The ICB wrongly removed Mrs J’s funded nursing care
18. Before we decide if we should conduct 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 indication that something has gone wrong.
19. The National Framework, sections 270 to 272, explains that FNC is the funding provided by the NHS to care homes with nursing, to support the provision of nursing care by a registered nurse for those assessed as eligible for it. An individual is eligible for FNC if they have such a need and it is determined the individual’s overall needs would be most appropriately met in a care home with nursing.
20. The National Framework defines registered nurse input in the following terms: ‘Services provided by a registered nurse and involving either the provision of care or the planning, supervision or delegation of the provision of care, other than any services which, having regard to their nature and the circumstances in which they are provided, do not need to be provided by a registered nurse’.
21. It says ‘nursing care by a registered nurse’ covers time spent on nursing care, in the sense of care which can only be provided by a registered nurse, including both direct and indirect nursing time.
22. The National Framework also says
‘Section 22 of the Care Act 2014 places a limit on the care and support that can lawfully be provided to individuals by local authorities. That limit is set out in section 22(1) and is as follows: ‘A local authority may not meet needs under sections 18 to 20 by providing or arranging for the provision of a service or facility that is required to be provided under the National Health Service Act 2006 unless – (a) doing so would be merely incidental or ancillary to doing something else to meet needs under those sections, and (b) the service or facility in question would be of a nature that the local authority could be expected to provide’’
23. Mrs K gave the following examples of why disagrees with the ICB, and she feels her mother had nursing care needs. She explained Mrs J suffered repeat urinary tract infections (UTIs). She had two requiring antibiotics from May 2023, monitored by the nurse. She explained Mrs J had oedema (fluid build up) in both legs which required additional support overnight, monitored by the nurse.
24. Mrs K also says Mrs J had seborrheic keratosis (a skin condition), fluctuating blood pressure and a persistent cough, all monitored by the nurse. She also says Mrs J was unable to manage her medication, so this was ordered and monitored by the nurse. She explained Mrs J’s healthcare was delivered under the direction of a registered nurse and she had nurse intervention and management for her health conditions.
25. We cannot consider or comment on the previous decision made before May 2023 about Mrs J’s FNC. The purpose of the FNC review is to consider an individual’s needs at that time. Our CHC adviser has looked at the evidence about Mrs J’s needs at the time of her FNC review and DST in April and May 2023, to consider if Mrs J had nursing needs at that time. The records show Mrs J’s behaviour had settled. She was settled emotionally and would respond to reassurance and distraction. They also note Mrs J was independently mobile, with a history of falls. She was independent with her eating but required some assistance with cutting up her food and required prompting. They note Mrs J was compliant with taking her medications.
26. Our adviser says this indicates Mrs J did not have any needs which required input from a registered nurse over a 24-hour period. Overall there was no indication she required immediate access to and oversight from a nurse. Our adviser says her needs were for social care. It was helpful that at this home, it was both residential and nursing so there was no need to move Mrs J to another home when she was there for residential and social care purposes, rather than nursing care.
27. We also asked our adviser specifically about the reasons Mrs K gave for why she feels Mrs J should have remained on FNC. Our adviser says Mrs J’s UTIs did not require registered nursing care at the time of the FNC review. Mrs J was noted to be at risk of UTIs and required assistance from carers to look out for signs and symptoms of UTI. Staff could ask for GP input when required for urine samples and antibiotics. Our adviser says this would not cause any significant delay in Mrs J’s treatment as this would have needed to happen even if she had continued to get FNC. Mrs J’s UTIs could be managed through existing NHS services when required, in line with the National Framework. Monitoring her for this was met through social care as carers are trained to recognise signs of UTI.
28. The UTIs Mrs J had which required admissions to hospital were in October 2023, January and February 2024. Mrs J became eligible for FNC in March 2024. Our adviser explains this was due to a combination of her needs such as hospitalisation from repeat UTIs, catheterisation, bowel incontinence, 17% weight loss, being immobile, compromised skin integrity and a decline in cognitive function. These all indicated Mrs J again required access to a registered nurse 24 hours per day at that point in March 2024.
29. Mrs K also said Mrs J had oedema in both legs. Our adviser said care home staff can recognise oedema and follow instruction when a patient’s legs require elevation. Care home staff are required to monitor residents and know when to involve relevant NHS services, such as GPs and district nurses, in line with the National Framework, when a patient requires input. Our adviser confirms there would be no immediate need to have a nurse observing Mrs J’s oedema and this could be done by carers.
30. Mrs J’s seborrheic keratosis, fluctuating blood pressure and a persistent cough again would all involve the GP but would not require daily nursing care. If required, district nurses would be asked to attend but residential carers do know how to monitor blood pressure. For example if the GP asked for a weeks’ worth of readings to manage the patient, this is something the carers would do. The persistent cough would again involve a GP if necessary as they can refer the patient where needed and prescribe medication. Our adviser says there is no indication this would require daily nursing care or oversight from a nurse.
31. We appreciate how worrying the removal of FNC was for Mrs K, as this was something Mrs J had since moving into the care home. A person’s needs can change, both increasing and decreasing, which is why the National Framework asks an ICB to review individuals regularly. There is no indication Mrs J met the criteria in the National Framework to require daily input from a nurse through FNC when she was reviewed in May 2023. Mrs J’s needs could be met within the provision of the local authority and through other NHS services such as district nursing and the GP as and when required. We have not seen indications of failings in relation to the ICB’s decision that Mrs J was not eligible for FNC in May 2023 and its removal of this.
The ICB did not notify the family in writing that Mrs J’s FNC was under review, or that it decided to withdraw it.
32. Having looked at the evidence, we think the ICB got things wrong in its communication, but that has already done enough to put right the impact of this.
33. The core values and principles of the National Framework say a person centred approach involves keeping the individual and/or their representative fully informed. The general principles throughout the National Framework also indicate that an ICB should communicate any proposed changes and outcomes clearly in writing to the individual and/or their representative, with reasons for the decision and details on how to complain about a decision.
34. Our CHC adviser says the ICB should have made Mrs J and her daughter and family aware at the outset of the DST meeting that her needs were being assessed and should have explained that this meant Mrs J’s FNC was under review. Without the ICB informing the family of this, they were not aware the DST was a review of Mrs J’s needs including her eligibility for FNC. It was therefore a shock to them when they found out Mrs J’s FNC had been withdrawn.
35. The ICB should also have confirmed in writing to Mrs K and her daughter its decision to withdraw FNC, its detailed reasons for this and details on how to complain. The ICB only provided an outcome letter to confirm Mrs J was not eligible for CHC and did not mention the removal of her FNC or its rationale for that decision. It did not provide enough detail for its rationale for removing FNC in its complaint response. It provided a further detailed explanation after we asked it to, after we got Mrs K’s complaint.
36. In its complaint response letter, the ICB accepts it should have notified the family in writing, rather than just by telephone. It has apologised to Mrs K for not confirming this in writing and confirmed at the time it was making improvements to its service to address this issue.
37. As detailed above, we have reviewed the ICB’s decision and have not seen any indication its decision Mrs J did not meet the criteria for FNC was wrong. How it informed the family and communicated its decision therefore had no impact on its decision to remove FNC. But we accept because Mrs K was not appropriately informed, this caused her frustration and came as a shock.
38. The outcome Mrs K wanted was for us to ask the ICB to reconsider its decision and reimburse the FNC back to when it withdrew it. We cannot ask the ICB to do that because we have not found its decision was wrong.
39. The ‘NHS Complaint Standards’ say NHS organisations should acknowledge when it gets things wrong, think about how to put things right and learn from complaints. We think it has done enough to put right the impact of what it got wrong in its poor communication of the process and rationale for its decision. It has apologised to Mrs K for this. It has also identified that it needs to learn from her experience and is reviewing how it can improve its service.
40. We are sorry this is not the outcome Mrs K was hoping for. We hope Mrs K does not feel in any way our decision diminishes the impact of the worry, frustration and distress these issues caused her and the family at a difficult time.