4. Mrs I complains that Northamptonshire CCG has not provided her with adequate financial redress following its decision that her late husband was eligible for NHS continuing healthcare (CHC) funding. She says the CCG refused to reimburse her for eight days of the post death fee the care home charged her.
5. Mrs I says this had a financial impact. This is estimated to be around £910.
6. Mrs I would like the CCG to reimburse her for the fees.
7. The following is intended to be a brief background.
8. In December 2017 Mr I suffered an aneurism and was admitted to hospital. In hospital he suffered a cardiac arrest and stroke resulting in a hypoxic brain injury (when the brain does not get enough oxygen). He remained in hospital until June 2018. The hospital then discharged him to a care home.
9. In June 2018 the CCG assessed Mr I’s eligibility for continuing healthcare funding (CHC). It concluded he was not eligible for CHC funding but eligible for funded nursing care. The CCG said it would review Mr I at three and 12 month intervals.
10. These reviews did not take place at the time. The CCG has since retrospectively found Mr I should have been assessed and found eligible for period June 2018 until the date of his death. It has agreed to reimburse Mrs I for this period.
11. The care home charged Mrs I a fee for 10 days after Mr I’s death to cover the costs of cleaning the room. The CCG agreed to fund two of these days.
Redress
14. Mrs I complains the care home charged her 10 days’ worth of care fees she should not have been liable for after her late husband, Mr I’s death. The CCG paid for two of these days and refused Mrs I’s request for reimbursement of the rest of fee.
15. The CCG says these fees are part of a private contract with the care home. It says it will not consider reimbursement arrangements Mrs I agreed as part of a private contract.
16. We have first looked at what happened. We will then consider what should have happened in line with the redress guidance.
17. Mr I went into the care home in June 2018. As Mr I was deemed not to be eligible for CHC at the time, Mrs I funded Mr I’s care. She had to sign a private contract at the time with Midland Care because of this, which we have considered.
18. Mr I resided at the home until he sadly died. Mrs I then had to pay for ten days’ worth of care fees post death. The CCG has since accepted that Mr I should have been eligible from June 2018 until he died.
19. In finding Mr I retrospectively eligible, the CCG has recognised Mr I should have been eligible at the time when he went into the care home.
20. We recognise the CCG says it has an arrangement with nursing homes that it will only fund two days of fees following a patient’s death for to cover cleaning costs. It says it is the care homes decision to charge for the additional eight days. The CCG says the fees are part of the terms and conditions of a formal contract the patient and/or their family have signed with the care home.
21. We acknowledge what the CCG has told us and recognise it is the care home who is deciding to charge for an additional eight days after a patient has died.
22. This aside, if Mr I had a robust assessment at the right time, Mrs I would not have needed to take out a private contract with the care home. Mrs I would not have been responsible for finding a private placement and signing the contract with the care home.
23. If the correct process had been followed and CHC awarded at the time, the CCG would have been responsible for finding a placement that was not a private arrangement. The CCG would have been responsible for the contract with the care home, and any fees associated with it. There would not have been a private arrangement in place at the time of Mr I’s death.
24. The redress guidance sets out what should happen if something in the CHC process has gone wrong, like it did in this case. It says: ‘The purpose of redress is solely to restore the individual to the financial position they would have been in had NHS continuing healthcare been awarded at the appropriate time’.
25. We recognise the CCG has a responsibility in managing public money. However, the redress guidance also allows for CCG’s to have discretion to make payments above the cost of care to remedy its mistakes in individual circumstances.
26. Our Principles for Remedy set out the approach we think public bodies should take when things go wrong. They say: ‘Where maladministration or poor service has led to injustice or hardship, public bodies should try to offer a remedy that returns the complainant to the position they would have been in otherwise. If that is not possible, the remedy should compensate them appropriately. Public bodies should: calculate payments for financial loss by looking at how much the complainant has demonstrably lost or what extra costs they have incurred’.
27. Our view is that if CHC had been put in place at the appropriate time, the family would not have had to take out a private contract with Midland Care. This means they would not have been liable for any after death fees. We think the family incurred this fee because CHC was not in place when it should have been.
28. The CCG has not restored the family to the position they would have been in, in line with the Redress Guidance and Our Principles. We have found a failing here.
29. We will now go on to consider the impact of this. Mrs I has explained this had a financial implication as she was charged £910.64.
30. The CCG says it has compensated the family fairly. It has accepted Mrs I would not have had to enter into a private arrangement if CHC had been in place. It feels it has rectified this by accepting the mistake and retrospectively awarding CHC funding.
31. It is right the CCG had reimbursed Mrs I for the period Mr I was eligible. We recognise it has taken this action. However, Mrs I has suffered a further financial loss directly as a result of Mr I not having CHC at the time.
32. The CCG has not acknowledged this or compensated Mrs I for the loss. We have set out recommendations below to address this.
1. We have found the CCG’s decision not to reimburse Mrs I for eight days of care home fees to be a failing which resulted in a financial loss. We therefore uphold this complaint.
2. We acknowledge this issue has been a source of stress and concern for Mrs I. We do not think the CCG has done enough to put things right, so we have recommended it takes action to address this.
3. We have recommended the Trust reimburse Mrs I for eight days of care home fees she paid, in recognition of the financial loss its actions caused.
33. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.
34. Our principles say that public organisations should put things right and, if possible return the person affected to the position they would have been in the poor service had not occurred. If that is not possible, they should compensate them appropriately.
35. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale. We think the CCG should reimburse Mrs I for eight days of care home fees in recognition of the fee she paid. It should do this within four weeks of the date of our final report.