13. 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 R was eligible for CHC on 13 September 2022. The National Framework sets out the principles and processes ICB’s and NHS England should follow when considering if someone is eligible for CHC.
14. We cannot consider the discretionary decisions the IRP made when it decided on eligibility. This includes the decisions it makes based on clinical judgement and clinician’s opinions. We can only consider if the IRP has followed the National Framework. This means we can only uphold a complaint about a CHC eligibility decision if we find the IRP did not follow the National Framework when it made its decision.
15. 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 was coming to its eligibility decision to make sure it was acting in line with the National Framework. If the IRP does find the ICB made a mistake, it can:
•recommend the ICB reconsiders if the patient had a primary health need, and •recommend the ICB addresses any procedural faults the IRP identified.
16. 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. To help us make a decision, we consider two key areas.
Did the IRP clearly explain how it had reached its decision?
17. Ms R has told us she disagrees with six of the domains that are assessed to determine someone’s care needs.
Breathing
18. Ms R says her mother’s needs in this domain were low from 8 April 2013 to 27 February 2015. Ms R says her mother’s needs were moderate in this domain from 28 February to 6 June 2015.
19. The IRP found Ms R’s mother’s needs in this domain were low for the period from 8 April 2013 to 27 February 2015.
20. The decision support tool defines low needs in this domain as:
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. The decision support tool 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 living 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.
22. At the IRP, Ms R stated that her mother suffered from an upper respiratory infection on 27 February 2015, paramedics said she was chesty, and her oxygen saturation levels were only 82%. Ms R stated her mother could be restless in her chair and become frustrated at times. Ms R stated her mother was treated for the infection with antibiotics. Ms R said her mother was experiencing breathlessness in her day-to-day life from this point on,
23. The IRP stated that on 27 February 2015, the care home tested Ms R’s oxygen saturation levels and they were found to be 88%. The care home called the GP, who advised to call an ambulance. When the paramedics attended, they sat Mrs R up, got her over the acute episode she was having, and her oxygen saturation levels returned to 97%. The GP later checked her chest and found it to be clear, but as a precaution, they prescribed antibiotics. The IRP noted Mrs R did not have any acute problems after this time.
24. The IRP outlined that the use of inhalers was not a decisive factor for determining whether needs were low or moderate, and it accepted the account provided by Ms R that her mother’s breathing was laboured between every other day and one visit in every four. It stated that because Mrs
25. R was not mobile for reasons other than her breathing, it could not see evidence that her breathing impacted on her daily activities.
Our consideration
26. Ms R is relying on the episode of 27 February 2015 to outline that her mother’s needs were moderate in this domain from that point onwards. We can see the IRP has considered the points Ms R has made, and it has given its reasoning for why it considered her needs remained low in this domain.
27. Ms R has also sent us hospital records for her mother; however, these were from before her mother was admitted to the care home. This means we cannot consider this evidence because it is before the claim period.
28. When we weigh up the evidence, we can see the IRP acted in line with the National Framework when it considered Mrs R’s breathing needs. To give a weighting of moderate in this domain, the IRP would have had to see Mrs R’s breathing impacted on her daily activities and did not consistently respond to management.
29. The GP records back up what the IRP outlined, in that Mrs R’s oxygen saturation levels were 88%, but upon the paramedics treating her, they were up to 97%. The GP records show were no further call outs to the paramedics or the GP for the remainder of the period. We have not seen any evidence to show the IRP did not appropriately consider Mrs R’s needs in this domain.
30. We can see from the discussions at the IRP that Ms R felt the weighting was conservative because her mother suffered with laboured breathing. We can appreciate how concerned she was.
31. The records log in the care home records shows Mrs R did engage in activities in May and June 2015 such as watching the residents play bowls in the garden on 4 June 2015, and Mrs R was observed to be enjoying listening to a singer in the care home on 11 June 2015.
32. There is no indication from the records that her breathing impacted on her ability to do things in the care home from February to June 2015.
33. We can see no indication of a failing in how the IRP considered this domain.
Nutrition – Food and Drink
34. Ms R says her mother’s needs in this domain were high from 8 April 2013 to 6 June 2015. The IRP found that her mother’s needs in this domain were moderate from 8 April 2013 to 6 June 2015.
35. High needs in this domain are defined as: ‘Dysphagia requiring skilled intervention to ensure adequate nutrition/hydration and minimise the risk of choking and aspiration to maintain airway.
OR Subcutaneous fluids that are managed by the individual or specifically trained carers or care workers.
OR Nutritional status “at risk” and may be associated with unintended, significant weight loss.
OR Significant weight loss or gain due to identified eating disorder.
OR Problems relating to a feeding device (for example PEG) that require skilled assessment and review.
36. Moderate needs in this domain are 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.’
37. At the IRP, Ms R stated her mother had experienced a well-documented impaired swallow whilst in hospital, which progressed to pouching. It was very difficult to get her mother to swallow, but Ms R was not sure if this was due to a dysphagia or her mother’s cognitive issues. Ms R also said her mother suffered weight loss. Ms R said her mother could start a meal by herself, but they often had to help get it finished. Ms R said her mother was prescribed a pureed diet, and her mother was at risk of malnutrition.
38. The IRP stated it could not find any evidence to show Ms R’s mother needed carers with specific training to assist her with her nutritional intake, or that skilled interventions were required to assist Mrs R with her eating. The IRP also stated Mrs R’s GP had said there were no swallowing or choking concerns. There would need to be evidence of this to meet the criteria for the high descriptor in this domain.
Our consideration
39. We can see the IRP has considered the descriptors for moderate needs and high needs in this domain. Ms R has also provided us with some of her mother’s records. One of the records shows Mrs R’s weight fluctuated from 48 to 51.5kg from April to December 2013. A record from 11 June 2013 stated Mrs R was not willing to take food so easily, she was taking fortified milk, and her weight was being monitored weekly. She was shown to be at a high risk of malnutrition on 2 July 2013, however, Mrs R’s food record charts from 26 July to 1 August 2013 show she was regularly eating her breakfast, lunch and supper. This shows that whilst there was a risk, her eating had improved in July 2013.
40. A letter from the stroke specialist nurse to Mrs R’s GP dated 4 September 2013 stated Mrs R was able to feed herself, but she required supervision, and she had recently started eating better when her diet was changed to a pureed diet. The nurse also stated the care home need to make sure Mrs R receives a health low salt diet.
41. The care home record dated 1 October 2013 stated Mrs R was eating well with a pureed diet. Ms R has provided an undated extract of a social services assessment that was done when Mrs R was resident in the care home that stated there was an ongoing swallow risk due to her diagnosed dysphagia, but there had been no evidence of Mrs R choking or experiencing aspiration since she had been admitted to the care home.
42. The care home records in April 2013 describe Mrs R as eating and drinking well, feeding herself and enjoying her food. On 25 July 2013, the notes stated Mrs R enjoys meals.
43. On 22 March 2014, the care home records stated Mrs R was independent at mealtime, and only needed minimal supervision. On 10 May 2014, Mrs R was noted to be having meals independently with some prompting. On 16 August 2014, Mrs R was noted to be eating independently, and she only needed a bit of supervision, and on 24 March 2015, Mrs R was noted to be eating and drinking well.
44. The evidence shows Mrs R was able to eat mostly independently, and there were no issues with her eating, and there was no evidence she required specialist intervention to ensure she ate, or that she experienced significant weight loss.
45. We understand the concerns Ms R has raised, but we have not seen any indication to show that the IRP has not considered Mrs R’s needs in this domain appropriately.
46. We can see no indications of a failing in how the IRP considered this domain.
Psychological and emotional needs
47. Ms R considers her mother’s needs in this domain were high for the period from 8 April 2013 to 6 June 2015. The IRP found that Mrs R’s needs in this domain were moderate for the period from 8 April 2013 to 6 June 2015.
48. High needs in this domain are defined 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 any attempts to engage them in care planning, support and/or daily activities.’
49. Moderate needs in this domain are defined 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.’
50. At the IRP, Ms R stated her mother suffered a tragic life changing event (suffering a stroke in November (2012). Mrs R would become agitated when she tried to get out of her chair, and she was constantly demonstrating her anxiety and not wanting to be in that situation by constantly moving in her chair and her bed. Ms R said her mother became withdrawn, easily upset, and agitated. She demonstrated her upset by refusing food and medication. Ms R said her mother would be bothered and agitated by certain care staff. Ms R said there was a capabilities assessment done every month that showed her mother looked worried or sad all the time, her level of social interaction was low, and she has not established any relationships. Ms R said her mother could not hear or see what was going on, and she was constantly agitated.
51. Ms R has also provided us with a care home record from July and October 2013 that shows Mrs R was either unwilling, or she needed persuading to join a group activity.
52. The IRP looked at the descriptor for high and determined it did not see sufficient evidence that showed Mrs R met the criteria for the high descriptor. There was no clear evidence of mood disturbance or hallucinations, and her anxiety and distress could not be said to have been having a severe impact on her health and wellbeing. The IRP also said that although her engagement with daily activities was limited, it would be a stretch of the definition to characterise it as total withdrawal.
53. The IRP also looked at the definitions for the low and moderate descriptors. The low descriptor states:
‘Mood disturbance, hallucinations 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.’ It considered the low descriptor equated to a great level of engagement than was supported by the available evidence.
54. The IRP considered Mrs R appeared calm and content most of the time, but there were also records of her looking sad and tearful. Anxiety and distress were also observed, but she would sometimes respond to reassurance. There was evidence she was engaged with some activities, she seemed to respond to music, and there are records of her having done some knitting and enjoying other activities. Equally there were other times when she did not. The IRP considered that the moderate descriptor was the best fit for Mrs R.
Our consideration
55. We think the IRP followed the National Framework when it considered Mrs R’s psychological and emotional needs domain. The difference between the moderate and high descriptors in this domain is the impact of hallucinations, mood and anxiety on the person’s health or wellbeing, and how far they have withdrawn from attempts to engage them.
56. The care home records show Mrs R had not completely withdrawn from attempts to engage her in care support and activities. This is what is needed to meet the criteria for the high descriptor.
57. For example, on 30 July 2013, Mrs R was described as very happy in the care home records. On 2 October 2013, Mrs R was said to have enjoyed all the exercises and she tried all the movements, and on 11 October 2013, Mrs R was noted to be listening to music that she seemed to enjoy. The care home records dated 11 October 2014 described as cheerful and chatty. On 23 November 2014, Mrs R was said to have joined in with activities, and on 24 November 2014, Mrs R was described as cheerful and chatty.
58. Social care assessment from January to April 2014 outlined Mrs R appeared to look happy from January to April 2014.
59. A record dated 9 January 2015 on the acute intervention record sheet outlined Mrs R had been washed and dressed, she was happy to cooperate, and she was chatting with the care staff member.
60. After taking all the evidence into account, we consider the IRP report clearly explains why, based on the evidence including Ms R’s account, the IRP felt her mother’s mood and anxiety was not having a severe impact on her health and wellbeing. This is what it would have needed to see to weight her needs as high.
61. We can see no indications of a failing in how the IRP considered this domain.
Behaviour
62. Ms R considers her mother’s needs in this domain were high for the period from 8 April 2013 to 6 June 2015. The IRP determined Mrs R’s needs in this domain were moderate for the period from 8 April 2013 to 6 June 2015.
63. High needs in this domain are described 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 in minimising but not always eliminating risks. Compliance is variable but usually responsive to planned interventions.’
64. Moderate needs in this domain are described 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.’
65. The key difference between the two descriptors is the level of risk posed by the individual with their behaviour.
66. At the IRP, Ms R stated her mother was agitated throughout her period in the care home, for example by trying to leave her chair and putting her leg over the side of the bed, being frustrated that her physical disabilities meant she could not do the things she wanted to.
67. Ms R said her mother was also resistive to having her dentures removed, and this meant staff had to retreat and return. Ms R said her mother would lick lotion off her hands, which care staff felt caused a rash.
68. The IRP looked at the descriptors for both moderate and high in this domain. The IRP found Mrs R’s behaviours followed a predictable pattern rather than a predictable risk of harm. Risk assessments focussed on the actual behaviours and what needed to be done to address them, rather than any risk to self, others, or property. The level of resistance Mrs R offered did not prevent care being delivered, nor did it present serious difficulties.
Our consideration
69. We can see the IRP had a detailed discussion about Mrs R’s behaviour needs. It asked Ms R to describe her observations of the different aspects of her behaviour at the time of the assessment and previously. It weighed up her concerns about the changes in her behaviour and whether these indicated a higher weighting might be appropriate.
70. The IRP has also looked carefully at the descriptors for moderate and high, and it has given its reasoning for why it considered Mrs R’s needs fell within the moderate descriptor.
71. Ms R has provided us with an extract from the decision support tool that the ICB did. It outlined Mrs R was compliant when she was assisted to wash and dress, but she may become resistive during continence care. She may try to hold the hand of the staff member and prevent them from what they are doing, but once the procedure is complete, she always says thank you to staff members, and she is grateful after an intervention. It also outlined Mrs R may refuse to have her dentures removed, and staff may need to go away and return to complete the care intervention. It also outlined that Mrs R could feed herself, and she was compliant with receiving medication, but the family stated there were times when Mrs R would refuse to take her medication.
72. We have carefully reviewed all the evidence, and we have not seen any indication that the IRP has failed to appropriately consider Mrs R’s needs in this domain.
73. The monthly functional needs assessment for April to December 2013 outlined Mrs R did not display any challenging behaviour. The activities log from July to October 2013 outlined Mrs R enjoyed participating in various activities such as getting her hair cut and knitting.
74. Mrs R’s plan of care dated 4 October 2014 stated she is non-compliant with taking medication at times. The record does show there was a plan in place to address this though. The plan stated if Mrs R does refuse her medication, the staff nurse will come back again and re-offer her medication, and it will also be offered whilst she is eating meals, as she was noted to spit medication out if it was not given with food.
75. Records dated 9 January 2015 outlined Mrs R was happy to cooperate with care interventions and she was chatting to a member of care staff as she was receiving care interventions.
76. The activities log from February to June 2015 outlined Mrs R was happy to sit and listen to a singer in the care home.
77. We think the IRP acted in line with the National Framework when it considered Mrs R’s needs in the behaviour domain. The report acknowledges Mrs R’s behaviour was challenging, but it followed a predictable pattern. We have not seen evidence her behaviour posed a risk to either herself or others in the care home.
78. The report explains why the IRP did not think her needs were in line with the high weighting, notably that her behaviour did not pose a risk to herself or others. This is what the IRP would have needed to see to give a higher weighting. The evidence, including that provided by Ms R, indicates while Mrs R’s behaviour needs were variable, her carers could plan for and usually manage this.
79. We can see no indications of a failing in how the IRP considered this domain.
Drug therapies and medication
80. Ms R says her mother’s needs in this domain were high. The IRP found her mother’s needs were moderate.
81. High needs in this domain are defined as: ‘Requires administration and monitoring of medication regime by a registered nurse, carer or care worker specifically trained for the task because there are risks associated with the potential fluctuation of the medical condition or mental state, or risks regarding the effectiveness of the medication or the potential nature or severity of side-effects. However, with such monitoring the condition is usually non-problematic to manage.
OR Moderate pain or other symptoms which is/are having a significant effect on other domains or on the provision of care.’
82. Moderate needs in this domain are defined as: ‘Requires the administration of medication (by a registered nurse, carer or care worker) due to: non-compliance, or type of medication (for example insulin), or route of medication (for example PEG).
OR Moderate pain which follows a predictable pattern; or other symptoms which are having a moderate effect on other domains or on the provision of care.’
83. Ms R stated her mother was prescribed antiplatelet medication and was replaced by warfarin. She was reluctant to take medications, and she could not follow instructions. She was reliant on staff to ensure she took medications, and staff used a retreat and return approach to overcome non-compliance. Staff put medication in her food if she refused to take it, and she was prescribed paracetamol for pain, but she could not communicate if she was in pain. In October 2014, Mrs R was admitted to hospital and diagnosed with Atrial Fibrillation. Her warfarin dose was checked weekly and adjusted eight times over an eight-month period. Ms R said it created a high risk if her mother was not compliant with her medication regime, and very skilled carers were needed to administer her medication.
84. The IRP outlined it considered the evidence, and it looked at the criteria needed to meet the high descriptor. The IRP found the level of pain did not reach the significance necessary to meet the descriptor for high. Her pain was managed with paracetamol, without the regular use of opiates that are normally associated with the higher descriptor. The IRP outlined there was no evidence of her needs in this domain having a significant impact on needs in other domains. Her pain was best described by the moderate descriptor which denotes a predictable pattern and having a moderate effect on other domains and the provision of care.
85. The IRP said Mrs R met the moderate descriptor because her medication had to be administered by a nurse or care worker because of non-compliance. The IRP did outline the prescription of warfarin may have introduced an element of risk. Ultimately it outlined that decisions regarding the dosage for warfarin were made by the GP, and staff followed the GP’s instructions on any adjustments. It outlined there were no problems or side-effects arising from the warfarin prescription.
Our consideration
86. We can see the IRP carefully looked at the descriptors for both moderate and high and gave careful analysis for which of the two descriptors Mrs R’s needs fell into.
87. Mrs R’s care plan dated 4 October 2014 outlined she could be non-compliant with taking her medication. It stated she spat them out if they are not given with food. It was noted in the care plan that the staff nurse was to come back again and reoffer the medication if Mrs R was refusing her medication. It was also noted that medication should be given with her meals.
88. The records show that at times, Mrs R could refuse her medications, for example, in October 2014, the care home records show Mrs R had refused her morning medications, and the staff member had only been able to give her antibiotics.
89. Ms R has sent us a copy of a medication risk assessment dated 14 April 2015. This outlined Mrs R was spitting out some of her medications. It was noted on this risk assessment that after discussion with the GP, the plan was to cut her medication in half before giving it to her, but it was some noted that the medication may not be as effective when given this way, but this decision was taken in Mrs R’s best interests.
90. The medication administration records show Mrs R was in regular receipt of her medication. The monthly abilities and functional needs assessment chart for 2014 shows her medication was administered, with no as needed medication being prescribed.
91. We think the IRP acted in line with the National Framework when it considered Mrs R’s drug therapies and medication needs. We have considered Ms R’s views regarding her mother being on warfarin and this making her medication regime more complicated. The IRP report shows how the IRP weighed this up in terms of what the descriptors say. It carefully considered the level of risk the warfarin presented, and it highlighted there were no problems or side-effects arising from the warfarin prescription. To give a higher weighting, the IRP would have needed to see there were risks regarding the effectiveness of the medication, or the nature or severity of side-effects that presented.
92. We can see no indications of failings in how the IRP considered this domain.
Altered States of Consciousness (ASC)
93. Ms R considers her mother’s needs in this domain were moderate for the period from 8 April 2013 to 6 June 2015. The IRP found her mother’s needs in this domain were low for the period from 8 April 2013 to 6 June 2015.
94. Low needs in this domain are defined as: ‘History of ASC but it is effectively managed and there is a low risk of harm.’
Moderate needs in this domain are defined as: ‘Occasional (monthly or less frequently) episodes of ASC that require the supervision of a carer or care worker to minimise the risk of harm’.
95. At the IRP, Ms R said her mother had a history of transient ischaemic attacks (TIA’s) in January and August 2012, and she had multiple strokes in November 2012, followed by a further stroke on 17 December 2012. Ms R said the TIAs manifested themselves in different ways, such as headaches or being nauseous, which even trained A&E staff could not recognise. Ms R said it was reasonable to suspect her mother was suffering from TIAs (mini strokes) whilst she was in the care home.
96. We can see the IRP considered the strokes Mrs R had prior to being admitted to the care home, and it considered this was consistent with the low descriptor. We can also see the IRP looked at the difference in the definitions of the descriptors for the low and moderate descriptors. It pointed out that for Mrs R to meet the criteria for the moderate descriptor, it would be necessary to evidence occasional (monthly or less frequently) episodes of altered states of consciousness that require the supervision of a carer to minimise the risk of harm. It pointed out that the suggestion Mrs R was experiencing TIA’s in the care home was speculative, and it was not supported by any evidence, such as recorded incidents.
97. The IRP also pointed out the idea that TIA’s occurred but remained undetected, or were undetectable, meant, by definition, that there could be no requirement for supervision. Monitoring for unobservable signs would be pointless and the absence of detected evidence of harm resulting from episodes would suggest that the any “risk of harm” was minimal to start with.
98. We think the IRP has acted in line with the framework here. It has considered Ms R’s points, and it has looked at the descriptors for both low and moderate needs. Ms R suspected her mother was experiencing undetectable TIA’s in the care home, but there is no evidence for this. The IRP has robustly explained why it considered Mrs R’s needs were low in this domain.
99. We can see no indication of failings in how the IRP considered this domain.
Did the IRP apply the eligibility tests properly and reach an evidence-based conclusion about them?
100. The IRP also applies an eligibility test to help it make a decision 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.
101. 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 R’s needs.
102. Ms R has told us she disagrees with the IRP’s consideration of each of the four key characteristics. We can see she gave her view on each key characteristic directly to the IRP.
Nature
103. 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.’
104. Ms R told the IRP her mother was severely cognitively impaired, and this impacted all aspects of her life. She outlined her mother also had a history of pulmonary tuberculosis (TB) (bacterial lung infection) and pneumonia (lung inflammation caused by bacteria or a virus). These compounded with her frailty put her at a big risk when she acquired new chest infections.
105. Ms R informed the IRP her Mrs R had dysphagia, which meant she had an impaired swallow. Ms R says her mother was doubly incontinent and she was at a high risk of skin breakdown. Ms R says her mother had two carers to help her mobilise, and she was paralysed on the right side of her body following her stroke.
106. Ms R says her mother was diagnosed with aphasia (language disorder) and a cognitive communication disorder. Ms R says her mother was withdrawn from, disengaged from, and not compliant with care she received at the care home, including the receiving of her medication. Ms R also says her mother had an irregular heart rate, and for these reasons, the nature of her needs amounted to a primary health need.
107. The IRP outlined Mrs R required 24-hour care, her cognition needs were severe, and her mobility and communication needs were high. The IRP outlined the domains which were disputed but said the nature of those needs was largely agreed, and the differences arose from how those needs were interpreted. The IRP outlined Mrs R’s condition was broadly stable, but it showed a generally deteriorating trajectory.
108. Mrs R’s cognitive impairment required a fully supportive environment, she needed support for personal care, and her skin required monitoring. There was no evidence Mrs R was in constant pain, and the IRP highlighted Mrs R had not complied with her medication being given on 54 occasions, which represented 5-6% of the time, and so this was not particularly significant.
109. Her needs were routinely met by care staff, and there was no evidence that care plans needed to be changed frequently, and there was no evidence of interlay between different needs. For these reasons, the IRP did not consider the nature of Mrs R’s needs amounted to a primary health need.
Our consideration
110. As we have already addressed the IRP’s consideration of Ms R’s mother’s needs in the domains she has disputed, we will not go over that again here. We have looked at PG 3 of the national framework that gives guidance on how the four key indicators should be approached. This prompts the IRP to consider the following:
•How does the individual or the practitioner describe the needs?
•What is the impact of the need on the overall health and wellbeing?
•What types of interventions are required to meet the need?
•Is there any knowledge/skill/training required to address and anticipate the need?
•Is the individual’s condition deteriorating/improving?
•What would happen if these needs were not met in a timely way?
111. We can see the IRP has considered these points in detail. It has commented on Ms R’s mother’s needs with regards to her mobility, nutrition, cognitive and medication needs.
112. We can see the IRP considered the impact of these needs on her overall health and wellbeing. It stated she required 24-hour care, and her cognition, communication and mobility were the main factors having an impact on her overall health.
113. The IRP also looked at the types of care Ms R’s mother needed to keep her safe and well. The report sets this out in detail. It includes needs such as support for personal care, monitoring for UTI’s, and supervision and support with feeding. She was monitored and provided with support for occasional pain. The IRP outlined she was assisted with taking her medication, some of her care was met by medically trained staff, and apart from access to a GP, there were no referrals for external specialist support.
114. The report shows how the IRP discussed the levels of training Ms R’s mother’s carers needed. For example, it outlined her needs were routinely met by staff at the nursing home, without the need for additional staff to be brought in or additional training provided.
115. The IRP weighed everything up before it concluded the nature of her needs was within the remit of social services, with the support of community healthcare services and the GP.
We consider the IRP assessed the nature of Ms R’s mother’s needs in line with the national framework.
Intensity
116. The National Framework says this characteristic ‘relates both to the extent (‘quantity’) and severity (‘degree’) of the needs and to the support required to meet them, including the need for sustained/ongoing care (‘continuity’).
117. Ms R says her mother had a severe level of cognitive impairment, and she was unable to communicate with care staff. She says her mother was totally reliant on care staff for moving and handling. Ms R says maintaining her mother’s position in a chair or in bed would have been, and at least two care staff were required to move her and provide her personal care. Mrs R was at risk of developing skin integrity issues, and she had pressure sores that needed to be addressed. She says ensuring her mother was kept hydrated to prevent UTI’s and drops in blood pressure was an intense need, and it could take up to an hour with support for her mother to eat a meal. Ms R says her mother suffered weight loss, and she had an impaired swallow, and because of this, she required complete supervision when she was eating her meals.
118. Ms R says her mother’s continence needs were extremely intense. She required full assistance of staff to manage her continence needs, both to prevent further escalation and to deal with daily issues of fluctuating bowel movements. She says her mother required full assistance with her medication regime due to her known non-compliance and her swallow issues, and it would take around 20 minutes for medication to be administered. She says that during a 24-hour period, her mother required frequent and lengthy care interventions to maintain her health and wellbeing. Ms R says for these reasons, the intensity of her mother’s needs amounted to a primary health need.
119. The IRP outlined one care domain was assessed as severe: cognition. Mobility and communication were assessed as high, and five domains were assessed as moderate. The IRP did not consider any one single domain to warrant intense needs on its own. The IRP outlined Mrs R required two carers for personal care and transfers, and she needed assistance with taking her medication, but overall, the amounts of care did not go beyond a standard level of support. It said two to four hourly repositioning, and being checked on once an hour each night is standard practice. The IRP did look at Mrs R’s continence needs, as Ms R considered they were intense. It outlined a requirement for occasionally more frequent pad changes did not add up to a greater severity, or a requirement for significantly more time or skill that the domain score would imply, and no external input was needed. The IRP did not consider the intensity of Mrs R’s needs amounted to a primary health need.
Our consideration
120. As we have already considered Ms R’s mother’s needs in relation to each of the domains she has challenged, we will not specifically discuss these again here.
PG 3 paragraph 3.4 outlines the IRP may wish to consider the following questions when looking at the intensity of needs:
•how severe is the need •how often is each intervention required •for how long each intervention is 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.
121. As outlined above, we can see the IRP has looked at the severity of Ms R’s needs. It looked carefully at her continence needs, and it outlined that overall, the level of care she needed did not go beyond the standard level of support that would be expected in a nursing home. It considered how long and frequent the interventions were, and how many carers were required to meet her needs.
122. The IRP recognised Ms R’s mother had a level of need in all the domains. It weighed up all the evidence before it concluded the levels of care and monitoring required in these domains were not severe enough to determine a primary health need. We think the IRP acted in line with the National Framework when it considered the intensity of Ms R’s mother’s needs.
Complexity
123. The National Framework says, ‘this is concerned with how the needs present and interact to increase the skill required to monitor the symptoms, treat the condition(s) and/or manage the care.’
124. Ms R says her mother had impaired cognition following on from her stroke, and this resulted in complex needs that were interrelated across many domains. Ms R says ger mother’s stroke caused need to interrelate in the following domains: Mobility, Communication, Nutrition, Drugs, Psychological and Emotional, Continence and Behaviour and Skin. She says her mother’s impaired swallow impacted on her nutritional intake. Ms R says her mother had been diagnosed with hyponatraemia, frequent episodes of low blood pressure, constipation and diarrhoea, and UTI’s, and it was imperative staff ensured she received an adequate fluid intake during the day.
125. Ms R says her mother was resistant during personal care, and she did not respond to reassurance. Ms R says her mother was at high risk or a very high risk of skin breakdown, and the only reason her skin did not breakdown further than a grade two pressure sore was because of the care she received. Ms R says her mother’s lack of communication made needs in other domains more challenging. She was unable to follow instructions, and she was fully dependant on staff to anticipate her needs because she was unable to communicate them. She says her mother became socially isolated as she spent a lot of time in her room, and she expressed her psychological and emotional needs by being withdrawn and refusing food. Ms R also says her mother displayed challenging behaviours.
126. Ms R says her mother was not compliant with her medication, and she was susceptible to chest infections due to her poor physical condition and risk of aspiration, and immobility. Ms R says it was clear that her mother had a complexity of care needs during the review period. Ms R says the staff had to be skilled and knowledgeable to manage her mother’s condition, and there was interaction between the domains throughout the period.
127. The IRP outlined it considered all the evidence, and it acknowledged that although Mrs R’s care related to needs in several domains, there was no unusual interaction between them that would have exceeded normal expectations. The IRP outlined there were links between nutrition, continence and skin, which is commonly found. All three domains were assessed as moderate, and no complex interaction had been observed. The IRP outlined that Mrs R’s cognition impacted on her behaviour, but her behaviour needs were assessed as moderate, and her behaviour had not made it more difficult for care to be delivered to her. The IRP outlined that although Mrs R’s care plans were reviewed regularly, they were not changed significantly or frequently.
Our consideration
128. Paragraph 3.5 of PG 3 of the National Framework asks the IRP to consider the following when looking at the complexity of needs:
•how difficult is the need to manage •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 and skill is required to address the needs •how does the individual’s response to their condition make it more difficult to provide appropriate support.
129. We have already looked at Ms R’s mother’s needs in relation to each of the domains she has challenged, so we will not look at them directly again here.
130. It is clear some of Mrs R’s care needs interacted with each other, such as her skin and continence needs, and her behaviour, cognition, medication and psychological needs because she lacked capacity to understand what she was doing, or the implications of refusing medication. We can see the IRP identified that some of Mrs R’s needs were interrelated. It specifically highlighted her nutrition, continence and skin needs were linked.
131. The IRP looked at how difficult her needs were to manage, it outlined she needed 24-hour care, and it outlined her needs did not require any additional knowledge or skills beyond those that would be possessed by trained staff working in such a setting. There had been no call for specialist interventions beyond support from the GP. It correctly outlined Mrs R had one hospital admission during the review period, and there was one incident where paramedics attended, which did not lead to a hospital admission. The GP was ultimately able to manage this situation by prescribing antibiotics.
132. There was a care plan in place to manage Mrs R’s medication, staff were aware her medication needed to be given with her food, and a retreat and return approach was also employed to help ensure Mrs R’s medication was given to her.
133. We can see the IRP weighed up all the evidence before they decided this key characteristic did not indicate a primary health need for Ms R’s mother. It set out why it thought the level of skill needed to manage the interaction of her needs was not complex, or that any of the interactions posed a significant barrier to the carers looking after her.
134. We think the IRP acted in line with the National Framework when it considered the complexity of Ms R’s mother’s needs.
Unpredictability
135. The final key characteristic of a person’s level of need is unpredictability. The National Framework defines it as ‘the degree to which needs fluctuate and thereby create challenges in managing them. It also relates to the level of risk to the person’s health if adequate and timely care is not provided. An individual with an unpredictable healthcare need is likely to have either a fluctuating, unstable or rapidly deteriorating condition.’
136. Ms R says the nature of her mother’s underlying health condition created an unpredictable physical and mental health pathway, and it inevitably led to her death in June 2015. She says her mother’s care needs fluctuated throughout the review period and caring for her on a day-to-day basis required staff to respond to any changes in her condition related to acute infection, cerebral events, skin rashes and cardiac issues. Ms R says her mother was prescribed medication to reduce the risk of further cerebral events, but she often refused to take medication. She was encouraged to have supplements because she was malnourished, but this was contraindicated due to her underlying conditions. Managing her mother’s health risks was very difficult, and this created an unpredictability in her care needs.
137. We have already looked at Ms R’s mother’s needs in relation to each of the domains that she has challenged, so we will not look at them directly again here.
138. Paragraph 3.6 of PG 3 of the national framework asks the IRP to consider the following questions when looking at the unpredictability of needs:
•is the individual or those who support him/her able to anticipate when the need(s) might arise •does the level of need of need often change. Does the level of support often have to change at short notice •is the condition stable •what happens if the need isn’t addressed when it arises and 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.
139. The IRP outlined Mrs R’s dementia caused a decline that followed a slow predictable pattern. The IRP pointed out it was clear that despite Mrs R’s communication needs, carers could predict when Mrs R’s needs might arise and anticipate what would be necessary to address them.
140. The IRP outlined the level of support Mrs R required did not change at short notice, and care plans remained broadly consistent throughout the review period. It stated delivering Mrs R’s care required nothing beyond the routine skills and training necessary for staff working in the nursing home where she resided.
141. The records show that care interventions were generally able to be carried out each day, and staff could plan to mitigate the risks of non-compliance with care interventions such as Mrs R refusing her medication. The records also show Mrs R was admitted to hospital once during the period, which shows her needs were largely stable.
142. We think the IRP acted in line with the National Framework when it considered the unpredictability of Ms R’s mother’s needs.
143. We are satisfied there are no failings how the IRP considered the four characteristics of Ms R’s mother’s needs. We think it acted in line with the National Framework. This does not take away from the account Ms R has given us, or the challenges her mother faced towards the end of her life. We are very sorry to read of the issues Ms R’s mother faced, we understand this was an incredibly difficult time for her and her family.
Process issues
144. Ms R complains about three specific process issues. We will address each one in turn. It is important to point out we are looking at how the IRP has considered the process issues Ms R has raised, not the actions of the ICB directly.
Constitution of the ICB’s multidisciplinary team panel (MDT)
145. Ms R complains that the IRP has not appropriately considered her complaint that a social worker was not present at the ICB’s MDT.
146. In the IRP report, the IRP outlined the suggestion that the MDT was not properly constituted was not technically correct, as it had met the appropriate requirements. It said that whilst the appointment of a social worker at the MDT is desirable, the ICB does not have the power to compel a local authority to release its staff, and Surrey County Council has a general policy of not doing so.
Our consideration
147. Section 140 of the national framework sets out what is expected of an MDT. It states an MDT consists of two professionals who are from two different healthcare professions, or one professional who is from the healthcare profession and one who is responsible for assessing persons who may have needs for care and support under part 1 of the Care Act 2014.
148. Section 141 outlines that whilst as minimum requirement an MDT can comprise of two professionals from different healthcare professions, the MDT should usually include both health and social care professionals who are knowledgeable about the individual’s health and social care needs, and, where possible, have recently been involved in the assessment or treatment or care of the individual. Standing Rules require that, as far as is reasonably practicable, the ICB must consult with the relevant local authority before making any decision about an individual’s eligibility for NHS Continuing Healthcare and in doing so cooperate with that local authority in arranging for such persons to participate in an MDT for that purpose.
149. We can see the IRP has taken this into account, and it has outlined that Surrey County Council has a policy of not releasing its staff to assist with MDT’s. The ICB outlined in its local resolution meeting report that a local authority member is normally part of the MDT process, but in Surrey, despite numerous requests from the ICB, Surrey Social Services decline to take part in Local Resolution Meetings. The report also specifically addressed Ms R’s complaint about the make up for the MDT. It stated the local authority informed it that it is not able to provide a representative to engage with the retrospective review process. Therefore, considering the national framework, the ICB sought to make up the MDT with two registered nurses from two different disciplines.
150. The LRM report shows one of the panel was a registered nurse who worked in palliative care, and one of the nurses was a district nurse. We can see the IRP considered that the ICB had made attempts to procure a social worker for the MDT. Whilst the national framework outlines attempts should be made to procure a social worker, it does not say a social worker must be part of the MDT. Therefore, we have not identified any indications of failings with how the IRP has considered this.
The review periods the ICB had looked at
151. Ms R complains about the IRP’s consideration of the periods of care the ICB looked at. Ms R says the ICB wrongly considered the period of care where her mother was in hospital, prior to being admitted to the care home.
Our consideration
152. The IRP rightly pointed out it was inappropriate to review the period when Mrs R was in hospital. This period of care has already been funded by the NHS by virtue of Mrs R being in hospital, and so it was not necessary to review this period. The IRP acknowledged this could have been confusing for Ms R.
153. Ultimately, the ICB considered too much, not too little, and this was addressed at the IRP by it considering the correct period of care. We consider this addressed the impact of any confusion at local appeals stage. The NHS Complaints Standards outline the remedy should return anyone affected to the position they would have been in had the failing not happened. Remedies may include: a meaningful apology, explanation, and acceptance of responsibility, remedial action including any combination of things like: • correcting an error • reviewing or changing a decision
154. The correct period was assessed at the IRP, and so we do not consider there is any unremedied injustice to Ms R because of this. This is because the correct period of care was independently review at the IRP.
Time taken to complete the review process
155. Ms R complains about the IRP’s consideration of the length of time it took the ICB complete the review process.
156. In the LRM report, the ICB stated it apologised for any distress caused to the family for the time it had taken to conclude the case. The ICB said there were a number of alterations to the review period requested, and requests from the family to source further information, which required the ICB to obtain further records, and the time taken to complete this was not within the ICB’s control.
157. The IRP outlined the time taken to deal with the case was excessive, notwithstanding that some delay was beyond the ICB’s control. It stated that overall, the ICB had failed to demonstrate a suitably person-centred process. The IRP recommended the ICB take note of the IRP’s analysis of its procedures and act accordingly. It said it was not making any specific recommendations as the ICB has already taken on board the issues that have been raised. We can see from looking at the LRM report that the ICB specifically addressed 11 process issues that Ms R had previously raised.
158. The NHS complaints standards outline that organisations should set out whether any mistakes were made, and fairly reflect on the experiences of all those involved. We can see the ICB has provided Ms R with an apology and explanation for the delays that occurred in the process. Based on this rationale, we consider the IRP has addressed this appropriately, in line with the NHS complaints standards.
Conclusion
159. We have not identified any indications of failings or maladministration with the IRP’s consideration of Ms R’s complaint.