4. Mr N complains on behalf of his late mother, Mrs N. He complains NHS England’s independent review panel (IRP) upheld NHS Lancashire & South Cumbria Integrated Care Board (the ICB)’s decision that Mrs N was not eligible for NHS continuing health care (CHC) funding for the period 9 July 2016 to 1 November 2017.
5. Mr N tells us his mother was financially impacted and she had to sell her house to pay for her care.
6. Mr N would like NHS England to reconsider its decision.
7. CHC is a package of care arranged and funded by an ICB for people who have a primary health need. A ‘current assessment’ is where the ICB decides if the person has a primary health need at that time. But a person or their representative can ask the ICB to consider if they may have been eligible for CHC for a past period, as long as they did not have an assessment during that time. This is called a previously unassessed period of care (PUPoC).
8. NHSE manages the last stage in the appeals process for CHC eligibility decisions, after an ICB has made and reviewed those decisions. NHSE convenes an independent review panel (IRP) to consider the appeal.
9. Mr N applied for a PUPoC assessment of his mother’s care for the period 9 July 2016 to 21 January 2018, which is when she died.
10. The ICB initially found Mrs N eligible for CHC from 15 January 2018. At local appeal, the ICB decided she was eligible from 2 November 2017.
11. Mr N and his family appealed the decision that she was not eligible before this to NHS England and asked for an IRP. This was held on 26 July 2023. Unfortunately Mr N and family were unable to attend but they had submitted written evidence which the IRP took into consideration.
14. It is our role to decide whether NHS England’s IRP acted in line with the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (2022) when it considered whether Mrs N was eligible for CHC. The National Framework sets out the principles and processes ICBs and NHS England should follow when considering if someone is eligible for CHC.
15. We cannot consider the discretionary decisions the IRP made when it decided on eligibility. This includes the decisions it makes based on clinical judgements and clinician’s opinions. We can only consider if the IRP has followed the National Framework. This means we only uphold a complaint about a CHC eligibility decision if we think the IRP did not follow the National Framework when it made its decision.
16. The IRP reviews if the ICB should have found the person to have a primary health need and therefore be eligible for CHC. It also reviews the ICB’s procedures when it made its eligibility decision to make sure it was acting in line with the National Framework. If the IRP does find the CCG made a mistake, it can:
• recommend the CCG reconsiders if the patient had a primary health need, and • recommend the CCG addresses any procedural faults the IRP identified.
17. When we look at a complaint about an IRP, we consider if it took into account all the relevant information when it made its eligibility decision. Mr N has told us he disagrees with the IRP’s consideration of his mother’s needs in five domains. He feels the nature, intensity, complexity, and unpredictability of his mother’s needs in those domains demonstrated she was eligible for CHC. We are going to look at the IRP’s consideration of Mrs N’s needs in these six domains, and how it considered the four key characteristics of those needs.
Did the IRP clearly explain how it reached its decision?
18. The National Framework says the CCG and NHS England should use the decision support tool (DST) to determine a person’s CHC eligibility. The DST breaks a person’s care needs down into 12 areas. These are what we refer to as the domains. Each domain is broken down into levels of need and can range from ‘no needs’ to ‘priority’ (for some domains). It also describes each level of need to guide clinicians. We call these the descriptors. Mr N has specifically complained how the IRP considered five of the domains, and we will look at each one of these here.
Breathing
19. Mr N tells us his mother had difficulty breathing. She also suffered from pneumonia in November 2016 and heart issues. He believes his mother had a high level of need in this domain.
20. The IRP considered Mrs N had a moderate level of need in this domain.
21. The DST define high needs in this domain as:
‘Is able to breath independently through a tracheotomy that they can manage themselves or which the support of carers or care workers
OR
Breathlessness due to a condition which is not responding to treatment and limits all daily living activities.’
22. The DST defines moderate needs in this domain as:
‘Shortness of breath or a condition which may require the use of inhalers or a nebuliser and limit some daily activities.
OR
Episodes of breathlessness that do not consistently respond to management and limit some daily living 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.’
23. We can see the IRP had a detailed discussion of Mrs N’s breathing needs.
24. The IRP considered Mr N’s written submission that his mother had medication for breathing, and she had to be hospitalised for pneumonia. She also suffered from bronchitis. Mr N also informed the IRP that his mother had oxygen to help her breathing. Mrs N could also become breathless on transfers and when she was agitated. She also had angina and had medication for this.
25. The IRP could find no evidence in the records that Mr N was regularly short of breath to an extent that restricted her daily activities. It acknowledged that Mrs N had some health conditions which may have had an effect on her breathing.
26. The IRP considered there were no records to show oxygen was in use during the review period, but acknowledged the family’s submission that it was kept in Mrs N’s bedroom. It also could find no evidence that medication such as warfarin and an angina spray was prescribed at the time under review.
27. We can see the IRP acknowledged the family’s input and explained why it considered Mrs N’s needs met the descriptor for moderate needs. It explained that the moderate weighting reflected the family’s submission that she sometimes used oxygen therapy that was stored in her room. It explained that it did not consider the descriptor for high needs applied to Mrs N at the time of the review. In order for the IRP to give a high weighting of needs in this domain it would have to see that Mrs N had breathlessness due to a condition not responding to treatment, that limited all her daily activities. This was not the case and therefore Mrs N’s needs aligned with the moderate descriptor.
28. We can see no indication of a failing in the way the IRP considered this domain. We think it considered it in line with the National Framework and DST descriptors.
Nutrition
29. Mr N tells us his mother was on a diet because of her weight but she was swapping her food with other residents. He believes his mother had moderate needs in this domain.
30. The IRP considers Mrs N had low needs in this domain.
31. The DST defines low needs in this domain as:
‘Needs supervision, prompting with meals, or may need feeding and/or a special diet (for example to manage food intolerances or allergies)
OR
‘Able to take food and drink by mouth but requires additional/supplementary feeding’
32. The DST defines moderate needs in this domain 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 a non-problematic PEG.’
33. The family submission said that Mrs N could eat and drink unaided at first. Then she could then spill drinks and burn herself so was given a cup with a lid. She could also steal food from other residents as she did not like her diet food. The family also said that in 2017 Mrs N was not eating well.
34. The IRP considered the evidence and noted Mrs N needed some adaptations, such as a cup with a lid, but that she fed herself independently. There was also no evidence of rapid weight loss and she was not at risk of malnutrition.
35. We can see the IRP considered all the information and explained why it considered Mrs N needs met the descriptor for low needs. To weight the needs in this domain as moderate the IRP would need to see that Mrs N needed help with feeding, or was unable to take any food by mouth.
36. The IRP could see Mrs N needed supervision or prompting with meals and had a special diet, as the family reported. This is consistent with the descriptor of low needs.
37. We can see no indication of a failing in the way the IRP considered this domain. We think it considered it in line with the National Framework and DST descriptors.
Mobility
38. Mr N tells us his mother was in a wheelchair but would try to mobilise on her own which put her at risk of falls. He also mentions that Mrs N would refuse her bed rails. He feels his mother had high needs in this domain.
39. The IRP considered Mrs N to have moderate needs in this domain.
40. The DST defines high needs in this domain as:
‘Completely unable to weight bear and is unable to assist or cooperate with transfers and/or repositioning
OR
Due to risk of physical harm or loss of muscle tone or pain on movement needs careful positioning and is unable to cooperate
OR
At a high risk of falls (as evidenced in a falls history and risk assessment)
OR
Involuntary spasms or contractures placing the individual or others at risk’
41. The DST defines moderate needs in this domain as:
‘Not able to consistently weight bear
OR
‘Completely unable to weight bear but is able to assist or cooperate with transfers and/or repositioning
OR
In one position (bed or chair) for the majority of time but is able to cooperate and assist carers or care workers
OR
At moderate risk of falls (as evidenced in a falls history or risk assessment)
42. We can see the IRP had a detailed discussion about Mrs N’s mobility needs.
43. The family said Mrs N was not mobile, was wheelchair dependent and required two carers and a hoist to move. They also submitted Mrs N had falls in 2016 and was often in pain.
44. The IRP considered Mrs N was mobilising in the review period and she was able to do a standing transfer. It said there was no evidence which would indicate Mrs N was unable to weight bear at all. It also considered that the falls risk assessment would fluctuate between medium and high.
45. The IRP noted Mrs N had oedema (build up of fluid) in her legs which would have affected her mobility. The IRP noted that on 29 October 2016 care staff had recorded a deterioration in mobility and then required assistance of two carers but was not always cooperative.
46. We have reviewed the falls assessments which are available in the records. We can see that Mrs N was assessed at a medium risk with a score of 15 (a score of 11-15 is considered medium risk) in May 2016. The records state this assessment remained appropriate until May 2017 when her score increased to 19 which indicates a high risk. The score reduced back to 15 in July 2017. The increase may have been due to Mrs N standing independently. We can see a record that states Mrs N sometimes stood independently and balanced herself on tables and chairs which increased her risk of falls. We can see this care plan was updated in July 2017 to say that Mrs N remained seated for long periods of time so the risk decreased at this time.
47. We can see the IRP considered all the information and explained why it considered Mrs N needs met the descriptor for moderate needs. The IRP concluded that Mrs N was sometimes able to weight bear, that she was not at risk of physical harm, and there was no history of frequent falls, and there was no evidence of involuntary spasms or contractures as described in high needs. The IRP considered Mrs N was not consistently weight bearing.
48. There was a period of a few weeks, between May and July 2017, when Mrs N’s mobility needs were in line with the high descriptor. This is the period when her falls risk was high rather than moderate. It would have been better for the IRP to have acknowledged this. But we recognise that it was looking at her needs over a period of 18 months. And it is very unlikely that a high need in the mobility domain alone would have changed the overall eligibility decision for that short period. When we weigh everything up, we do not think the IRP’s decision here fell so short of the standards that it got things wrong. It appears that, overall, its view that Mrs N’s needs were in line with the moderate descriptor is evidence-based.
49. We can see no indications of a failing in how the IRP considered this domain. Overall, we think it considered it in line with the National Framework and DST descriptors.
Psychological and emotional needs
50. Mr N that his mother suffered from regular mood swings. He considered his mother had high needs in this domain.
51. The IRP considered Mrs N had moderate needs in this domain.
52. The DST defines high needs in this domain as:
‘Mood disturbance, hallucinations, or anxiety symptoms, or periods of distress, that have a severe impact on the individual’s health and/or well-being
OR
Due to their psychological or emotional state the individual has withdrawn from attempts to engage them in care planning, support and/or daily activities’
53. The DST defines moderate needs in this domain as:
‘Mood disturbance, hallucinations, or anxiety symptoms, or periods of distress, which do not readily respond to prompts, distraction and/or reassurance and have an increasing impact on the individual’s health and/or well-being
OR
Due to their psychological or emotional state the individual has withdrawn from most attempts to engage them in care planning, support and/or daily activities’
54. Both descriptors capture that the person has mood disturbances, hallucinations, distress and has withdrawn from activities. The difference between moderate needs and high is the degree to which these affect the individual’s wellbeing, and how much they have withdrawn from support and activities. In order to weight the needs as high, the panel would have to see a severe impact on health and wellbeing, and that Mrs N had withdrawn from all attempts to engage her.
55. We can see the IRP had a detailed discussion about Mrs N’s psychological needs.
56. The family said Mrs N needed reassurance every day and did not have insight into her condition. They also said her mood swings could make her a danger to herself and other residents.
57. The IRP considered Mrs N had a long standing history of depression. It also noted that she had a lot of health conditions which could make her feel frustrated. She was taking a large amount of medications and could be resistive at times, and withdrawn. The IRP considered Mrs N was engaging with others the majority of the time, and care interventions were usually successfully delivered.
58. The IRP notes Mrs N was prescribed quetiapine (an antipsychotic medication) which reduced the severity of her challenging behaviour. Her GP increased the dose of this in June 2017. The IRP noted when Mrs N had an instance of low mood she would not respond to care and staff would withdraw.
59. The IRP also noted a referral from the GP to care home educational support team. They visited Mrs N three times in 2016. The outcome was that she was diagnosed with vascular damage to the front lobe of her brain.
60. The IRP considered all the information and explained why it felt Mrs N’s needs met the moderate descriptor. The IRP considered even with her medication Mrs N required monitoring and support from staff. The panel considered that there were periods of distress and anxiety that impacted Mrs N’s wellbeing, but did not consider that this impact was severe. The IRP also considered the level to which Mrs N would be withdrawn. The IRP could see that Mrs N had not withdrawn from all care planning, support or daily activities.
61. The records show some instances of Mrs N engaging with staff. She could be verbally abusive but would respond to reassurance, and staff would be able to provide care when she had settled.
62. We have not seen an indication of a failing in how the IRP considered this domain. We think it considered it in line with the National Framework and DST descriptors.
Behaviour
63. Mr N tells us that the care staff could not manage his mother’s behaviour without her quetiapine. The family acknowledged that over time Mrs N settled, but it was as a result of the medication and not an improvement in her condition. He believes his mother had a high level of needs in this domain.
64. The IRP considered Mrs N had a moderate level of needs in this domain.
65. The DST defines high needs in this domain as:
‘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 at minimising but not always eliminating risks. Compliance is variable but usually responsive to planned interventions.’
66. The DST defines moderate needs in this domain as:
‘Challenging behaviour that follows a predictable pattern. The risk assessment indicates a pattern of behaviour that can be managed by skilled carers or care workers who are able to maintain a level of behaviour that does not pose a risk to self, others or property. The individual is nearly always compliant with care’
67. We can see the IRP had a detailed discussion about Mrs N’s behaviour needs.
68. The family submitted that Mrs N could be angry, violent and weepy and hit out at staff and other residents. She also thought another resident was her husband. The family said that Mrs N had always suffered mood swings.
69. The IRP considered Mrs N had a history of depression and anxiety and was frustrated by her health conditions. It noted she had been verbally aggressive throughout the review period, with some instances of hitting out. Staff would monitor and plan how to provide care. The IRP did not consider this led to a need for care to be greater than normal. The IRP considered the challenging behaviours were linked with care interventions, a change in environment or an invasion of personal space. As such the risk associated with the challenging behaviours was predictable. Staff would adopt a leave and return strategy, after Mrs N had calmed down staff would return and be able to provide care. The IRP said there was no evidence that these behaviours meant that care could not be given.
70. The IRP explained that in order to weight this need as ‘high’ it would have to see that planned interventions were not always effective at eliminating risk. The IRP considered that this was not the case as there were no reports of safeguarding referrals, or damage to people or property.
71. The IRP considered all the evidence and explained why it felt Mrs N’s needs met the descriptor for moderate needs. The IRP concluded staff did not have to deviate from care plans, and the leave and return strategy was effective as Mrs N would eventually be compliant with care. It considered Mrs N’s needs were predictable and care staff were able to maintain a level of behaviour that did not pose a risk to herself, property of others. This is consistent with the descriptor for moderate needs.
72. We have not seen an indication of a failing in how the IRP considered this domain. We think it considered it in line with the National Framework and DST descriptors.
Did the IRP apply the eligibility tests properly and reach an evidence-based conclusion about them?
73. The IRP also applies an eligibility test to help it decide about a person’s CHC eligibility. The National Framework separates this test into four key characteristics: nature, intensity, complexity, and unpredictability. This test is used to establish if the quantity or type of a person’s care needs are more than what the local authority can provide. This indicates they have a primary health need, which in turn indicates they are eligible for CHC.
74. The National Framework sets out questions for the IRP to consider to help establish a person’s level of need. They are outlined in ‘Practice Guidance 3, When identifying a primary health need, how should the four key characteristics be approached?’ (PG3). The National Framework is clear the questions it provides are not meant to be strictly applied and are there to guide the IRP’s considerations. We use these questions when we are looking at whether the IRP properly considered the four key characteristics of Mrs Curbishley’s needs.
75. We will consider each key characteristic below.
Nature
76. The National Framework says this characteristic should ‘describe the particular characteristics of an individual’s needs (which can include physical, mental health or psychological needs) and the overall effect of those needs on the individual, including the type (‘quality’) of interventions required to manage them.’
77. The National Framework provides some questions that professionals can consider when looking at the nature indicator. These are listed in the Practice guidance 3 (PG3) of the National Framework and include
• How does the individual or the practitioner describe the needs (rather than the medical condition leading to them)? What adjectives do they use?
• What is the impact of the need on overall health and well-being?
• What types of interventions are required to meet the need?
• Is there particular knowledge/skill/training required to anticipate and address the need? Could anyone do it without specific training?
• Is the individual’s condition deteriorating/improving?
• What would happen if these needs were not met in a timely way?
78. The National Framework is clear that the questions are simply prompts to guide those making decisions about CHC on what to think about. They do not need to be answered in turn. This is the same for the prompt questions for the other key characteristics, which we set out later.
79. The IRP report shows the panel had a thorough discussion about the nature of Mrs N’s needs. It noted she had needs across several domains as a result of her vascular dementia and physical health conditions. These meant that she required care in a 24 hour setting to manage her daily personal needs.
80. The IRP noted Mrs N had low or moderate needs in all but one of the care domains (except other significant care needs, in which she had no needs). It took information from its discussions about each domain and recognised the types of interventions and skill levels required to meet those needs.
81. The IRP noted that Mrs N was doubly incontinent but was able to ask for help to go to the toilet, and was able to communicate her needs. Her continence care was managed by the carers. Mrs N could display challenging behaviours which were managed by a retreat and return strategy. The IRP considered Mrs N’s behaviour did not prevent her from receiving care and that staff had ways of supporting her when distressed and her behaviour was difficult.
82. The IRP also noted that Mrs N ate independently but was given a special diet to manage her weight. She was also able to weight bear. Mrs N required carers assistance to apply creams as she had oedema, and to administer medication. The IRP also noted that Mrs N needed help from two carers to mobilise but did not usually require a hoist.
83. The IRP concluded that the type of care required to meet Mrs N’s needs was not beyond that which could be provided by a local authority, with assistance from her GP and core NHS services as needed.
84. There are no indications of a failing in how the IRP considered the nature of Mrs N’s needs. We can see the IRP had PG3 of the National Framework in mind when it considered the nature of Mrs N’s needs. The IRP based this on the available evidence, including the evidence referred to in Mr N’s submissions. We understand that Mr N disagrees with the decision.
85. The records suggest Mrs N’s needs were not outside of that expected from the care home setting. There is no evidence to suggest the care staff could not deliver the care or the changes to this that were required. The evidence suggests Mrs N’s care could be anticipated and planned accordingly without the need for complex care planning or frequent reviews. This is also supported by the evidence, particularly that carers did not need to depart from their care plans to manage her needs.
86. We are satisfied the IRP has considered Mrs N’s needs individually and interactively, which is in line with the National Framework. There are no indications of failings in the IRP’s decision-making about the nature of Mrs N’s needs. The IRP’s reasoning is supported by the records and is in line with the National Framework.
Intensity
87. The National Framework explains that ‘Intensity’ is about the quantity, severity and continuity of needs.
88. The key prompt questions outlined in the National Framework include:
• How severe is this need?
• How often is each intervention required?
• For how long is each intervention required?
• How many carers/care workers are required at any one time to meet the needs?
• Does the care relate to needs over several domains?
89. The IRP recognised Mrs N had needs in many of the domains at a moderate level. It agreed that she required supervision and monitoring as well as help with every day activities. It considered this care was not ‘sustained’. The panel also noted care was provided by carers, her GP and core NHS services as needed.
90. The IRP accepted that at the start of the review period Mrs N was already suffering a significant cognitive impairment which impacted on her communication and her behaviour. The IRP noted that apart from the care home educational support team service there were no other specialist referrals. This indicates that Mrs N’s care was being met without specialist input. The IRP also noted that there was no evidence of frequent changes to care plans, or records of people or property being injured or damaged.
91. There was no evidence of multiple interventions required or interventions that frequently took a long time, even when Mrs N exhibited challenging behaviour when staff were trying to care for her. Both of these areas required oversight, monitoring and supervision and they were straightforward to manage by carers. When staff retreated and returned, she had usually calmed down and would receive the necessary care.
92. The IRP considered the different types of care required to meet Mrs N’s needs in each domain. This included consideration of the number of staff required to meet different needs, the length of time it would take them, and whether there was any particular complexity or challenge to meet those needs which required a higher than normal level of skill or knowledge, for example any specialist training beyond that ordinarily expected of care staff.
93. The records show Mrs N’s behavioural needs could be addressed through a retreat and return approach, coupled with reassurance, and evidence of only short delays in meeting personal care needs when she was distressed or agitated. We are satisfied the evidence shows Mrs N’s care and treatment was routine. While there was a need for close and careful monitoring of her needs, there is no record of a departure from the original care plans.
94. When we weigh up what the IRP considered, there are no indications of failings in its decision-making about the intensity of Mrs N’s needs. The IRP’s reasoning is supported by the records and in line with the National Framework.
Complexity
95. The National Framework says, ‘complexity refers to how the needs arise and interact to increase the skill needed to monitor and manage the care’.
96. The prompt questions set out in the National Framework include:
• How difficult is it to manage the need(s)?
• How problematic is it to alleviate the needs and symptoms?
• Are the needs interrelated?
• Do they impact on each other to make the needs even more difficult to address?
• How much knowledge is required to address the need(s)?
• How much skill is required to address the need(s)?
• How does the individual’s respond to their condition make it more difficult to provide appropriate support?
97. The IRP noted that at times increased skill and knowledge was needed to care for Mrs N. This was not regular, but on an as needed basis and required input from core NHS services such as her GP.
98. The panel noted some interaction between the domains. In particular, her cognitive impairment had an effect on her communication, continence, medication, tissue viability, and nutrition needs. It also had an impact on her mental health and behaviour.
99. The IRP considered there was no evidence of an increased level of skill required. It felt that prescribed medication and general supervision was successful in moderating Mrs N’s behaviour.
100. The IRP considered the rest of Mrs N’s needs and concluded there was no evidence to suggest deviations from care plans, and there was no requirement for skilled professionals to get involved in her care. Her care requirements were routine and well managed.
101. We have considered the submissions of the IRP and the evidence available to us. We can see there is evidence of interactions between some areas of Mrs N’s healthcare needs. However, we are satisfied the IRP’s view that there was no indication that her needs were complex to manage is supported by the evidence. This is particularly in the documented success of the retreat and return method in relation to non-compliance.
102. We can also see evidence to support the IRP’s view that Mrs N’s care could be anticipated and planned without the need for complex care planning or frequent reviews. It shows carers did not need to depart from their care plans to manage those needs.
103. We note the IRP also considered the level of skill staff required to meet Mrs N’s needs, and what strategies they used to meet those needs when she was resistive to support, such as distraction, encouragement, or withdrawing and returning later to try again.
104. There are no indications of failings in how the IRP considered the complexity of Mrs N’s needs. It looked at the evidence of Mrs N’s needs, including Mr N’s written and verbal submissions. There appear to be no omissions in the consideration of evidence.
105. There is no evidence in the records to suggest an interaction between the needs which led to an increase in the level of skills or knowledge required to care for Mrs N. The IRP acknowledged on some occasions interventions took longer, however this was not daily and did not result in changes to care plans.
106. We are satisfied the IRP considered the complexity characteristic in line with the National Framework and based its decision on the available evidence.
Unpredictability
107. The National Framework sets out that unpredictability is concerned with the degree to which needs fluctuate, thereby creating challenges in meeting them on a day-to-day basis.
108. The prompt questions set out in the National Framework include:
• Is the individual or those who support him/her able to anticipate when the need(s) might arise?
• Does the level of need often change? Does the level of support often have to change at short notice?
• Is the condition unstable?
• What happens if the need isn’t addressed when it arises? How significant are the consequences?
• To what extent is professional knowledge/skill required to respond spontaneously and appropriately?
• What level of monitoring/review is required?
109. The IRP acknowledged Mrs N had many needs, with some interactions. But it considered these were not so unpredictable as to evidence a primary health need. It explained that unpredictability is not about predicting every health episode.
110. The IRP concluded that there was no evidence which showed that Mrs N’s needs changed at short notice, or that care plans were being frequently amended. Care staff could anticipate her needs as they were familiar with her. The IRP also considered that Mrs N’s condition was not rapidly deteriorating or fluctuating. She displayed challenging behaviour at times but she eventually received all necessary care. There was no requirement for staff to have an increased level of knowledge or skill.
111. We have reviewed information available, including the notes in the annex and records. Based on this, we have seen no evidence that Mrs N’s needs were so unpredictable that they were difficult to manage and therefore the records support the IRP’s rationale.
112. As noted above, there were no changes to care plans, which would suggest that staff were able to predict her behaviour and manage it accordingly. There was no evidence that Mrs N’s level of support changed frequently or at short notice. We have seen nothing to suggest that her needs changed or fluctuated significantly on a day-to-day basis.
113. In summary, the IRP noted Mrs N required carers who could anticipate and manage risks and her wellbeing. But the ability to recognise and prepare for those care needs were not of a level of skill or knowledge above what could be expected of a local authority provided service.
114. We have seen the records support the IRP’s rationale that there was no sudden or critical changes in the care responses that were required, and skilled interventions were not needed.
115. We think the IRP considered this key characteristic in line with the National Framework. It considered the records to identify if any interventions were required. We can see the IRP’s conclusions are in line with the National Framework and are supported by the records.
Conclusion
116. The IRP’s rationale for its decisions is in line with the National Framework and refers to the relevant evidence throughout. We think the IRP fairly considered the comments and observations of both the family and the ICB in coming to its final decision.
117. We appreciate the time and effort Mr N has taken to bring his complaint to us. While we did not see indications of failings in the eligibility consideration, we understand the distress and frustration of pursing a CHC complaint. We were sorry to learn of his concerns and hope that our explanations provide reassurance that the IRP followed the right process.
1. We have carefully considered Mr N’s complaint about how NHS England (NHSE) reviewed the Integrated Care Board’s (the ICB) decision not to give his mother, Mrs N, NHS funded continuing healthcare (CHC). We have seen no indication NHSE did anything wrong when it made its decision.
2. We are sorry to hear Mr N and his family have found the process distressing and we appreciate the amount of time he has dedicated to taking his complaint through the NHS appeals procedure and then bringing it to us. We also appreciate the cost of Mrs N’s care and the impact this had.
3. We have reviewed the relevant evidence and we are satisfied NHSE acted in line with the National Framework for NHS Continuing Healthcare and NHS funded nursing care when it made its decision.