16. Before we decide if we should carry out a detailed investigation of 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. We have done this and have not found any signs that something went wrong when NHSE made its decision.
17. It is our role to decide whether NHSE’s IRP acted in line with the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care when it considered whether Mr P was eligible for CHC. The National Framework sets out the principles and processes CCGs (now ICBs) and NHSE should follow when considering if someone is eligible for CHC. The 2012 version of the National Framework was in place at the time of the initial assessment in this case. It was revised in 2018. Please note we refer to the CCG (rather than ICB) throughout this decision as it was a CCG at the time.
18. We cannot consider the discretionary decisions the IRP made when it decided on eligibility. This includes the decisions it made based on clinical judgement and clinician’s opinions. We can only consider if the IRP has followed the National Framework. This means we can only uphold a complaint about a CHC eligibility decision if we find the IRP did not follow the National Framework when it made its decision.
19. The IRP reviews if the CCG should have found the person to have a primary health need and therefore be eligible for CHC. It also reviews the CCG’s procedures when it was coming to its eligibility decision to make sure it was acting in line with the National Framework. If the IRP does find the CCG made a mistake, it can:
• recommend the CCG reconsiders if the patient had a primary health need, and • recommend the CCG addresses any procedural faults the IRP found.
20. When we look at a complaint about an IRP, we consider if it took into account all the relevant information when it made its eligibility decision. To help us make a decision, we consider four key areas.
Did the IRP get all the relevant evidence?
21. Paragraph 199 of the National Framework says the following:
‘The key elements involved in considering requests for independent reviews of NHS Continuing Healthcare eligibility include:
• scrutiny of all available and appropriate evidence as described in the Local Resolution section.’
22. We have reviewed the information given to us in NHSE’s case file and can see the IRP had access to the following:
• summary of Mr P’s case including a chronology of events • checklist completed in December 2013 • decision support tool completed in March 2015 • decision making panel meeting minutes and outcome letter from March 2016 • local resolution meeting documentation from November 2017 • multi-disciplinary team (MDT) decision letter from February 2018 • the family’s submissions and other general correspondence • care home records • GP records • mental health records • hospital records.
23. We also have a copy of the IRP report. The report documents the submissions the family and their representative gave in person.
24. It is clear the IRP had access to all the information the CCG used to make its decision in March 2016. It gave the family an opportunity to give verbal evidence during the meeting in April 2021 and had access to their written submissions. The IRP also received Mr P’s medical records from the CCG which showed his needs during the review period.
25. We can see there are no obvious gaps in the documents and evidence NHSE considered. We are satisfied there is no sign of a failing in how the IRP established all the appropriate and relevant clinical facts. The IRP had access to information clearly detailing Mr P’s needs during the period before the MDT decision in February 2018.
26. We think the IRP acted in line with paragraph 199 of the National Framework here.
Before it made its decision, did the IRP consider all the relevant evidence?
27. We have looked at the information in the IRP report and considered how the panel discussed all the available evidence when it was weighing up the disputed domains. We can see the IRP discussed the family’s written and verbal evidence. This is clearly detailed in sections 7, 9 and Annex 1 of the IRP report where it outlines Mr P’s views on each individual domain and key characteristic.
28. We know the family feel the IRP did not discuss the community psychiatric nurse (CPN) assessment letter. They feel it ignored the letter and it was a crucial document about their case.
29. There is no specific reference to the letter in the IRP report. But we can see the IRP noted the CPN was unable to complete the specific assessments due to Mr P’s agitation at the time. This information is mentioned in the assessment letter. The CPN states that it was clear Mr P was impaired of his short- and long-term memory, but he did not show obvious signs of a mental health condition or mood disorder. The CPN did not make any plan to see Mr P again and recommended a placement be found at a care home registered to take people with dementia and its associated problems. We cannot see that the letter adds any information which would have changed the outcome of the IRP decision.
30. We can see the IRP also considered the information in Mr P’s medical records. When it explained its weighting for each domain, it refers to specific pieces of information it had taken from the medical records. We can also see the IRP had the National Framework in mind when it discussed its weighting of each domain and key characteristic. It outlined how it weighted each domain and explained how its weighting was in line with the National Framework.
31. Paragraph 199 of the National Framework is also relevant to this part of the IRP’s considerations, and we think it acted in line with this guidance here.
Did the IRP clearly explain how it had reached its decision?
32. The family have told us they disagree with how the IRP considered the continence, skin, mobility, communication, psychological and emotional, cognition, behaviour, and drug therapies and medication domains the health service uses to determine a person’s care needs.
Continence
33. The family believe Mr P’s needs in the continence domain were moderate throughout the review period. They say he was doubly incontinent and wore pads in the care home. Staff changed him several times a day due to his incontinence. His prostate cancer worsened his urine incontinence, and he had a catheter from previous hospital treatment for cancer. He fluctuated between loose stools and constipation which needed skilled monitoring. The hospital consultant managed his condition. He also had stage 3 chronic kidney disease.
34. The CCG weighted this domain as no needs from 2005 to September 2007, low from October 2007 to 2009, and moderate from 2010. The IRP partly agreed with the CCG. It said Mr P’s needs were low from August 2005 to February 2010 and moderate from March 2010 to May 2010.
35. The decision support tool (DST) defines low needs in this domain as:
‘Continence care is routine on a day-to-day basis; incontinence of urine managed through, for example, medication, regular toileting, use of penile sheaths, etc.
AND is able to maintain full control over bowel movements or has a stable stoma, or may have occasional faecal incontinence/constipation.’
36. The DST defines moderate needs in this domain as:
‘Continence care is routine but requires monitoring to minimise risks, for example, those associated with urinary catheters, double incontinence, chronic urinary tract infections and/or the management of constipation or other bowel problems.’
37. We can see the IRP had a detailed discussion about Mr P’s continence needs. It asked the family and their representative to describe their observations about why they felt his needs were of a higher weighting. It considered their concerns about his urinary tract infections (UTIs) and catheter and whether these showed a higher weighting might be appropriate.
38. The IRP noted that Mr P had prostate cancer which needed ongoing treatment. He had no continence issues in 2005. In 2007, he was diagnosed with a UTI and was prescribed antibiotics. In 2008, he was occasionally incontinent of urine. In 2009, his kidney function decreased. In April 2010, his catheter was fitted. But it set out the reasons why it did not think he was at risk.
39. The records show Mr P had an episode of frank haematuria (blood in the urine) in April 2010. He was taken into hospital and received treatment. Our adviser said this was a physical manifestation of his cancer condition and not due to his continence. The GP records also show a record of all the urology appointments Mr P attended and his chest Infections. They show he could get to the toilet and had occasional urinary accidents.
40. We think the IRP acted in line with the National Framework when it considered Mr P’s needs in the continence domain. The report recognises his urine incontinence was managed through regular toileting and he had occasional faecal incontinence. This is consistent with the family’s own evidence from the discussions, and the DST descriptor for low needs. The report explains why the IRP thought his needs were in line with the moderate weighting from March 2010. This is when his continence needs become more problematic and when he had a catheter fitted. The evidence, including the family’s, shows that while Mr P needed help with his continence needs, his carers could plan for and usually manage this.
41. We can see no signs of a failing in how the IRP considered this domain. We think the IRP considered Mr P’s continence needs in line with the National Framework and the DST guidance.
Skin
42. The family believe Mr P’s needs in the skin domain were moderate to high as he needed treatment for falls in the care home which included skin injuries. He suffered from repeated fungal infections in his groin and abscesses in his mouth. He had Waterlow scores of 23-29. He had a growth on his hand which was removed and had specialist dressings in place.
43. The CCG weighted this domain as no needs from 2005 to September 2007 and low from October 2007 to 2010. The IRP disagreed and said Mr P’s needs were moderate throughout.
44. The DST defines moderate needs in this domain as:
‘Risk of skin breakdown which requires preventative intervention several times each day without which skin integrity would break down.
OR Pressure damage or open wound(s), pressure ulcer(s) with ‘partial thickness skin loss involving epidermis and/or dermis’, which is responding to treatment.
OR An identified skin condition that requires a minimum of daily treatment, or daily monitoring/reassessment to ensure that it is responding to treatment.’
45. The DST defines high needs in this domain as:
‘Pressure damage or open wound(s), pressure ulcer(s) with ‘partial thickness skin loss involving epidermis and/or dermis’, which is not responding to treatment.
OR Pressure damage or open wound(s), pressure ulcer(s) with ‘full thickness skin loss involving damage or necrosis to subcutaneous tissue, but not extending to underlying bone, tendon or joint capsule’, which is/are responding to treatment.
OR Specialist dressing regime in place; responding to treatment.’
46. We can see the IRP had a detailed discussion about Mr P’s skin needs. It asked the family and their representative to explain why they felt his needs were of a higher weighting. It considered their concerns about his skin injuries, infections and pressure sores and whether these showed a higher weighting might be appropriate.
47. Our adviser said the evidence shows Mr P was very mobile, and his Waterlow scores were very high. (The Waterlow score is an assessment of a person’s risk of developing pressure sores.) He needed treatment for fungal infections in his groin. A lump was removed from his left hand which was later found to be non-cancerous. Mr P suffered breaks to his skin because of his falls and on one occasion needed stitches in a wound to his scalp. The wounds healed well and did not cause any concern.
48. We think the IRP acted in line with the National Framework when it considered Mr P’s needs in the skin domain. The report recognises care staff dressed the area on the back of his hand. In 2007, sutures were applied to the lesion in his left hand. In 2008, cream was applied to his sore groin. In 2010, there was no sign of any skin integrity issues. We can see Mr P had a skin condition which needed monitoring to make sure it was responding to treatment. This is consistent with the family’s evidence from the discussions, and the DST descriptor for moderate needs. The evidence, including the family’s, does show that while Mr P needed help with his skin needs, he did not need any specialist dressing regime or had any open wound which did not respond to treatment.
49. We can see no signs of a failing in how the IRP considered this domain. We think the IRP considered Mr P’s skin needs in line with the National Framework and the DST guidance.
Mobility
50. The family believe Mr P’s needs in the mobility domain were high as he had difficulties in moving independently and struggled to walk without help or supervision. He was at a high risk of falls and needed a wheelchair to move about the care home. He had over 90 falls, and several needed hospital treatment for head and other wounds. Mr P’s balance and co-ordination had badly deteriorated putting him at risk of serious injury.
51. The CCG weighted this domain as no needs from 2005 to 2006 and high from 2007 to 2010. The IRP disagreed and said Mr P’s needs were moderate throughout.
52. The DST defines moderate needs in this domain as:
‘Not able to consistently weight bear.
OR Completely unable to weight bear but is able to assist or cooperate with transfers and/or repositioning.
OR In one position (bed or chair) for the majority of time but is able to cooperate and assist carers or care workers.
OR At moderate risk of falls (as evidenced in a falls history or risk assessment).’
53. The DST defines high needs in this domain as:
‘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.’
54. Our adviser said the clinical evidence does not support the IRP’s reasoning in this domain.
55. We can see the IRP discussed Mr P’s mobility needs. The report recognised his needs were moderate because he was at a moderate risk of falls. It relied on the falls risk score that the care home calculated, which was moderate throughout the claim period.
56. A falls risk assessment assigns a score to certain aspects of the person’s presentation and other factors. Our adviser said the evidence available to the IRP does not support a moderate falls risk. She said a desk top assessment of risk would have given Mr P a score of 20. This reveals a high risk of falls. This is supported by incidents recorded in the care plans, which detail frequent falls.
57. We do not think the IRP acted in line with the National Framework when it considered Mr P’s needs in the mobility domain. The evidence, including the family’s, shows he was at a high risk of falls and was often found on the floor. This is in line with the high descriptor. Mr P fell while going up and down the downstairs. Staff needed to be aware when he tried to leave the care home as he was disorientated and would wander.
58. We can see a sign of a failing in how the IRP considered this domain. We think the IRP did not consider Mr P’s mobility needs in line with the National Framework and the DST guidance.
59. We discuss the impact of this further below.
Communication
60. The family believe Mr P’s needs in the communication domain were high throughout the review period as he had difficulties in communicating with others and could not understand or absorb information in the short or long term. His short-term memory loss increased considerably in his last few years. He would not say or show if he was in pain.
61. The CCG weighted this domain as no needs. The IRP disagreed and said Mr P’s needs were low.
62. The DST defines low needs in this domain as:
‘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.’
63. The DST defines high needs in this domain as:
‘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.’
64. We can see the IRP had a good discussion about Mr P’s communication needs. It asked the family and their representative why they felt his needs were of a higher weighting. It considered their concerns about his communication needs and whether these showed a higher weighting might be appropriate.
65. Our adviser said the records show Mr P’s communication was impacted by his cognitive difficulties and not because of a physical deterioration in the mechanics of his communication. His cognitive function meant he was unable to keep new information. The IRP would not consider communication impairment as a result of cognitive impairment in this domain.
66. We think the IRP acted in line with the National Framework when it considered Mr P’s needs in the communication domain. The report recognised there was only a small amount of evidence about Mr P’s communication during the review period. It said he needed help to communicate and had a basic level of communication that staff could understand. This is consistent with the family’s evidence from the discussions, and the DST descriptor for low needs. The evidence, including the family’s, does show that while Mr P needed help with his communication, he was not unable to communicate in any way at any time. For example, he was able to tell staff whether he wanted to shave before or after breakfast, and would ask about his wife and say he could not find her anymore.
67. We can see no signs of a failing in how the IRP considered this domain. We think the IRP considered Mr P’s communication needs in line with the National Framework and the DST guidance.
Psychological and emotional
68. The family believe Mr P’s needs in the psychological and emotional domain were high. They say he would show anxiety, irritable and distressed behaviour, emotional problems, tearfulness, mood swings and depression. Following his wife’s death, he would often become tearful for long periods of time and expressed a wish to die. He would not get out of bed for days due to his general depression. He was on medication for depression for a number of years and had CPN involvement. He experienced hallucinations.
69. The CCG weighted this domain as no needs from 2005, moderate between 2006 and 2009 and no needs from 2010. The IRP disagreed and said Mr P’s needs were moderate throughout the period.
70. The DST defines moderate needs in this domain as:
‘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.’
71. The DST defines high needs in this domain as:
‘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.’
72. We can see the IRP had a detailed discussion about Mr P’s psychological and emotional needs. It asked the family and their representative about why they felt his needs were of a higher weighting. It considered their concerns about his depression, distress and agitation and whether these showed a higher weighting might be appropriate.
73. Our adviser said the records show Mr P would go into the kitchen and make himself a sandwich. He was seen to use the knife appropriately and there was no risk found. The CPN stated that he did not show obvious evidence of a mental health condition or mood disorder. The citalopram 10mg he was prescribed once daily increased six months later to 20mg per day. This is a standard dose of medication for adults in line with details on the NHS webpage for citalopram.
74. We think the IRP acted in line with the National Framework when it considered Mr P’s needs in the psychological and emotional domain. The report recognised his wife’s death in 2006 left him upset and emotional. He became depressed during this time. He was prescribed citalopram to help treat his depression. He had various hallucinations and unsettled nights. This is consistent with the family’s evidence from the discussions, and the DST descriptor for moderate needs. The evidence, including the family’s, does show that while Mr P would forget his wife had died and was sad when he was told again, struggled to look after himself and needed reassurance, his periods of distress did not have a severe impact on his well-being. He did not completely withdraw from any attempts to engage him in care planning and support. This is the information the IRP would have needed to see to give a high weighting.
75. We can see no signs of a failing in how the IRP considered this domain. We think the IRP considered Mr P’s psychological and emotional needs in line with the National Framework and the DST guidance.
Cognition
76. The family believe Mr P’s needs in the cognition domain were severe as he had difficulty recognising family or friends. He had short- and long-term memory problems. He showed signs of disorientation. He was unable to focus or concentrate and had difficulty making decisions about his life. He had no understanding of basic risks. Mr P thought his son was his brother at times and that he handled the building works at the care home. He said he was staying in a hotel and not a care home. He also occasionally thought his daughter was his wife. He had no concept of times or dates or where he was living. He was an avid newspaper reader but lost his ability to read a newspaper or anything else. He would ask care home staff and his family several times a day about how and where his late wife was.
77. The CCG weighted this domain as no needs from 2005 to September 2007 and high from October 2007 onwards. The IRP disagreed and said Mr P’s needs were high throughout.
78. The DST defines high needs in this domain as:
‘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.’
79. The DST defines severe needs in this domain as:
‘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.’
80. We can see the IRP had a good discussion about Mr P’s cognition needs. It asked the family and their representative to explain why they felt his needs were of a higher weighting. It considered their concerns about his confusion and inability to process information and whether these showed a higher weighting might be appropriate.
81. Our adviser said the records show Mr P was not reliant on others to anticipate and carry out daily living activities, and was independent in his personal hygiene and dressing. He was able to sequence events and when hungry he was able to find the kitchen in the care home. He would use what he could find there to make himself something to eat, like a sandwich.
82. We think the IRP acted in line with the National Framework when it considered Mr P’s needs in the cognition domain. The report recognised he was disorientated and required orientation. He needed reminding his wife had died. He would be up in the night and needed redirecting back to bed. This is consistent with the family’s evidence from the discussions, and the DST descriptor for high needs. The evidence, including the family’s, does show some of Mr P’s actions could pose a risk of untoward incidents happening and he needed supervision.
83. We can see the care plans show Mr P got angry that a lady was calling out for the toilet and the carers were busy, so he found a carer and told them off for leaving the lady without help. He told the carer that if she wets all over the floor, they would be to blame.
84. It is clear he had a short-term memory problem. But he was still able to notice certain aspects in his environment that he found disturbing or unusual. There is no evidence to show he was unable to assess basic risks even with prompting or help. This is the information the IRP would have needed to see to give a severe weighting.
85. We can see no signs of a failing in how the IRP considered this domain. We think the IRP considered Mr P’s cognition needs in line with the National Framework and the DST guidance.
Behaviour
86. The family believe Mr P’s needs in the behaviour domain were severe as he showed aggressive, violent and unpredictable behaviour. He was noisy, restless and challenging. He interfered with others in the care homes. He tended to wander away from the building and was resistant to care. He tried to hit other residents in one care home and was transferred to another. He was on a half hour watch programme at the second care home throughout the night and an alarm call sensor mat was placed by his bed.
87. The CCG weighted this domain as no needs from 2005, high between 2006 and 2008 and low from 2009 onwards. The IRP disagreed and said Mr P’s needs were moderate throughout.
88. The DST defines moderate needs in this domain as:
‘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.’
89. The DST defines severe needs in this domain as:
‘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.’
90. We can see the IRP had a detailed discussion about Mr P’s behaviour needs. It asked the family and their representative to describe why they felt his needs were of a higher weighting. It considered their concerns and whether these showed a higher weighting might be appropriate.
91. Our adviser said there is no evidence to show Mr P posed a significant risk to himself or others or their property. The concern about the first care home was that it did not have a registration for dementia and it was not a ‘locked’ unit. So, Mr P could leave the premises whenever he wanted. The CPN was not concerned about his presentation but recommended he was better suited to a dementia registered home.
92. We think the IRP acted in line with the National Framework when it considered Mr P’s needs in the behaviour domain. The report recognised that his behaviour, even though challenging, followed a predictable pattern that skilled carers could manage. This is consistent with the family’s evidence from the discussions, and the DST descriptor for moderate needs. The evidence, including the family’s, does show Mr P’s behaviour posed a challenge to his care. But there is no evidence to support that he caused anyone injury or harm, or of any antecedent, behaviour and consequence (ABC) records. The episodes were not frequent, and Mr P was easily distracted and redirected. While waiting to be moved, the carers at his first home were able to manage him within routine care plans.
93. We can see no signs of a failing in how the IRP considered this domain. We think the IRP considered Mr P’s behaviour needs in line with the National Framework and the DST guidance.
Drug therapies and medication
94. The family believe Mr P’s needs in the drug therapies and medication domain were severe. He was on various medications which the care home administered daily. The care home struggled with his symptom control and comorbidity. He had abnormal blood readings because of his cancer.
95. The CCG weighted this domain as no needs from 2005 to September 2007, low between October 2007 and December 2007, moderate from 2008 and no needs from 2009 onwards. The IRP disagreed and said Mr P’s needs were moderate throughout.
96. The DST defines moderate needs in this domain as:
‘Requires the administration of medication (by a registered nurse, carer or care worker) due to: non-compliance, or type of medication (for example insulin), or route of medication (for example PEG).
OR Moderate pain which follows a predictable pattern; or other symptoms which are having a moderate effect on other domains or on the provision of care.’
97. The DST defines severe needs in this domain as:
‘Requires administration and monitoring of medication regime by a registered nurse, carer or care worker specifically trained for this task because there are risks associated with the potential fluctuation of the medical condition or mental state, or risks regarding the effectiveness of the medication or the potential nature or severity of side-effects. Even with such monitoring the condition is usually problematic to manage.
OR Severe recurrent or constant pain which is not responding to treatment.
OR Non-compliance with medication, placing them at severe risk of relapse.’
98. We can see the IRP carefully discussed Mr P’s drug therapies and medication needs. It asked the family and their representative about why they felt his needs were of a higher weighting. It considered their concerns about his prescribed medications and whether these showed a higher weighting might be appropriate.
99. Our adviser said the records show Mr P’s medication prescription was not complex. The GP and district nurse monitored it, visiting to administer his treatment for prostate cancer every three months. They sought advice when, and as soon as, they needed to.
100. We think the IRP acted in line with the National Framework when it considered Mr P’s needs in the drug therapies and medication domain. The report recognised his prostate cancer and the altering of his medications and creams after his blood results. This is consistent with the family’s evidence from the discussions, and the DST descriptor for moderate needs. The evidence, including the family’s, does show he needed his medication administered. But, his prescriptions did not change often, and he was mostly compliant with his medication.
101. We can see no signs of a failing in how the IRP considered this domain. We think the IRP considered Mr P’s drug therapies and medication needs in line with the National Framework and the DST guidance.
Impact of problem in how the IRP considered the mobility domain.
102. We know the family feel the mistakes in the IRP’s decision-making meant it made the wrong conclusion about Mr P’s eligibility for funding.
103. The National Framework says eligibility for CHC funding is based on whether the person has a primary health need. A primary health need is determined by looking at the four key characteristics. The domain weightings are used to help direct the consideration of the four key characteristics, but the decision about eligibility is not based on the combination of weightings.
104. Now we have considered how the IRP looked at each of the disputed domains, we can see it appears to have made a mistake in just one of these – mobility. As we go on to explain, we think the IRP properly considered the four key characteristics of Mr P’s needs, including his needs relating to mobility. This means we cannot say the mistake in the mobility domain consideration means the IRP made the wrong decision.
Well-managed needs principle
105. The family told us in their submissions that they feel the IRP did not properly apply the well-managed needs principle. They feel Mr P’s needs were minimised.
106. The National Framework says, ‘Care must be taken not to misinterpret a situation where the individual’s care needs are being well-managed as being a reduction in their actual day-to-day care needs.’
107. We can see why the family were concerned about the IRP’s consideration of the well-managed needs principle. Mr P had a variety of needs and a high dependency level which they felt the IRP did not recognise.
108. Our adviser said the IRP discussed Mr P’s needs in totality and there was evidence it considered the need for skilled intervention. It recognised he needed a degree of skilled oversight and input, but did not think he needed a skilled response outside routine provision at a care home. He had trained staff input, but this was generally to oversee the care rather than being directly involved in care interventions other than medication administration.
109. We have considered if the IRP did misinterpret Mr P’s needs because of the level of care he received. We think the IRP correctly applied this principle. The IRP has detailed in its report the level of care Mr P needed in each domain and the key characteristics, and how the care he was receiving met this need. It had to do this to properly consider his needs. As we have set out above, we do not think the IRP weighted the mobility domain in line with the evidence available to it. But, this was not because it misapplied the well-managed needs principle and marginalised any of his needs because they were well managed.
Did the IRP apply the eligibility tests properly and reach an evidence-based conclusion about them?
110. The IRP also applies an eligibility test to help it decide about a person’s CHC eligibility. The National Framework separates this test into four key characteristics: nature, intensity, complexity and unpredictability. This test is used to establish if the quantity or type of a person’s care needs are more than what the local authority can provide. This shows they have a primary health need, which in turn shows they are eligible for CHC.
111. The National Framework sets out questions for the IRP to consider to help establish a person’s level of need. They are outlined in ‘Practice Guidance 3, When identifying a primary health need, how should the four key characteristics be approached?’ (PG3). The National Framework is clear the questions it provides are not meant to be strictly applied and are there to guide the IRP’s considerations. We use these questions when we are looking at whether the IRP properly considered the four key characteristics of Mr P’s needs.
112. The family have told us they disagree with the IRP’s consideration of each of the four key characteristics. They say it overlooked Mr P’s dementia and physical condition and his need for 24/7 care. He fell in the care home over 90 times, often needing A&E attention. He was poorly managed in one care home.
Nature
113. The National Framework says nature should ‘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.’
114. The nature section of the IRP report recognises Mr P had a number of conditions and a range of needs that arose from these, and concluded that the nature of his needs did not constitute a primary health need.
115. We can see the IRP considered the nature of Mr P’s needs at a level of detail we would expect to see and with PG3 in mind. The IRP has focused on Mr P’s individual needs rather than his diagnosed medical conditions. Its decision in the nature indicator is clear and gives a full picture of how Mr P’s needs were met. The IRP described the nature of his condition well. We can see it looked at the care plans to suggest the care staff could provide his care routinely. The records were clear enough for the IRP to make the decision. It discussed the impact of his needs on his health and well-being, establishing he needed a level of care to be kept safe from harm. It mentioned the potential interrelation between his behaviour, cognition and psychological and emotional needs. But the IRP did not find this increased the range, type or level of care Mr P needed.
116. The IRP also looked at the types of care Mr P needed to keep him safe and well. The report sets this out in detail. It includes needs such as managing his medication, monitoring his mobility and observing his skin condition. The report shows how the IRP discussed the levels of training Mr P’s carers needed. They were knowledgeable and well-trained in dementia care and older person care. Although Mr P had features of dementia, he was still able to carry out his personal care independently. There was also a support team on hand and access to Mr P’s GP if needed. The IRP weighed everything up before it concluded the nature of his needs was within the remit of social services, with the support of community healthcare services and the GP.
117. We think the IRP acted in line with the guidance set out in the National Framework when it considered the nature of Mr P’s needs.
Intensity
118. The National Framework says this characteristic ‘relates 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’).’
119. The IRP’s report shows a detailed discussion about the intensity of Mr P’s needs. This included considering how intense his needs were in the areas his family mentioned. It recognised that by the time of the assessment, he would leave the care home building and carers were able to locate him. They could manage his skin needs. He had to be prompted to eat and drink. He had to be monitored for various needs, including breathlessness and UTIs. And he needed his medications given to him. It said he was anxious at times but responded to reassurance from carers and engaged with them. He had a high risk of falls, but care staff were familiar with his needs and followed the care plan in place. They completed a chart every 15 minutes to check on his location.
120. The IRP considered the amount of time needed to provide the care, how much planning was involved and how many carers were needed. These are the considerations PG3 advises it to look at. Carers could deliver his care following a routine care plan, with district nurses and carers monitoring this in the care home. The family say Mr P needed care 24 hours a day, but this alone does not show a primary health need. It shows that at different times of day, Mr P needed more or less help.
121. The IRP recognised Mr P had a level of need in most of the DST care domains. It weighed up all the evidence before it concluded the levels of care and monitoring needed in these domains were what a care home could be expected to provide and were not severe enough to determine a primary health need.
122. We think the IRP acted in line with the National Framework when it considered the intensity of Mr P’s needs.
Complexity
123. The IRP carefully considered the complexity of Mr P’s level of need. The National Framework says, ‘This is concerned with how the needs present and interact to increase the skill required to monitor the symptoms, treat the condition(s) and/or manage the care.’
124. The report shows the IRP considered how difficult it was for the carers to manage Mr P’s needs, and it established the care was not complex to deliver. The report shows how the IRP considered the interaction of various combinations of Mr P’s needs. It specifically discussed the interaction between his cognition, behaviour, communication, psychological and emotional needs, mobility, continence and nutrition as Mr P was prone to agitation. He would get lost in the home and its grounds. It also clarified there were simple methods the carers used to ease this challenge. It set out how the carers managed these in line with the care plans. This included reassuring him, calming him and returning him to the premises. Further advice and support were sought from the community mental health team to complete a mini mental state examination. It said as his dementia progressed and he could not reliably communicate, carers had to anticipate his needs through familiarity and understanding his care plans. He needed help with his medications to treat his cancer.
125. We can see the IRP weighed up all the evidence before they decided this key characteristic did not show a primary health need for Mr P. It recognised there was interaction between some of his needs. But it set out why it thought the level of skill needed to manage these was not complex, or that any of the interactions posed a significant barrier to the carers looking after him. It noted his needs were not difficult to plan or provide for.
126. We think the IRP acted in line with the National Framework when it considered the complexity of Mr P’s needs.
Unpredictability
127. The final key characteristic of a person’s level of need is unpredictability. The National Framework defines it as ‘the degree to which needs fluctuate and thereby create 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. An individual with an unpredictable healthcare need is likely to have either a fluctuating, unstable or rapidly deteriorating condition.’
128. The IRP report gave a good explanation about what an unpredictable need is. It referred to the variation in a person’s presentation day by day and explained why such variations did not reveal unpredictable needs. It said it had to consider whether Mr P’s needs changed in an irregular or unexpected way, so they created challenges in care staff knowing how to manage them.
129. The IRP provided a detailed review of the unpredictability of Mr P’s needs in its report and we can see the panel had PG3 in mind to inform its discussions. The report recognises he had varying levels of need at different times. But carers knew what to expect, including the need to help Mr P with regular routine preventative measures to help promote and protect his skin integrity, and regular support to manage his continence care. He needed anticipation and planned routines, with monitoring and encouragement as appropriate. The IRP said care staff were able to effectively meet his needs. While his needs fluctuated, the IRP referred to them as predictable and suggested he had a stable level of need. There were no rapid deterioration or sudden changes in the level or type of support Mr P needed.
130. We think the IRP acted in line with the National Framework when it considered the unpredictability of Mr P’s needs.
131. We are satisfied there are no failings in how the IRP considered the four characteristics of Mr P’s needs. We think it acted in line with the National Framework. This does not take away from the account the family has given us, or the challenges Mr P faced towards the end of his life. We appreciate Mr P was reliant on the care he received. The IRP’s conclusion that his care did not reveal a primary health need and fell within the remit of the local authority appears to be in line with the National Framework.