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Cambridgeshire and Peterborough Integrated Care System

P-002911 · Statement · Decision date: 26 September 2024 · View Cambridgeshire and Peterborough Integrated Care System scorecard
Continuing healthcare Continuing healthcare Care plan failures
Complaint (AI summary)
Mrs K complained the ICB wrongly removed her mother's funded nursing care without notification, causing inappropriate care, delays, and distress to the family.
Outcome (AI summary)
The complaint was closed. The ombudsman found no serious fault in the decision to remove funded nursing care, and the ICB had already adequately addressed the poor communication.

Full decision details

The Complaint

3. Mrs K complains Cambridgeshire & Peterborough Integrated Care System (the ICB) wrongly removed her mother, Mrs J’s funded nursing care (FNC) from May 2023 to March 2024. Mrs K also complains the ICB did not notify them in writing that the FNC was under review, or that it had decided withdraw it.

4. Mrs K says because of this, her mother did not get appropriate care for her needs, and this was very distressing and concerning for the family to witness. This meant delays in her mother’s care as district nurses had to be called to assist her when needed instead. During the time following the decision her mother required an ambulance twice in two months following unwitnessed falls and for high blood pressure, temperature, confusion and a wait for bloods which showed acute kidney injury. They feel upset, frustrated and dismissed.

5. Mrs K would like the ICB to reimburse the FNC to when the decision to withdraw it was made.

Background

6. Mrs J was aged in her eighties at the time of these events. She had a medical history of vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain) and hyperthyroidism (where the thyroid gland produces too much of the hormones which control metabolism, growth, and many other bodily functions). She also had a history of transient ischemic attack (a TIA is a temporary disruption in the blood supply to the brain that causes symptoms similar to a stroke) and stroke (when the supply of blood to the brain is reduced or blocked completely, which prevents brain tissue from getting oxygen and nutrients).

7. In March 2020, Mrs J was struggling to care for herself so in July 2020 carers began to visit her several times a day to assist her.

8. As she was presenting a risk to herself, from May 2021 she moved into a care home. On 22 July 2021, Mrs J had a continuing healthcare (CHC) checklist. A checklist is a screening tool which is to help identify individuals who may need a referral for a full assessment of eligibility for CHC. This is a package of care for people who are assessed as having a ‘primary health need’. It is arranged and funded by the NHS. If the checklist is positive, the individual has a full assessment, using the decision support tool (DST).

9. Following the positive checklist, the ICB’s multidisciplinary team (MDT) carried out a full DST assessment on 17 August 2021. It found Mrs J was not eligible for CHC. It said, however, Mrs J’s needs indicated that she was entitled to a weekly NHS funded nursing care (FNC) contribution, paid directly to the care home from 22 July.

10. On 16 April 2023, another CHC checklist was completed. This was positive and she therefore a DST on 4 May. The multidisciplinary team (MDT) who completed this found Mrs J was not eligible for CHC, but was still eligible for FNC. The ICB’s complex cases team disagreed with this decision on 12 May and withdrew Mrs J’s FNC.

11. On 27 July 2023, Mrs J’s care home submitted an FNC proforma (request for FNC). The ICB’s complex cases team reviewed this and the records and decided Mrs J remained not eligible for FNC.

12. Mrs J’s daughter complained to the ICB about its decision to remove FNC on 6 October. It replied on 18 October and said it reviewed the DSTs from August 2021 and May 2023 and Mrs J did not require daily input from a registered nurse to meet her needs.

13. On 11 March 2024, the care home again submitted an FNC proforma and on 19 March the ICB confirmed Mrs J was eligible for FNC so it began funding this again.

14. Mrs J sadly died on 25 April 2024.

Findings

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.

Our Decision

1. We have carefully considered Mrs K’s complaint about Cambridgeshire and Peterborough Integrated Care System. We have seen no indication that anything went seriously wrong and have not seen the ICB made the wrong decision when removing Mrs J’s FNC. We understand how disappointing the ICB’s decision was for Mrs K and are sorry to hear it caused her worry.

2. We have decided the ICB has already done enough to put right the impact of its poor communication with Mrs K around the review and decision of FNC, and there is nothing further we would ask it to do. We understand how frustrating this was for Mrs K and that its decision came as a shock.

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