13. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation concerned 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 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.
14. To decide if an individual falls well outside the eligibility criteria, the IR considers the four key indicators – the nature, intensity, complexity, and unpredictability of their needs. We have seen how the IR considered these in turn. Having done this, we have seen no indication that anything went wrong when NHSE made its decision. Therefore, there are no indications of failings.
Nature
Mr O’s view
15. Mr O says his father suffered numerous falls from April 2016, including one which hospitalised him. He does not have good skin integrity. He has very delicate skin due to the medication he needed for his heart, and this can lead more easily to lacerations. His father bruises easily.
16. Mr O says his father did not communicate his needs well. He has dementia, with limited mental capacity. He does not realise when he has injured himself.
NHSE’s view
17. The IR chair and clinical advisor said, generally, Mr H was accepting of care and interventions. There were some isolated incidents when he made inappropriate comments to other residents, but he was usually a placid man.
18. The IR said he was able to orientate himself around the home and make some limited choices. However, he had poor risk awareness and needed help to make most decisions. His short term memory had deteriorated. Mr H was stable in mood, though forgetful and tearful if reminded of his wife’s death, or when his son left the care home. He took part in some social activities and slept well.
19. Although he was sometimes muddled, Mr H communicated his needs well, and liked to chat with others, though his speech was often repetitive. There were no falls recorded in the review period. He was mobile and used a Zimmer frame, but he was noted to be at high risk of falls as sometimes he forgot to use his walking aid. Staff needed to watch his mobility needs.
20. The IR said Mr H’s risk of developing pressure sores was low due to his good mobility, adequate nutrition, and the use of pressure relieving equipment. His skin integrity was good. He needed help with personal hygiene, including the use of an emollient for dry skin. Mr H was independent with his own toileting requirements. He ate a normal diet without help though occasionally he needed prompting and encouragement. His weight was stable during the period under review and there was no evidence of breathing issues. He was compliant with his medication regime. There was no history of altered states of consciousness.
21. The IR said Mr H’s needs were routine in nature and linked to his activities of daily living. Dementia is a progressive disease, and it is noted that there would be a general decline in his condition. However, at no point in the period under review were the nature of his needs over and above what a local authority could legally provide.
Our view
22. Our adviser said the clinical evidence supports the IR’s rationale for the nature indicator.
23. When the IR considers the nature indicator, in line with the National Framework, we would expect it to, ‘describe the particular characteristics of an individual’s needs (which can include physical, mental health or psychological needs) and the overall effect of those needs on the individual, including the type (‘quality’) of interventions required to manage them’.
24. We can see the IR report notes the IR’s consideration of the nature of Mr H’s presentation. The description is detailed and considers the available evidence about his identified needs, and the way in which those needs were met.
25. We can see the IR did look at the right things. It noted that Mr H had a condition that was deteriorating. We can see the IR considered the way in which his needs were met. We know Mr O disagrees with some of the detail. We have looked at what the clinical evidence tells us. We can see the records, including those of his father’s daily care, support the IR’s picture of his needs.
26. The IR described the nature of his condition well. It is clear he has many care needs, as Mr O says. We know Mr H has a cognitive impairment that affected his domains of care. However, the care plans and care records show he was able to respond to prompts and supervision by the carers to carry out many of his activities of daily living. The IR noted Mr H had falls while living in his own home before moving to the care home. He had no falls since, but the IR took into account that he remained at risk of falling if he did not use his Zimmer frame. He was able to respond to a prompt that reminded him to use his walking frame when he forgot to use it. He was able to find his own room, make some basic choices, and was accepting of care.
27. We can see no evidence to show that Mr H could not be reassured. His care was supplied within a regular daily pattern provided by carers trained in the delivery of care to individuals with an impaired cognition and overseen by registered nurse.
28. There is no evidence to support that Mr H’s needs could not be met within normal daily care routines. He did not need intervention from specialist teams. The care home did not raise any concerns that they were unable to meet his care needs, or occasional unsettled behaviour, as they presented. The records presented were clear enough for the IR to make the decision. There was no clinical evidence to show needs of a nature associated with a primary health need.
29. We are satisfied the rationale for the IR’s decision about the nature of Mr H’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 IR considered the nature of his needs.
Intensity
Mr O’s view
30. Mr O says his father’s needs were not routine. He needed constant and ongoing support to minimise the risks he would otherwise be exposed to.
NHSE’s view
31. The IR chair and clinical advisor said Mr H’s provision of care in the period under review was largely routine. He needed a safe environment with 24-hour care. He needed help with personal hygiene, monitoring of behaviour and weight, prompting and encouragement with nutritional intake, and the administration of medication. His needs were not severe or problematic to manage. The management of Mr H’s needs did not take an extended period and could be delivered by one or two carers. He did not need sustained interventions, continual care, or monitoring over and above what a local authority could legally supply.
Our view
32. Our adviser said the clinical evidence supports the IR’s rationale for the intensity indicator.
33. 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’)’.
34. We can see the IR report sets out the IR’s consideration of the intensity of Mr H’s presentation. The description is detailed and considers the available evidence about his identified needs and the way in which those needs were met.
35. We can see the IR did look at the right things. Again, we know Mr O disagrees with some of the detail. We have looked at what the clinical evidence tells us. We can see the records support the IR’s view on the intensity of his father’s needs. For example, they refer to his father staying settled most days. He had a stable mood and when upset, in remembering that his wife had died, the care staff were able to easily reassure him. There is only one incident where Mr H lashed out at another resident within the home.
36. The records show the care and help he 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 his father care or meet his needs within normal planned daily routines overseen by the registered nurse. He was monitored by therapists from community services, such as the GP.
37. As set out above, Mr H’s occasional inappropriate behaviour to other residents was recorded but was not a regular occurrence. His behaviour did not need regular specialist intervention, 1:1 intervention, or advice to manage it.
38. We are satisfied the rationale for the IR’s decision, about the intensity of Mr H’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 IR considered the intensity of his needs.
Complexity
Mr O’s view
39. Mr O says his father's needs were complex because he has increased physical fragility. This makes him vulnerable to falls and other injuries. He has no risk awareness as he fell in the care home early one morning trying to get dressed because he thought he was late for work. He has an ongoing need for heart medication that must be administered to him and has poor skin integrity. He behaved inappropriately towards others in the care home.
NHSE’s view
40. The IR chair and clinical advisor said Mr H’s needs were not difficult to manage. There was some evidence of interaction between his cognition needs and his mobility needs. He often did not understand the risk to himself if he walked without the use of his walking aid or said inappropriate things to others. Staff needed to be mindful of these elements when managing his care.
41. The IR said Mr H may, at times, become anxious, especially in noisy environments. But there was no evidence that he did not respond to reassurance at these times. His drug regime was noted to be non-complex although it needed to be administered by staff.
42. There was no need for increased knowledge or skill to address his needs. Indeed, the level of skill needed to manage his needs was well within the level that would have been expected in supplying necessary care and help.
Our view
43. Our adviser said the clinical evidence supports the IR’s rationale for the complexity indicator.
44. 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.’
45. We can see the IR report notes the IR’s consideration of the complexity of Mr H’s presentation. The description is detailed and considers the available evidence about Mr H’s identified needs, and the way in which those needs were met.
46. Again, we can see that the IR did look at the right things. The clinical evidence supports the IR’s view on the complexity of Mr H’s needs. For example, the records confirm that he was generally settled. They also show his needs could be met within routine planned care on a regular basis.
47. The care records show that Mr H’s presentation impacted across many areas of activities of daily living, as Mr O says. There was evidence of interaction between several domains on the Decision Support Tool, but his care plans remained relevant. They did not need repeated changes or increased knowledge to address his needs. There is also no sign Mr H needed the frequent input of specialist healthcare teams, or changes in either care, medication, or hospital admission. There was no evidence to support that his care was difficult to manage. There was no sign of a complexity of needs associated with a primary health need.
48. We are satisfied the rationale for the IR’s decision about the complexity of Mr H’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 IR considered the complexity of his needs.
Unpredictability
Mr O’s view
49. Mr O says his father suffered a number of falls, was verbally aggressive to other residents, and behaved inappropriately. He would undress himself in front of a female resident present in his room.
NHSE’s view
50. The IR chair and clinical advisor said Mr H’s condition was noted as being stable during the review period. Staff were able to predict his needs as they arose. His level of need did not change in quality or quantity. There was no evidence to suggest that he needed an increased level of skill or knowledge in response to any change in need.
51. Care plans and risk assessments were in place and evaluated. There was no evidence to suggest that Mr H’s needs were outside the scope of the care delivered through the routine plans of care in place at the care home.
Our view
52. Our adviser said the clinical evidence supports the IR’s rationale for the unpredictability indicator.
53. 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’.
54. We can see the IR report sets out the IR’s consideration of the unpredictability of Mr H’s presentation. The description is detailed and considers the available evidence about his identified needs and the way in which those needs were met.
55. We can see the IR did look at the right things. We can see the clinical evidence supports its view on the unpredictability of Mr H’s needs. For example, the records refer primarily to a stable condition with no considerable changes to care plans or medication regimes. While there were interactions between the domains, influenced by Mr H’s underlying condition, his care did not fluctuate unduly on a daily basis.
56. There were references to some isolated challenging behaviour, but there was no evidence that it created a barrier to care on a sustained basis. The records show staff could anticipate Mr H’s needs and his care could be planned to minimise risk. There was no evidence in the records, of his daily care, that care plans had to be changed often or at short notice. His care followed a natural format that was appropriate to his underlying condition.
57. As Mr O says, his father needed varying degrees of care, support and help throughout a 24-hour period to meet his needs. This is not evidence of unpredictability. It shows that at different times of the day his father needed more or less help. The care records show he had recognised, predictable patterns of behaviour, and care needs. Staff could meet these through routine approaches and care procedures. His needs were assessed, planned, overseen, and evaluated by a registered nurse. There is no evidence that his needs were unpredictable.
58. We are satisfied the rationale for the IR’s decision about the unpredictability of Mr H’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 IR considered the unpredictability of his needs.