfied the rationale for the IRP’s decision about the nature of Mrs R’s needs is supported by the evidence available. We can see it acted in line with the National Framework. There are no indications of failings in how the IRP considered the nature of her needs.
Intensity
93. Mr R disputes how the IRP considered the intensity indicator, which was used to determine whether his wife’s needs were primarily for health.
94. Mr R says he visited his wife daily and usually found her in the residents’ lounge. However, this was not always the case. Sometimes, on entering, he could hear his wife screaming and shouting from the toilet and a number of staff tried to deal with the disturbance. Mr R says at other times he would find her isolated in the dining room or her own room because of her behaviour in the lounge. The manager, who was a qualified nurse, would intervene to deal with the situation. Visiting nurses and doctors were also often needed to see his wife.
95. The IRP said Mrs R’s needs were addressed straightforwardly by the care plans and the 24-hour care available in a care home, with support from the GP, and community NHS services. There was no provision needed outside these arrangements. NHS community services would be available if called upon. All care provision remained within the view of her care home placement. All her care needs were being met through the support from often one, and no more than two carers; the latter needed for all movement, transfers, and handling.
96. Mrs R's nutritional status was still being checked but she was not at significant risk. She was regaining weight at that time. She did need supervision and help at mealtimes; she could refuse food and needed increasing encouragement and prompting. Her skin integrity was promoted satisfactorily. There was no evidence of any associated issues such as recurrent urinary tract infections (UTIs), at that time.
97. The IRP said there were no significant adverse consequences from Mrs R’s episodes of anxiety and occasional outbursts of hitting out or trying to hit herself. The potential risks were known to staff.
98. The IRP said Mrs R’s mental health did not stop her carers from delivering the essential personal and hygiene care she needed. No external services were involved in Mrs R's mental or physical health around the time of the DST review.
99. Overall, nothing happened outside the planned and arranged care for Mrs R in her care home. Any risk of skin breakdown, or Mrs R's double incontinence, remained within the view of the care put in place at the care home.
100. The IRP said staff knew about Mrs R's tendency to become anxious and unsettled and that she might hit out. Through arrangements such as distraction and lots of encouragement and reassurance, essential care was delivered satisfactorily. The IRP agreed that the practical arrangements to manage and carry out the care for Mrs R did not represent intensity in her provision.
101. Mrs R's medication regime was not complex and was administered straightforwardly by care staff. The protective measures and monitoring around her skin integrity were an example of standard care within such provision. There were no care interventions that took an excessive time to complete or needed more than a maximum of two carers; one carer was sufficient for much of the time.
102. The IRP said Mrs R's care needs did not need higher skilled interventions, an increased number of interventions with extra carers, or for lengthy periods. Therefore, did not demonstrate the intensity of needs associated with a primary health need.
103. Our adviser said the clinical evidence supports the IRP’s rationale for the intensity indicator.
104. In line with the National Framework, we would expect the IRP’s consideration of the intensity indicator to ‘relate both to the extent (‘quantity’) and severity (‘degree’) of the needs and to the support required to meet them, including the need for sustained/ongoing care (‘continuity’)’.
105. We can see the IRP did look at the right things. Again, we know Mr R disagrees with some of the detail. We have looked at what the clinical evidence tells us. We can see the records support the IRP’s view on the intensity of his wife’s needs. For example, they refer to her staying settled most days.
106. The records show the care and help she needed could be delivered by carers following a care plan that was assessed, planned, and monitored by a member of care staff. These did not need frequent amendments. Within the daily entries, there were very few references to care needs of any intensity. There was no evidence from the clinical records that care staff could not give Mrs R care or meet her needs within normal planned daily routines that were overseen by the registered nurse. Mrs R was monitored by health professionals from community services, such as the GP.
107. As detailed above, Mrs R’s unsettled behaviour was recorded but was not a regular occurrence. Staff provided a reassuring approach which seemed to calm her. Her behaviour did not need regular specialist intervention, the ongoing need for 1:1 intervention, or advice to manage it.
108. We are satisfied the rationale for the IRP’s decision about the intensity of Mrs R’s needs is supported by the evidence available. We can see it acted in line with the National Framework. There are no indications of failings in how the IRP considered the intensity of her needs.
Complexity
109. Mr R disputes how the IRP considered the complexity indicator, which was used to determine whether his wife’s needs were primarily for health.
110. Mr R says his wife had complex needs and without staff dealing with these she would not survive. She was unable to look after her needs herself. Moving was her biggest problem because of her anxiety and she became aggressive when being moved. She was unable to stand, needed all support for transfers with a mobile hoist and sling, and slide sheets on her bed. This was to allow him to change his wife’s position for her.
111. Mr R says his wife had complex continence needs including a complete unawareness when she needed to empty her bladder and bowels. She needed continence products day and night, and two staff were needed for all care needs. This included washing and personal care at least four to five times during the day to support her continence needs.
112. Due to her diagnosis of dementia, she also had complex behavioural needs. She showed aggressive behaviour towards staff, hitting out, pinching, throwing objects and being verbally abusive. On occasions this was towards other residents.
113. The IRP said there was no increase in the level or type of care interventions needed from carers, beyond the normal actions such as prompting, encouraging, monitoring, interpreting, anticipating, and responding to her needs as necessary.
114. The IRP said Mrs R presented no significant challenging behaviours of any frequency. The predictable form of her anxious and restless episodes of behaviour meant that the carers would have had to adopt suitable measures to ensure that essential care was delivered satisfactorily.
115. The IRP was satisfied Mrs R's mental health did not create a barrier to the delivery of the necessary personal and hygiene care she needed. There were no obvious associated risks to herself or others in practice. There was no evidence that Mrs R's mental health had wider practical implications or created any complicating factors for her general welfare, beyond the care arrangements at the care home.
116. The IRP said there was no evidence to suggest a significant impact across her different areas of need, or an increased effect on Mrs R's health and wellbeing because of any interaction. Her overall needs were not demonstrated to be difficult to plan and provide for.
117. There was the potential for some interplay between Mrs R's health care needs but the resulting implications for her care were not complex. There was potential interaction between several care domains in the DST, however, the IRP concluded that the care needs developing from these interactions did not need enhanced skills or knowledge to address them. They did not indicate the complexity of needs associated with a primary health need.
118. Our adviser said the clinical evidence supports the IRP’s rationale for the complexity indicator.
119. When the IRP considers the complexity indicator, in line with the National Framework, we would expect it to ‘look at how the needs present and interact with one or more other conditions to increase the skill required to monitor the symptoms, treat the condition(s) and/or manage the care.’
120. Again, we can see that the IRP did look at the right things. The clinical evidence supports the IRP’s view on the complexity of Mrs R’s needs. For example, the records confirm that she was generally settled. They also show her needs could be met within routine planned care on a regular basis.
121. The care records show that Mrs R’s presentation impacted across many areas of activities of daily living, as her husband says. There was evidence of interaction between several domains in the DST, but her care plans remained relevant. No repeated changes or increased knowledge were necessary to address her needs. There is also no sign Mrs R needed the frequent input of specialist healthcare teams, or changes in care, medication, or hospital admission. There was no evidence to support that her care was difficult to manage. There was no sign of a complexity of needs associated with a primary health need.
122. We are satisfied the rationale for the IRP’s decision about the complexity of Mrs R’s needs is supported by the evidence available. We can see it acted in line with the National Framework. There are no indications of failings in how the IRP considered the complexity of her needs.
Unpredictability
123. Mr R disputes how the IRP considered the unpredictability indicator, which was used to determine whether his wife’s needs were primarily for health.
124. Mr R says his wife would be anxious and aggressive, when and what it would bring could not be predicted. It was not just linked with movement and transfers. Her change in behaviour and mood swings were completely unpredictable for staff.
125. The IRP said there were no sudden changes or rapid deterioration in Mrs R's presentation around the time of the CHC assessment reviewed by this IRP. Her overall condition was generally stable. Mrs R's care needs were predictable and dealt with through suitable and planned care arrangements.
126. The fluctuations in, for example, her communication was consistent with what would be expected given her stroke, medical history, and overall presentation. The care arrangements for Mrs R did not need any particular or urgent adjustments.
127. The IRP said on a daily basis, carers knew what to expect from Mrs R in terms of her needs and care requirements. This included, for example, the potential for her to become anxious and the need to give reassurance and encouragement.
128. The IRP said any individual will have some variation in their presentation from one day to the next. In Mrs R’s case, her presentation was known to her carers, and measures in response were in place. Overall, her care needs required anticipation and planned routines, alongside monitoring and encouragement, as appropriate.
129. There was no daily unpredictability about Mrs R's wellbeing. There were no significant or exceptional challenges in delivering her care, as shown by the lack of complexity and intensity found in her presentation. The IRP concluded that there was not a level of unpredictability associated with a primary health need.
130. Our adviser said the clinical evidence supports the IRP’s rationale for the unpredictability indicator.
131. When the IRP considers the unpredictability indicator, we would expect it to look at: ‘the degree to which needs fluctuate and thereby create challenges in managing them. It also relates to the level of risk to the individual’s health if adequate and timely care is not provided. An individual with an unpredictable healthcare need is likely to have either a fluctuating, unstable or rapidly deteriorating condition’.
132. We can see the IRP did look at the right things. We can see the clinical evidence supports its view on the unpredictability of Mr R’s wife’s needs. For example, the records refer primarily to a stable condition with no considerable changes to care plans or medication regimes.
133. There were references to some challenging behaviour, but there was no evidence that it created a barrier to care on a sustained basis. The records show staff could anticipate Mrs R’s needs and her care could be planned to minimise risk. There was no evidence in the records of her daily care that care plans had to be changed often or at short notice. Her care followed a natural format that was appropriate to her underlying condition.
134. As Mr R says, his wife needed varying degrees of care, support, and help throughout a 24-hour period to meet her needs. This is not evidence of unpredictability. It shows that at different times of the day his wife needed more or less help. The care records show she had recognised, predictable patterns of behaviour and care needs. Staff could meet these through routine approaches and care procedures. Her needs were assessed, planned, overseen, and evaluated by a registered nurse. There is no evidence that her needs were unpredictable.
135. We are satisfied the rationale for the IRP’s decision about the unpredictability of Mrs R’s needs is supported by the evidence available. We can see it acted in line with the National Framework. There are no indications of failings in how the IRP considered the unpredictability of her needs.
Well managed needs
136. Mr R says without care and medical attention his wife would not have survived. Therefore, she did have a primary health need. He says the DST states ‘needs should not be marginalised just because they are successfully managed. Well-managed needs are still needs’. He says the IRP ignored this guidance.
137. The IRP considered whether it was only through the careful management and care intervention provided at the residential care home that Mrs R's needs may have been successfully prevented from becoming unstable, intense, or complex. However, it said this argument does not stand up within the meaning of the National Framework. The IRP said the available evidence shows Mrs R's needs were largely stable around the time of the DST review, subject to a very gradual deterioration consistent with her medical history and presentation. The IRP judged that very sudden change or fluctuation, which might have suggested needs that were 'hidden', was not evident.
138. The IRP said Mrs R’s placement in 'a different environment' (moving from hospital into a care setting), allowed her health condition to stabilise, meaning the care arrangements were straightforward to plan and put in place. The 24-hour planned and organised environment available, and the clinical evidence, showed her condition and the associated care needed was largely settled. It was therefore stable at the time of the CHC assessment and DST completed on 12 December 2018.
139. Our adviser said the IRP applied the eligibility criteria as it should have.
140. We can see in the report, the IRP gave a clear indication that it was aware and very clear in its understanding of the well managed needs guidance within the National Framework. We can see the IRP looked at and considered all sources of clinical evidence. The IRP considered the four key indicators, and domain interaction, in relation to the lawful limits of a local authority. The IRP appropriately applied the guidance within the National Framework (page 43, paragraphs 142-146 and page 53, paragraph 188) to Mrs R’s care. The IRP did not find that the CCG misapplied the well managed need principle. We cannot see that the IRP marginalised Mrs R’s needs. It referred to how staff managed her needs, which it must do to make decisions about the four key indicators.
141. We are satisfied there is no indication of failings in how the IRP applied the well managed needs principle. The report shows it was supported by the evidence available and in line with the National Framework.