North East London Integrated Care Board

6. Mr A complains about the following aspects of the ICB’s personal health budget (PHB) implementation for his mother, Mrs A. Specifically, Mr A complains:

• the ICB did not begin to arrange Mrs A’s PHB after her April 2020 appeal result until May 2021 or do a needs assessment until July 2021 • the ICB reimbursed Redbridge Local Authority (the LA) for social care it had paid for between January 2020 and 1 September 2021 but it did not consider the care Mr A and his brother provided in this time and failed to remedy this • the ICB commissioned 112 hours of care per week from July 2021 but Mrs A only received 52.5 hours of social care per week until August 2022 when the LA stopped the personal budget • the ICB did not appropriately manage Mr A and his brother’s request for them to provide some of his mother’s care; and • the ICB did not commission an appropriate care agency to accommodate his mother’s requirements.

7. Mr A tells us that the LA continued to fund 52.5 hours social care a week when there should have been a PHB in place, so Mrs A did not get the funding or care she needed. Mr A and his brother therefore felt they had no option but to step in and bridge what they saw as a care gap. They cared for their mother in the absence of PHB funding, without knowing the full picture of her needs until 15 July 2021, when the ICB completed a nursing care needs assessment. From this point onwards, Mr A and his brother still felt they had to step in and bridge the gap in care because the ICB did not manage implementing the PHB package appropriately.

8. Mr A says his mother’s care was negatively impacted by the ICB’s poor management in setting up the PHB package. He says there was a deterioration in her quality of life because she did not have the right care. Mr A also says his brother’s and his quality of life was negatively impacted because they had to focus on meeting their mother’s health needs. He said they could not enjoy the time they had with their mother because most of it was consumed by caring duties. Mr A adds that he and his brother gave up their jobs to care for their mother which had a financial impact on them.

9. Mr A wants the ICB to offer him and his brother a financial remedy to recognise the care they provided and the impact this had on them.

10. What follows is a summary of events. We have not included all the details as those involved are already aware of this information. However, we have included this information to put the complaint in context.

11. Mrs A became eligible for continuing health care (CHC) funding in April 2020.

12. NHS CHC is a package of care for adults aged 18 or over which is arranged and funded solely by the NHS.

13. Mrs A’s family opted for a PHB by way of CHC. A PHB is an amount of money to support an individual’s health and wellbeing needs which is planned and agreed between the individual (or their representative) and their ICB. A PHB is not additional money to CHC funding. It is a way of spending money differently so a patient can get the care they need. A PHB allows a patient to manage their healthcare and support such as treatments, equipment, and personal care, in a way that suits them.

Arrangement of PHB

17. Mr A tells us Mrs A became eligible for CHC funding in April 2020. Mr A explains the ICB did not contact him until May 2021 to arrange a PHB package.

18. The ICB explained that prior to Mrs A becoming eligible for CHC funding, she was receiving direct payment for her care needs from the local authority (LA). The ICB started to arrange Mrs A’s PHB once she became eligible in April 2020 and this was funded via the LA payment mechanism. The ICB explained it did not set up a PHB in April 2020 due to the pandemic which meant that CHC nurses could not visit patients at home. Subsequently, direct payments continued and where necessary, the ICB put in additional support.

19. The National Framework sets out when an individual is eligible for NHS Continuing Healthcare, the ICB is responsible for care planning, commissioning services, and for case management. This should be done in a person-centred approach to maximise personalisation and individual control and reflect the individual’s preferences.

20. We considered the evidence made available and found the following:

Date Event 18 May 2020 The ICB attempts to email eligibility decision to Mr A 27 May 2020 After a failed attempt to email the eligibility decision, the ICB send this via its postal service 28 May 2020 The ICB informs internal colleagues that Mrs A has been found eligible for CHC funding 27 May 2021 The commissioning officer advised the business administrator at the ICB that their team had not been told Mrs A was eligible for CHC funding after the Local Resolution Meeting. The CHC caseworker was asked to chase up the care package details with Mr A. The caseworker contacted Mr A to arrange a care plan review and confirm the care package and care agency with Mr A.

21. The National Framework outlines the responsibilities of an ICB when an individual is found eligible for CHC funding. We have seen no evidence to suggest the ICB contacted Mr A to arrange for a PHB or to discuss the family’s preferences as it should have done after Mrs A was found eligible for CHC funding in April 2020. The records show a long gap in the email trail and there is no documentation to show what it was doing during this time. The evidence we have seen does not support the ICB’s account that it began arranging the PHB in May 2020 after the appeal or that it did any needs assessments until 15 July 2021 or completed a support plan until 2 August 2021.

22. We were sorry to hear how Mr A’s experience caused him and his brother great distress. We were also sorry to learn how the failing negatively impacted their mother’s care. We will be making a recommendation for the ICB to put things right for Mr A and his family. We have discussed the impact of the ICB’s failure to contact to contact Mr A and implement a PHB package in a timely manner on his family including the recommendation we have made in detail below.

Remedy

23. Mr A tells us that for the period April 2020 and 1 September 2021, the ICB reimbursed the LA for the social care it had incorrectly funded but failed to reimburse him and his brother for the care they provided to Mrs A in the absence of a care package.

24. The ICB explained in its response that between April 2020 and 2 August 2021, it made sure it met Mrs A’s care needs.

25. Based on the evidence made available to us, we can see the LA was still funding Mrs A’s care without knowing she was eligible for CHC funding for the aforementioned period.

26. Paragraph 37 of the National Framework outlines the LA is not permitted to meet ongoing care and support needs once an individual is found eligible for CHC funding. It is our view that Mrs A was fully the responsibility of the NHS.

27. The National Framework 2018 clearly sets out the responsibilities of ICB’s in relation to care planning once an individual is found eligible for CHC. It is clear it is the role of ICB’s to decide what care an individual requires to meet their care needs.

28. The National Framework 2018’s Practice Guidance provides more information for ICBs about care planning. It also clearly sets out the link between care planning and commissioning:

‘169. In the context of NHS Continuing Healthcare case management necessarily entails management of the whole package, not just the healthcare aspects. The key elements of case management, which in any given case might be undertaken by more than one professional, include:

a) ensuring that a suitable personalised care plan has been drawn up for, and with, the individual;

b) ensuring that the agreed care and support package continues to meet the individual’s assessed health and associated care and support needs and agreed outcomes;

c) where the care plan includes access to non-NHS services, ensuring that the arrangements for these are in place and are working effectively;

d) monitoring the quality of the individual’s care and support arrangements and responding to any difficulties/concerns about these in a timely manner;

e) acting as a link person to coordinate services for the individual;

f) ensuring that any changes in the person’s needs are addressed;

g) initiating/undertaking reviews as described in paragraphs 181-191’.

29. The aforementioned guidance is clear that ICB’s are responsible for determining what an individual’s care package should be, the care package should meet all the individual’s assessed needs and the care package should be routinely reviewed. We would expect ICB’s to follow the National Framework in all but exceptional circumstances. We would also only expect ICBs to deviate from the National Framework where there is a clear and specific reason to do so and this deviation from the guidance been clearly documented.

30. Having considered all the documentation made available to us, we have seen no evidence a care plan was produced from the date of Mrs A’s eligibility for CHC funding up until 2 August 2021, when the ICB drafted a care plan. Nor is there any evidence to suggest it took appropriate steps to plan her care package. The lack of a care plan has already been confirmed in paragraphs 17 to 22 of this report.

31. It is our view the ICB failed to manage and plan Mrs A ’s care in line with the National Framework. This is because at no time, from the date of Mrs A’s eligibility for CHC funding to 2 August 2021, did the ICB produce a care plan setting out what Mrs A’s care needs were and what care she needed to meet those needs. This has been confirmed by our clinical adviser.

32. We can see Mrs A required support and assistance with most of the activities of daily living:

• food preparation • encouragement to eat and drink • re-orientation in time, place and person • reminders and reiteration of information as she was forgetful due to memory loss • supervision with all her continence and hygiene care needs • management of challenging behaviours as she was resistant to personal care interventions and could be verbally and physically aggressive • she would shout at her sons and sometimes pushed them away, sometimes taking off her clothes and faecal smearing onto walls and items • management of the bladder and bowel – continence and skin care • management of psychological needs and hallucinations, (seeing people come out of the mirror) • reassurance and distraction • she required assistance of two carers with her mobility needs including all transfers from one place to another. She had no risk awareness due to a significant cognitive impairment • she had no capacity to make any decisions relating to all activities of daily living, health and finance • she was totally reliable on those around her to keep her safe and protected against physical and emotional harm and financial extortion; and • she required supervision and care around the clock and all of her care needs were anticipated as she could not express them.

33. Another important factor is the COVID-19 pandemic. The Guidance for Local Authorities and Clinical Commissioning Groups in the delivery of direct payments and personal health budgets, published 21 April 2020 sets out:

34. ‘During this period it is essential that local authority and CCG commissioners continue to take a flexible approach to the arrangements people receiving all forms of direct payments, their families and carers will need to make in order to continue to meet their care and support needs during the COVID-19 pandemic. The expectation of flexibility should apply to all services provided by local authorities or CCGs (or both) that help maintain people’s wellbeing. In support of this during the COVID-19 pandemic, local authorities and CCGs should review local operating procedures and adapt or suspend those which prohibit or limit flexibilities that enable family members, including those who live under the same roof, to be employed as personal assistants and be paid through a direct payment or personal health budget for the period covered by the Coronavirus Act 2020’.

35. Our adviser confirmed there are no records available which define Mrs A’s care package requirements. Therefore, we consider in the absence of a care plan or funding, Mr A and his brother understandably provided care for their mother themselves.

36. We therefore uphold this aspect of Mr A’s complaint and we will be making a recommendation for the ICB to put things right for him and his family. We have discussed the impact of the ICB’s failure to implement a PHB package in a timely manner on his family including the recommendation we are making in detail below.

Commissioned care hours

37. Mr A tells us the ICB did not provide care for the commissioned hours after it agreed his mother would receive 112 hours of care per week on 2 August 2021. His mother only received 52.5 hours of care.

38. The ICB explains there was an agreement between itself and the LA that the LA would continue the service it was already providing but the ICB would lead the management of the case, as if there were a PHB in place. As such the ICB paid the LA for the direct payment that funded Mrs A’s personal assistant (PA) until the ICB implemented the PHB or CHC package.

39. On the 2 August 2021 ICB determined Mrs A needed 112 hours care per week. This included 8 hours per day for the PA (carer).

40. Paragraph 167 of the National Framework says:

‘Once an individual has been found eligible for NHS Continuing Healthcare, the CCG is responsible for their case management, including monitoring the care they receive and arranging regular reviews.’

41. We can see the ICB made sure the 112 hours of care were funded, however, it did not review the care the PA was providing and we have seen no evidence so far to suggest the ICB did anything in this time to ensure the PA was delivering the care as stated in the care package for Mrs A. Further to this there appears to be no documentation to determine how much care the PA had provided during the day and whether this was enough to meet the requirements of the care package and appropriately meet Mrs A’s needs. We have also seen no evidence so far of any communication between the ICB and the PA about the change in care package after it took over the funding from the LA.

42. It is our view that the ICB should have taken steps in line with the National Framework to review the care Mrs A was receiving. As a result of this Mr A and his brother had to step in and provide the remainer of the care.

43. Therefore, we uphold this part of Mr A’s complaint, and we will be making a recommendation for the ICB to put things right for him and his family. We have discussed the impact of the ICB’s failure to review the care provided to Mrs A to ensure that the care she was receiving appropriately met her needs on Mr A and his family including the recommendation we are making in detail below.

Family’s request

44. Mr A explains the ICB did not appropriately manage his request for him and his brother to be employed as part of the PHB package.

45. In its response the ICB explains it agreed for Mr A and his brother to deliver some of their mother’s care as part of the PHB package. Mr A insisted the ICB pay him directly so that he could manage the payroll and pay his brother and himself. The ICB did not agree to this because there would have been a conflict of interests if Mr A provided care to his mother and then authorise payment to himself and his brother for care invoices. The ICB advised the care agency Independent Living Agency (ILA) would set up the PHB and add Mr A and his brother to its payroll system.

46. We can see on 8 September 2021, the ICB informed Mr A he and his brother could not be employed under the PHB if they lived at the same address as Mrs A. The ICB reiterated its view within internal communications on 7 October and 10 November 2021.

47. On 3 November, the head of individualised care at the ICB told Mr A that the ICB could pay for carers the family had chosen but the ILA needed the details of the carer to set up payroll. Mr A confirmed he had sent all the documentation to the ILA.

48. On 4 November, the ILA confirmed it had received the details for one PAs but it was expecting details for two. The ICB asked Mr A to confirm whether there was another PA in place or whether he wanted a care agency to provide the care. Mr A confirmed he would be the other PA.

49. On 10 November the head of individualised care told Mr A he could not work on the PHB package as he lived in the same household as his mother.

50. Section 7.3 of Guidance on Direct Payments for Healthcare: Understanding the regulations (2014) says:

‘153 A direct payment can only be used to pay an individual living in the same household, a close family member (see Box 3 for a definition of a ‘close family member’) or a friend if the ICB is satisfied that to secure a service from that person is necessary in order to satisfactorily meet the person receiving care’s need for that service; or to promote the welfare of a child for whom direct payments are being made. ICB’s will need to make these judgements on a case-by-case basis.’

51. It is our view the ICB failed to follow the Guidance on Direct Payments. The guidance does not state family members at the same address cannot work as a PA as part of the PHB care package. The guidance clearly outlines that the ICB should consider whether family members are integral to the care.

52. In this case, the ICB gave a blanket rule that family members living in the same household could not provide care as part of a PHB, without any real further explanation to Mr A. We acknowledge the ICB did tell Mr A he and his brother were not integral to the care on 10 November 2021. However, there is no evidence to suggest the ICB properly considered and recorded whether or not Mr A and his brother were integral to their mother’s care. We consider it did not adequately explain its decision to Mr A at any point throughout the process.

53. We consider, it was misleading to tell Mr A that he and his brother could work as PAs within the care package, and arrange training for them before advising him that they could not from September 2021, as they were not an integral part of their mother’s care. There is a clear process for what the ICB should do if it considers a direct payment to be inappropriate.

54. We will be making a recommendation for the ICB to put things right for Mr A and his family. We have discussed the impact of the ICB’s actions including the recommendation we are making in detail below.

Care agency

55. Mr A tells us the ICB did not commission an appropriate care agency to meet his mothers’ needs. Mr A listed specific requirements about the language and religious background the carer would need to have to meet Mrs A’s needs.

56. On 2 August 2021, the ICB determined Mrs A required 112 hours of care per week. Subsequently the ICB tried to find care agencies that met the requirements to give Mrs A care.

57. We can see from the email correspondence, the ICB approached at least three care agencies between 1 September and 1 December 2021. It appears Mr A declined the first two care agencies but accepted Promise Care Agency to give eight hours waking night care per day that started on 1 December 2021.

58. On 15 December 2021, Promise Care services asked the ICB to fund a second waking night carer and the ICB decided to arrange a review. On 13 January 2022, the ICB did the review and decided it would only fund one waking night carer. In its review summary, dated 14 January 2022, it said the family members could help the carer.

59. On 2 February 2022, Mr A emailed the nurse assessor at the ICB. He outlined the care his mother needed in the night. He said his mother needed repositioning and changing several times and how this took a long time because of her behaviour needs. He said two people always needed because his mother was non-compliant.

60. On 14 February 2022, Mr A told the ICB his mother needed two people to help with toileting and changing in the night. He said her agitation had increased causing her to make jerky movements and hit herself. Mr A said he could not sustain the night care for much longer. The ICB reiterated its decision from 14 January 2022.

61. On 24 February 2022, Promise Care Agency spoke to the ICB about the night care difficulties and sent Mrs A’s log book to it on 28 February. On 3 March 2022, the ICB agreed to a second carer at night and sent the updated care plan to Promise Care Agency.

62. In June 2022 the ICB discussed Mrs A’s care plan and the need to put in appropriate care during the day. On 8 June, the ICB reviewed Mrs A’s eligibility. On 24 June, it emailed Sugarman Health and Wellbeing to ask whether it could cover eight hours a day (56 hours a week). On 8 July 2022, it added four drop-in calls (short additional visits) to the care plan, on top of the eight hours daily care.

63. On 15 July 2022, Sugarman Health and Wellbeing emailed the ICB with its view that Mrs A needed two carers during the day for 12 hours and it would take up to six months to find the right people for this care plan. It said it would not be able to meet all of Mrs A’s social needs but could meet her care needs. The ICB decided to explore other options.

64. One of the options was to set up the current live-in carer on the package so the ICB could pay her. When the ICB followed this up, it found the Independent Living Association (ILA – the organisation that managed the payroll for carers working on a PHB) had not received the relevant documents to process this request. Mr A said he had sent the documents by post in 2021. On 2 and 11 August 2022, the ICB asked Mr A to send the documents to the ILA again.

65. On 28 July 2022, Promise Care Agency (the current night care) confirmed it had Gujarati speaking carers ready to start the full care package. On 12 August 2022, Mr A had not confirmed he was happy for Promise Care agency to start the package. The ICB told Mr A that the Direct Payments he had been receiving to pay the live-in carer would stop. The ICB arranged for Promise Care to take over the full care package starting 13 August 2022. It reiterated its offer to set up a PHB, asking Mr A to send the correct documentation in. It attached the relevant forms to its email.

66. Mr A said he would not be able to fill in the forms due to struggling with his technology and a language barrier. He asked for an interpreter to help him and he stated he wanted someone to attend his home and explain the PHB process to him. Later in the email correspondence, a staff member at the ICB confirmed Mr A spoke fluent English after they visited him at his house.

67. On 2 September 2022, Promise Care Agency told the ICB it had stopped providing the day care because Mr A wanted to wait until the next CHC review had happened.

68. On 6 September, the ICB attend Mrs A’s home to do a CHC review. It updated her care package to 24-hour care per day, with one carer in the day and two carers at night. It also maintained the four one-hour drop-in calls. Mr A and Promise Care Agency both said at the meeting Mrs A needed two carers in the day but the ICB did not approve this.

69. On 20 September 2022, Mr A wrote to the ICB and explained his mother needed two carers during the day. He explained the role of the PA who had been caring for Mrs A for 16 years. Mr A also confirmed he was happy to allow Promise Care Agency into the property.

70. On 28 and 29 September 2022 Promise Care Agency told the ICB Mrs A would need the drop-in calls to increase to two-hour visits because she needed two carers to feed her. It explained in detail why this was necessary. The ICB approved this.

71. On 2 October 2022, Promise Care Agency told the ICB Mr A was not happy with the carers as they were not experienced enough and that no one told him about the changes to the care package. The Agency asked the ICB to find another provider.

72. From 2 August to 1 December 2021, we consider the ICB took steps to find a care agency that Mr A thought would be suitable for his mother. We think these steps were proportionate. When Mr A accepted a care agency for the night care, the ICB ensured its implementation as soon as possible. The actions of the ICB here were in line with the paragraph 72 of the National Framework which states:

‘72 - When commissioning the care package, the individual’s wishes and expectations of how and where the care is delivered should be documented and taken into account, along with the risks of different types of provision and fairness of access to resources.’

73. From 15 December 2021 to 3 March 2022, we can see both the care agency and Mr A explained why Mrs A needed double handed care at night. The ICB reviewed Mrs A’s needs on 13 January 2022, refused the request, and said the family could help where needed. It appears there is a failing here. The ICB was not funding a care package where family members were carers at night. The care package was for one carer at night. If Mrs A needed another carer, the ICB should have updated the care package to include this, not rely on a family member to provide the care instead.

74. At this point, the ICB should have taken steps to ensure the agreed care and support package met Mrs A’s needs in line with paragraph 189 of the National Framework which states:

‘189 - In the context of NHS Continuing Healthcare case management necessarily entails management of the whole package, not just the healthcare aspects. The key elements of case management, which in any given case might be undertaken by more than one professional, include:

• ensuring that a suitable personalised care plan has been drawn up for, and with, the individual • ensuring that the agreed care and support package continues to meet the individual’s assessed health and associated care and support needs and agreed outcomes • where the care plan includes access to non-NHS services, ensuring that the arrangements for these are in place and are working effectively • monitoring the quality of the individual’s care and support arrangements and responding to any difficulties/concerns about these in a timely manner • acting as a link person to coordinate services for the individual • ensuring that any changes in the person’s needs are addressed • initiating/undertaking reviews as described in paragraphs 201-211.’

75. We can see the ICB did a review on 13 January 2022 and refused the request, suggesting the family met the outstanding needs. This shows there were needs the ICB should have been meeting. Mr A and the care agency told the ICB why Mrs A needed another carer at night four times before the ICB approved the request on 3 March 2022.

76. From 8 June 2022 to 16 August 2022, the ICB took steps to ensure Mrs A would receive the care agreed. We think these steps were proportionate as it approached care agencies and explored realistic options to make sure Mrs A’s needs were met.

77. The ICB asked Sugarman Health and Wellbeing to provide the eight hours day care and drop-in care after the review. Sugarman Health and Wellbeing’s view, on 15 July 2022, was that Mrs A needed two carers in the day for 12 hours. The agency confirmed it did not have the resource to fulfil the care package requirements and the ICB said it would explore other options. By 28 July 2022, Promise Care Agency confirmed it could provide the full care package and agreed to start it by 16 August 2022.

78. We can see the ICB reviewed Mrs A’s care package on 6 September 2022 and changed it to 24 hour care with one carer in the morning and two carers at night. By the end of September, the ICB agreed to increase the drop in visits to two hour visits. Promise Care Agency agreed to start the package on 1 October but it appears there were problems with this as Mr A said he was not happy with the arrangement.

79. Based on the information we have seen, we think the ICB did what it should have to review and implement the right care at this point. The ICB and Sugarman care agency clearly experienced challenges when Mr A was not happy with the arrangement. We know these challenges stemmed from the communication breakdown between the ICB and Mr A around implementing a PHB, which we have addressed in a previous section of this report. However, we can see the ICB was trying to fulfil its requirements under the National Framework to provide the care to Mrs A at this time. As such we do not uphold this aspect of Mr A’s complaint.

1. We have carefully considered the information provided by Mr A, and that provided by the North East London Integrated Care Board (the ICB) as well as considering the standards and guidance relevant to this complaint.

2. After doing so, we found the ICB failed to implement Mrs A’s care PHB package in a timely manner. We also found that it should have reimbursed the family for the care it provided between January 2020 and 1 September 2021. There is evidence to suggest the ICB failed to provide commissioned care and did not manage the family’s requests in an appropriate manner.

3. We have not identified any failings in relation to the ICB’s commissioning of a care agency. It is important to acknowledge that where we have not identified any indications that something went wrong, it does not detract from the family’s experience, nor the impact this has had on them.

4. We partly uphold Mr A’s complaint. We have considered the impact of the failings on Mr A and his family.

5. We will explain the reasons for our decision in this report. Complaints give us valuable insight into the organisations we investigate, and we recognise this has been an emotionally challenging process for Mr A and his family. We would like to thank Mr A for sharing the families experience with us.

80. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

81. We have identified that the National Framework was not followed in the following instances:

• failure to implement PHB package in a timely manner • failure to repay care provided by the family between January 2020 and 1 September 2021 • failure to provide commissioned care; and • failure to appropriately manage family’s request.

82. We consider the actions of the ICB will have led to a gap in Mrs A’s care and as such Mr A and his brother understandably will have had to step in and provide care for their mother themselves. We also consider the gap in care provisions will have negatively impacted Mrs A care requirements and the lives of Mr A and his brother.

83. From the evidence we have seen, we have outlined the steps we would ask the ICB to take in order to remedy the failings and injustices highlighted in this report, below.

84. Our principles say that public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service. In line with this, we are likely to recommend that within three months of our final report, the ICB develops an action plan to explain how it will make changes to avoid repeating the failings in the care provided. This should identify the reason for the failings, where possible. It should explain the learning the ICB has taken from these issues, what it will do differently in the future, who is responsible and timescales for each action and how these will be monitored.

85. Our principles state that public organisations should put things right and, if possible, return the person affected to the position they would have been in if the poor service had not occurred. If that is not possible, they should compensate them appropriately. It cannot now be established precisely how much Mrs A’s care needs would have cost at the time under CHC funding. We know the ICB did not complete any care plans for arrange a PHB in May 2020 after the appeal, or that it did any needs assessments until 15 July 2021 or completed a support plan until 2 August 2021.

86. We cannot now compare the care she was assessed to have required under CHC funding with the actual care provided by the brothers. To help us understand Mrs A’s care needs at the time, we asked our adviser to consider Mrs A’s records. Our adviser confirmed there was no definitive care plan in place at the time. This is what we would normally do to ensure the family are only reimbursed for the care the individual was actually entitled to. As such we have recommended the ICB work with NHS England and Mr A to work out how much the family is owed for the care they provided.

87. The ICB did not comply with the National Framework and it did not complete a care plan for Mrs A after she was found to be eligible for CHC funding. Had the ICB complied with the National Framework and carried out these actions, the family would not have had to step in and provide additional care themselves to ensure Mrs A’s core healthcare needs were met. We recommend the ICB works with Mr A, with assistance from NHS England, to calculate an appropriate amount to recognise the care provided by the family between the date she became eligible to 3 March 2022. The ICB should do this within six months of the date of this report and write to us with the outcome.

88. In order to determine a level of financial remedy we have reviewed our financial scale (our scale) and similar cases. Our scale allows us to ensure the recommendations we make are consistent and transparent for everyone who uses our service. The figures included in the scale represent the Ombudsman’s judgement about the sort of sums that are both appropriate and proportionate for us to recommend. The scale contains six different levels of injustice that a complaint could fall into, which increase in severity. Each level is then linked to a range of the financial amounts we would usually recommend in those circumstances.

89. We recommend the ICB should pay Mr A and his brother £450 each within six months of the date of this report to recognise the distress and inconvenience caused to the family as a result of the ICB’s failings.

90. We would do not wish to underestimate how difficult this has been for Mr A and his family. We would like to thank Mr A once again for bringing his complaint to us.