The checklist
12. Mr and Mrs C argue that the ICB has incorrectly scored each of the domains it has considered. They state that a full retrospective continuing healthcare assessment should have been done to determine Mrs U’s eligibility for continuing healthcare funding. Continuing healthcare is NHS funding provided to cover the health and social care needs of people with complex health needs.
13. Paragraph 112 of the National Framework for continuing healthcare and funded nursing care 2022 (the National Framework) outline that the checklist is the only screening tool that can be used as the initial screening process to identify if there may be a need for continuing healthcare. This is what the ICB has done, it completed a checklist on 9 October 2023.
14. We cannot consider the discretionary decisions the ICB made when it scored the checklist. This includes the decisions it makes based on clinical judgement and clinician’s opinions. We can only consider if the ICB has followed the National Framework in how it has scored the checklist. This means we can only uphold a complaint about a checklist decision if we find the ICB did not follow the National Framework when it made its decision. To do this, we consider the definitions for each of the descriptors of the domains, and we look to see if the ICB has made its decisions based on the evidence.
15. A full assessment for NHS Continuing Healthcare is required if there are: • two or more domains selected in column A; • five or more domains selected in column B, or one selected in A and four in B; or • one domain selected in column A in one of the boxes marked with an asterisk (behaviour, breathing, altered state of consciousness and drug therapies and medication) with any • number of selections in the other two columns.
16. The ICB scored Mrs U as follows:
• 27 May to 1 July 2022, 9 Cs and 2 Bs negative checklist • 1 July to 21 August 2022, 8 Cs and 3Bs negative checklist • 22 August to 22 October 2022, 7 Cs, 3Bs and 1A negative checklist • 23 to 27 November 2022, 6Cs, 4Bs 1 A positive checklist clearly documented as end of life • in 111 reports and EMAS records evidence would support fast track funding for this period only.
17. The ICB recommended fast-track funding for the period from 23 November to 27 November 2022 due to the decline in Mrs U’s health.
18. We will therefore consider the period from 27 May to 22 November 2022. Mr and Mrs C disagreed with the ICB’s scoring in each of the checklist domains. We will consider each of these in isolation to determine if the ICB had scored Mrs U’s needs robustly and in line with the National Framework.
Breathing
19. The ICB scored Mrs U’s breathing needs as a C. Mr and Mrs C argue she should have been scored a B in this domain.
20. C in this domain is defined as: ‘Normal breathing, no issues with shortness of breath.
OR Shortness of breath or a condition, which may require the use of inhalers or a nebuliser and has no impact on daily living activities.
OR Episodes of breathlessness that readily respond to management and have no impact on daily living activities.’
21. B in this domain is defined as: ‘Shortness of breath or a condition, which may require the use of inhalers or a nebuliser and limit some daily living activities.
OR Episodes of breathlessness that do not consistently respond to management and limit some daily activities.
OR Requires any of the following: • low level oxygen therapy (24%); • room air ventilators via a facial or nasal mask; other therapeutic appliances to maintain airflow where individual can still spontaneously breathe e.g. CPAP (Continuous Positive Airways Pressure) to manage obstructive apnoea during sleep.’
22. Mr and Mrs C say Mrs U suffered episodes of breathlessness that did not respond to management, and this limited some of her daily activities. They refer to a clinical note dated 24 May 2022 that said Mrs U appeared chesty and she coughed up some phlegm. They said she was described as becoming wheezy and chesty, and on 2 and 23 August 2022, she was recorded as having low oxygen saturation levels. They stated Mrs U experienced severe breathlessness if she tried to walk, and she required a wheelchair for all transfers. They refer to a clinical entry on 2 August 2022 that said the doctor suspected Mrs U had a chest infection and they prescribed her with antibiotics.
23. Mr and Mrs C said the care notes pointed out Mrs U had a runny nose, and she was sniffing on 26 September 2022, and they refer to a clinical entry where Mrs U was described as testing positive for COVID-19 on 5 October 2022. Mr and Mrs C refer to an entry dated 25 November 2022 that said Mrs U had low oxygen saturation levels. As this falls outside of the period we are considering, we will not be taking this into account.
24. In its response, the ICB stated there was no evidence to support the claim that any of the breathing issues experienced by Mrs U did not respond to management or limit daily activities. It also said no evidence is held within the care plan to support the assertion that Mrs U became severely breathless when mobilising.
25. We have carefully considered the points Mr and Mrs C have made, and the response provided by the ICB. We have looked at Mrs U’s care home records to see if the ICB scored her needs robustly in this domain. A review dated 22 September 2022 stated Mrs U enjoys chatting with other residents and she has a great sense of humour. It stated she is physically mobile, and she can get up, walk, dance, and join in activities independently.
26. We have reviewed the care home records for early August, and we did not find evidence of concerns regarding Mrs U’s breathing during this time. Care home entry notes from 8 and 9 August 2022 stated Mrs U appeared fine and in good spirits. On 10 September 2022, it was noted Mrs U spent time in the lounge area, and there were no concerns reported.
27. We have not seen any evidence to show that Mrs U’s breathing impacted on her daily activities or did not respond to management. This is what we would need to see to demonstrate her needs fell into this category. After carefully considering the available evidence, we have not identified any indications of failings with how the ICB considered Mrs U’ needs in this domain.
Nutrition
28. The ICB scored Mrs U’s needs in this domain as a C. Mr and Mrs C state they consider her needs in this domain were a C until 30 June 2022, and from then until the end of the period they were a B.
29. C in this domain is defined as: ‘Able to take adequate food and drink by mouth to meet all nutritional requirements.
OR Needs supervision, prompting with meals, or may need feeding and/or a special diet (for example to manage food intolerances/allergies).
OR Able to take food and drink by mouth but requires additional/supplementary feeding.’
30. B in this domain is defined as: ‘Needs feeding to ensure adequate intake of food and takes a long time (half an hour or more), including liquidised feed.
OR Unable to take any food and drink by mouth, but all nutritional requirements are being adequately maintained by artificial means, for example via a non-problematic PEG.’
31. Mr and Mrs C say Mrs U required a high level of prompting and encouragement with her nutritional intake, and she frequently refused food and drink. Mrs U suffered a 3% weight loss on 29 August 2022, she required a fortified diet, and she was encouraged with snacks to ensure adequate nutrition. They state that as of July 2022, she had little to no appetite, and she had a liquid diet from July 2022, and it would take over 30 minutes for her to have this.
32. Mr and Mrs C have referred to the care home records. They refer to a note from 2 August 2022 that states she had poor intake. On 16 November 2022 it stated poor fluid intake. On 7 November 2022 it stated Mrs U continues to have a poor diet, staff are to continue to encourage. On 24 October 2022 the care home note stated Mrs U has a poor diet and she does not feel hungry. On 26 September 2022, it stated Mrs U has a small diet, please continue to encourage snacks and fluids.
33. In its response to Mr and Mrs C’s complaint, the ICB stated the evidence within the care plan does not support the narrative within their submission. The ICB stated the care plan states Mrs U had a good appetite and enjoyed a variety of foods, and she was able to eat independently.
34. The ICB stated that from November 2022, entries within the daily notes state Mrs U had poor nutritional intake and required monitoring, but there are also entries that state meals were eaten with encouragement. The ICB said there is no evidence of Mrs U having a liquid diet, and there was no PEG in place. (Percutaneous Endoscopic Gastrostomy tube.) PEG tubes are used to feed a person straight into their stomach if they have a problem feeding by mouth, cannot maintain their weight or are unable to digest food.
35. We have reviewed Mrs U’s care home records to determine if the ICB considered her needs in this domain in line with the National Framework. We have looked at the care plan review for each month, as these give the best picture of her overall nutritional needs for that month.
36. The care review note dated 22 July 2022 stated Mrs U appears to be eating well, and she eats independently. The care review dated 23 August 2022 stated she was not eating and drinking well at present and seems to be declining in health generally. Staff were to assist and prompt if needed.
37. The review note dated 30 August said Mrs U had been unwell lately and had lost some weight. However, we can see the ICB did consider this in the checklist, as it stated: ‘Although evidence of weight loss during August she also had an infection and risk assessment still indicated a low risk, she did have a poor diet and fluid intake and weekly weights supplements commenced during the period but remain low risk therefore C for the period.’
38. The care plan dated 22 September 2022 stated she needs encouragement to eat. However, the care plan dated 4 October 2022 stated Mrs U has a good appetite, and she enjoys a variety of foods. It stated she had gained weight that month. She has no dietary preferences or specialist requirements. It stated that Mrs U can eat independently without modified cutlery. The care plan stated Mrs U likes to eat her meals in the dining room, and she eats well.
39. We can see the ICB acknowledged in its checklist consideration that at times, Mrs U could refuse her food, and she needed encouragement to eat. It acknowledged she lost weight in August 2022, but it did outline she had an infection that could have contributed to her not eating as much.
40. Overall, we consider the ICB has appropriately considered Mrs U’s needs in this domain. We have not seen any evidence to show it took a long time to feed Mrs U (over 30 minutes) or that she was unable to take food and drink by mouth and she needed to be fed by artificial means, i.e., a PEG. We have not identified any indications of failings with the ICB’s consideration of her needs in this domain.
Continence
41. The ICB scored Mrs U’s needs in this domain as a C from 22 May to 30 June 2022, and then rising to a B for the rest of the period. Mr and Mrs C say that Mrs U’s needs were a C from 22 May to 17 July 2022, and then rose to a B from this date.
42. It looks like Mr and Mrs C have misinterpreted the ICB’s scoring here as in their complaint they say the ICB scored this as a C until 30 July 2022, when in actual fact it was 30 June 2022.
43. As the ICB has scored Mrs C higher in this domain than what Mr and Mrs C consider she should be, we do not think we need to do any analysis here. This is because they would not be disputing how this domain was scored with the knowledge that she was scored a B from 30 June 2022. We do not consider we need to add anything further to this.
Skin integrity
44. The ICB scored Mrs U’s needs in this domain as a C from 22 May to 23 November 2022. Mr and Mrs C consider her needs in this domain were a B throughout the period from 22 May to 27 November 2022.
45. C in this domain is: ‘No risk of pressure damage or skin condition.
OR Risk of skin breakdown which requires preventative intervention once a day or less than daily, without which skin integrity would break down.
OR Evidence of pressure damage and/or pressure ulcer(s) either with ‘discolouration of intact skin’ or a minor wound.
OR A skin condition that requires monitoring or reassessment less than daily and that is responding to treatment or does not currently require treatment.’
46. B in this domain is: ‘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.’
47. Mr and Mrs C say Mrs U’s was at risk of skin breakdown throughout the review period. The risk was increased by her incontinence. She required several care interventions each day, she needed creams to be applied and regular skin integrity checks. She required four hourly pressure area care, and she was repositioned every two hours. Mr and Mrs C have referred to entries from the care records that refer to Mrs U declining personal care interventions.
48. In its response to their complaint, the ICB said all the evidence indicates Mrs U required no pressure area care, and she was not repositioned 2 hourly. There is no evidence of any barrier creams being prescribed, or evidence she declined personal care that impacted on her tissue viability, or increased the need for monitoring, other than within the period where a rapid deterioration had been identified (23 November 2022).
49. The ICB said Mrs U’s care plan between August and October assesses her risk as low and based on the available evidence, she had no tissue damage, pressure area care was not routinely provided, and areas were assessed as requiring weekly checks.
50. We have reviewed Mrs U’s care home records to determine if the ICB considered her needs in this domain in line with the National Framework. We have looked at the care plan review for each month, as these give the best picture of her overall nutritional needs for that month.
51. The care review note dated 22 May 2022 stated Mrs U’s skin remains intact at the present and she continues to score low on the traffic light risk assessment, there are no changes required at this time.
52. The care review note dated 23 June 2022 stated Mrs U’s skin remains intact at the present and she continues to score low on the traffic light risk assessment. (The Traffic Light Model is based on three risk levels ((Green – Low, Amber – High and Red – Very High)). Risk levels are dependent on an individual’s risk factors. It also provides general advice on management, re-positioning regimes and skin checks to enable care staff to monitor individuals – promoting early identification of tissue damage with the aim of preventing pressure ulcer development.)
53. The care review note dated 22 July 2022 states Mrs U remains at low risk of developing pressure sores, she moves and repositions herself independently, staff are to observe for any skin damage and reassess risk assessment if any issues noted. Skin to be checked a minimum of weekly.
54. On 23 August 2022 the review notes outlined Mrs U continues to score low on the traffic light system. She is to have a skin check at least once a week. Any changes to skin should be documented and seniors informed so action can be taken. There are no changes to the care plan at present.
55. On 22 September 2022 it was stated Mrs U currently has no sore areas or areas of concern. She remains at low risk of developing pressure damage on the traffic light system. She requires a minimum of weekly skin observations.
56. We can see in the care home records that her needs increased in the last days of her life. For example, on 23 November 2022 there are notes relating to Mrs U lying on her back and refusing to be moved. On 25 November 2022 it was noted Mrs U was on 2 hourly pressure care.
57. The ICB acknowledged that her skin care needs increased in the final few days of her life. This is evident as they increased her needs to a B from 23 November 2022. Based on the evidence we have considered, the ICB has appropriately reviewed Mrs U’s needs in this domain. The evidence does not show she was at risk of skin breakdown throughout the period, or that she required several skincare interventions each day. We have not identified any indications of failings with the ICB’s consideration of Mrs U’s needs in this domain.
Mobility
58. The ICB scored Mrs U a C in this domain from 22 May until 22 August 2022 where it scored her an A for the rest of the period.
59. Mr and Mrs C say Mrs U should have been scored a B in this domain from 22 May until 22 August 2022, and then scored an A for the rest of the period.
60. As Mr and Mrs C agree with the ICB’s scoring of Mrs U from 22 August 2022. We will consider the period for the three months from 22 May to 22 August 2022.
61. C in this domain is defined as: ‘Independently mobile.
OR Able to weight bear but needs some assistance and/or requires mobility equipment for daily living.’
62. B in this domain is defined 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 majority of the 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).’
63. Mr and Mrs C say Mrs U was seemingly independent with her mobility needs at the start of the review period. They say she was as a risk of falls, and this was made worse by her dizzy spells. Mr and Mrs C say the C descriptor did not capture the extent of her mobility needs.
64. They refer to a care home record entry from 29 July 2022, that stated Mrs U was in a chair and she said she had fallen on her knees.
65. In its checklist, the ICB referred to the following entries from the records: 22 July 2022 -no falls since March continues to walk independently, 22 May to 23 June 2022 walking independently no falls. In its response to Mr and Mrs C’s complaint, it stated Mrs U was recorded as walking independently between March and June, and in the August 2022 review there is no indication she was at a moderate risk of falls.
66. The care review plan dated 22 May 2022 stated Mrs U continues to mobilise well and has no falls recorded since the last review, and no changes are required at this time. The review dated 22 June 2022 stated Mrs U continues to mobilise well and she has had no falls recorded since the last review. The review dated 22 July 2022 stated Mrs U had no recent falls recorded, and she continues to walk around the home independently. We can see that the 22 August 2022 review outlined Mrs U had an unwitnessed fall, and from this date the ICB scored her as an A in this category.
67. We have seen no indication to show that the ICB did not consider Mrs U’s needs in this domain in line with the National Framework. It Identified the change in need from 22 August 2022, and it increased the score from a C to an A from this point. We have not identified any indications of failings with how the ICB has scored her needs in this domain.
Communication
68. The ICB scored Mrs U a C in this domain for the period from 22 May to 27 November 2022.
69. Mr and Mrs C say Mrs U should have been scored a B in this domain for the period from 22 May to 27 November 2022.
70. C in this domain is defined as: ‘Able to communicate clearly, verbally or non-verbally. Has a good understanding of their primary language. May require translation if English is not their first language.
OR 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.’
71. B in this domain is defined as: ‘Communication about needs is difficult to understand or interpret or the individual is sometimes unable to reliably communicate, even when assisted. Carers or care workers may be able to anticipate needs through non-verbal signs due to familiarity with the individual.’
72. Mr and Mrs C say Mrs U could speak, but she was unable to reliably communicate her needs, even when assisted. They referred to care home notes that said she could become muddled, and they stated she was visually impaired.
73. The ICB referred to the following evidence in the checklist: • communication care plan can verbally communicate and hear what is said • able to speak to family and friends on the phone • holds conversations with other residents • can write but can get muddled up about what she is writing • able to read • blind in left eye and wears glasses • no communication aids.
74. In its response to the complaint, the ICB stated the evidence Mr and Mrs C had provided shows she could communicate well up until 22 November 2022. There is no evidence that communication around need was difficult to understand or interpret. Care workers were able to anticipate needs due to familiarity with Mrs U.
75. To determine if the ICB has considered Mrs U’s needs appropriately in this domain, we have reviewed the care plan review records. The care plan review dated 22 May 2022 stated Mrs U continues to communicate well, she likes to chat with staff and residents. There are no changes required at this review. The review plan dated 23 June 2022 stated Mrs U continues to communicate well and she likes to chat with staff and residents.
76. The review dated 22 July 2022 stated Mrs U was virtually blind in her left eye and she was on medication for this. It means she may misjudge distances and may need support when walking around the home. The care review plan dated 22 September 2022 stated she can verbally communicate and hear what’s being said to her. Mrs U can write, although she feels muddled about what she is writing, and she also likes to read the evening telegraph and magazines. She comes to find staff if she needs things, and she will approach staff if she has questions. She can effectively communicate her needs, and she does not need communication aids. It also stated Mrs U can use the phone effectively if people call for her.
77. Based on the evidence we have considered; we have not identified any indications of failings with how the ICB has considered her needs in this domain.
Psychological and emotional needs
78. The ICB scored Mrs U’s needs in this domain as a C. Mr and Mrs C argue that Mrs U’s need were a B in this domain.
79. C in this domain is described as: ‘Psychological and emotional needs are not having an impact on their health and well-being.
OR Mood disturbance or anxiety symptoms or periods of distress, which are having an impact on their health and/or well-being but respond to prompts, distraction and/or reassurance.
OR Requires prompts to motivate self towards activity and to engage them in care planning, support and/or daily activities.’
80. B in this domain is described 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 support, care planning and/or daily activities.’
81. Mr and Mrs C stated Mrs U experienced frequent mood disturbances, periods of distress and depression. This had an increasing impact on her health and wellbeing. She was noted to refuse care interventions when upset or agitated, and she had been recorded to be verbally aggressive with staff. She expressed she no longer wished to live. They said that during these times, reassurance was not always successful. They have referred to a care note that states: ‘staff have tried to encourage Mrs U to get washed…she declined each time…Mrs U would often decline to engage in activities around the home…’
82. On the checklist, the ICB refer to the care plan review dated 22 September 2022 that states Mrs U can get upset as forgets her husband has passed away staff offer comfort and support and answer any questions. Comforted by being told he has gone to spend time with his sister, reliving husbands’ death is a cause of depression she needs a quite area. Noted in how to achieve outcomes says she wants to die resolved by reassurance no detail of frequency/ how long reassurance takes. Has made no attempt to end her life.
83. The ICB referred to a care home entry that stated: ‘social lady and will mix with others, chats and initiates conversations with others.’ The ICB also referred to entries from 22 May to 23 August 2022 that stated Mrs U enjoyed joining in activities of her choosing.
84. To determine if the ICB considered Mrs U’ needs appropriately in this domain, we have reviewed the care review plans.
85. The care plan outlined Mrs U had a history of depression, dating back to 2004 and the death of her father. It stated since losing her husband in 2018 she has grieved and had been coping well at home. It stated she lost those memories after a urinary tract infection, and she can become upset when she relives learning her late husband has died. It was noted in the plan for staff to use verbal reassurance, and to reassure her that before she became ill, she had been coping, and she is stronger than she remembers.
86. The review dated 22 May 2022 stated Mrs U appears in good spirits, and there have been no changes reported. The review dated 23 June 2022 Mrs U had been in good spirits and there are no changes since the last review. The review dated 22 July 2022 stated Mrs U remains confused at times, although she is compliant with care delivery, she has been feeling a little low recently but is still attending communal area each day.
87. The review dated 22 September 2022 stated Mrs U is depressed and can get very anxious and worry about where she is, where her family are and where her husband is. The realization that her husband has passed away is devastating for her, and she needs a quiet area away from others as she is upset and embarrassed about others seeing her that way. Mrs U can say she wants to die, as there is no point in carrying on without her late husband. Staff must chat and reassure her through these dark thoughts.
88. This shows that the care home had a plan in place for when Mrs U displayed symptoms of feeling low or being upset or depressed. There is no evidence she did not respond to reassurance, or that her mood had a detrimental impact on her health.
89. The review also stated she is social and will mix with others. She has initiated conversations with other residents and chatted with them. She has spoken out for other residents when she sees that someone needs help, and she has called for staff out of the office for help. There is also evidence staff were able to make sure she maintained her personal hygiene. For example, the notes stated ‘if staff approach Mrs U saying her bath/shower is ready, the response is more likely to be positive. If Mrs U is asked does she wants a shower/bath, her response is she doesn’t need one or has already had one.’
90. The evidence shows Mrs U could have periods of low mood, but staff had care plans in place to provide reassurance to her and help her through these times.
We have not seen any indication to show the ICB has failed to consider Mrs U’s needs adequately and robustly in this domain.
Cognition
91. The ICB scored Mrs U a B in this domain. Mr and Mrs C argued her needs fell into the A category in this domain.
92. B in this domain is defined as: ‘Cognitive impairment (which may include some memory issues) that requires some supervision, prompting and/or assistance with basic care needs and daily living activities. Some awareness of needs and basic risks is evident.’
93. The individual is usually able to make choices appropriate to needs with assistance. However, the individual has limited ability even with supervision, prompting or assistance to make decisions about some aspects of their lives, which consequently puts them at some risk of harm, neglect, or health deterioration.
94. A in this domain is defined 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 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.’
95. Mr and Mrs C say Mrs U had Alzheimer’s disease, she suffered with memory loss, and she was disoriented to time, place, and person. They say she thought she was in her twenties and that she lived with her parents. Her communication was often muddled, and she was unable to assess basic risks.
96. In the checklist, the ICB referred to the following examples: ‘Care plan review 22/09/2022 recall is a few minutes, able to respond to prompts and answer yes/ no to questions. Able to follow a conversation with other residents. Disoriented to time and place.
Can remember the past. Able to find someone to help her if she needs it but will not use the call bell. Review: memory and understanding remains confused, compliant with care delivery feeling a little low no changes between 22/07/2022 – 22/08/2022.’
97. In its response, the ICB stated although Mrs U had been assessed as lacking capacity and having impaired cognition, she was still aware of some needs and able to communicate those to staff. Her long-term memory was intact, and she was orientated to self, but disoriented to place and time.
98. The ICB said the evidence within the care plan shows Mrs U could make choices appropriate to her needing assistance. She could decline care, but she would have a reason for doing so, that she believed would be correct. With support she was normally compliant with care unless there was an underlying reason such as an infection. The ICB said the evidence does not support the assertion that she was unable to make choices and decisions for most issues.
99. To determine if the ICB appropriately considered Mrs U’s needs in this domain, we have reviewed the care review records for this period. The review of Mrs U’s memory and understanding dated 22 September 2022 stated she had a diagnosis of Alzheimer’s in May 2017. Her short-term memory is impaired, and she has a recall time of minutes. She can remember the past, her working life, her family, and friends. It stated she has fresh grief as she can’t remember her husband passing away on 12 May 2018.
100. The review stated she can find someone to help her if she needs it, but she does not have the capacity to be able to use the call bell. This shows she had some awareness as to when she needed help. The review dated 22 July and 22 August 2022 stated Mrs U remains confused at times, although she is compliant with care delivery. She has been feeling low recently but is still attending communal areas each day.
101. The review also stated she enjoys chatting with other residents, and she can be a bit quiet at first, but a smiling face and someone starting off the conversation gets her involved. The review also stated she has a great sense of humour, and she is to be reminded of activities taking place in the home. Mrs U has joined in most things, and she can make choices from the options given about what is happening each day.
102. The care plans show Mrs U had short-term memory impairment, but she could make some choices for herself. We have not seen any evidence that shows the ICB failed to properly consider or assess her needs in this domain. The ICB has explained, with reference to the descriptor, why it considered Mrs U met the description for a ‘B’ in this domain. The evidence shows Mrs U had Cognitive impairment (which may include some memory issues) that requires some supervision, prompting and/or assistance with basic care needs and daily living activities. This fits with the ‘B’ descriptor on the checklist.
Behaviour
103. The ICB considered Mrs U’s needs were a ‘C’ in this domain. Mr and Mrs C stated they considered Mrs U’s needs in this domain to meet the ‘A’ descriptor.
104. The descriptor for a ‘C’ in this domain is: ‘No evidence of ‘challenging’ behaviour.
OR Some incidents of ‘challenging’ behaviour. A risk assessment indicates that the behaviour does not pose a risk to self, others or property or create a barrier to intervention. The individual is compliant with all aspects of their care.’
105. The descriptor for an ‘A’ in this domain is: ‘Challenging’ behaviour of type and/or frequency that poses a predictable risk to self, others, or property. The risk assessment indicates that planned interventions are effective in minimising but not always eliminating risks. Compliance is variable but usually responsive to planned interventions.’
106. Mr and Mrs C stated Mrs U was noted to frequently refuse food and drink, and this behaviour placed her at risk of further weight loss. She was also noted to refuse personal care, and this behaviour placed her at risk of infection and further skin breakdown.
107. Mr and Mrs C also stated that Mrs U had displayed aggressive behaviour. There was one instance where she pushed over a female resident, and another where she hit a male resident.
108. On the checklist, the ICB stated the following: ‘22/08/220 and 22/09/22 has not displayed any behaviours recorded in the memory and understanding care plan within the care home. 22/09/22 recorded in the cognition part of the care plan can be resistive to care support as she believes it has already been completed. Review: memory and understanding remains confused, compliant with care delivery feeling a little low no changes between 22/07/2022 – 22/08/2022. In good spirits no changes to care plan 22/05/2022 – 23/06/2022.’
109. In its response to Mr and Mrs C, the ICB stated there is no evidence within the care and support plan to show she struck or pushed other residents within the timeframe of this review. She did refuse personal care, however, this was normally able to be provided through a planned routine with one carer.
110. The ICB referred to the National Framework’s definition of challenging behaviour that states this covers, but is not limited to: •aggression, violence, or passive non-aggressive behaviour •severe disinhibition •intractable noisiness or restlessness •resistance to necessary care and treatment •severe fluctuations in mental state •inappropriate interference with others.
111. The ICB stated whilst she could refuse personal care, care interventions were normally able to be delivered during the day, and it was not normally necessary for the interventions to be delivered at the time they were being refused.
112. We have reviewed the care review records for the period from May to November 2022. The review dated 22 September 2022 stated she enjoys chatting to other residents, and she has a great sense of humour. A review dated 23 June 2022 stated Mrs U will join in activities of her choosing, she enjoys visits from her loved ones and local walks. The review stated she can believe she has already washed/showered, and she can get verbally defensive when it is suggested she needs to wash because she feels undermined. Staff are to get to Mrs U early enough before she gets dressed and put the shower on. It also stated Mrs U requires verbal prompts to complete effective oral hygiene, and she will say if she has any oral pain or if she wishes to see the dentist.
113. It is clear there were plans in place to make sure Mrs U’s care interventions were successfully delivered. For example, the notes stated ‘if staff approach Mrs U saying her bath/shower is ready, the response is more likely to be positive. If Mrs U is asked does she wants a shower/bath, her response is she doesn’t need one or has already had one.’
114. We have not seen any evidence that shows Mrs U was violent towards other residents in the care home. Mrs U could be resistive to care interventions, but the care home had plans in place to address this.
115. We have not seen any indication to show the ICB has not appropriately considered the evidence when assessing Mrs U’s needs in this domain.
Drug therapies and medication
116. The ICB considered Mrs U needs in this domain were a ‘B’ from 22 May to 22 November 2022. It considered her needs met the fast-track criteria from 23 November to 27 November 2022 as she was receiving end of life care.
117. Mr and Mrs C say they consider Mrs U needs to be a ‘B’ in this category from 22 May to 22 November 2022. They consider her needs were an ‘A’ from 23 November to 27 November 2022.
118. In the ICB’s response to Mr and Mrs C, it stated it had already agreed Mrs U was rapidly deteriorating from 23 November 2022. This means it agrees from this date she met the criteria for fast-track funding, and it is not disputing what Mr and Mrs C have said.
119. As Mr and Mrs C have not disputed the ICB’s findings with regards to this domain, we do not consider we need to add anything further to this.
Altered states of consciousness
120. The ICB and Mr and Mrs C both considered that Mrs U needs were a ‘C’ in this domain. We do not consider we need to add anything further here.
Conclusion
121. Overall, we have not seen any indications of failings with how the ICB has considered Mrs U’s needs in each of the domains. We consider it has explained its rationale with reference to the descriptors and the National Framework.
122. We understand pursuing the CHC appeals process can be difficult and distressing, particularly when it involves a close loved one who has sadly died. We were sorry to learn of the concerns Mr and Mrs C have brought to us, and we pass on our sincere condolences for the very sad death of Mrs U.