12. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something went wrong when NHS England made its decision.
13. It is our role to decide whether NHS England’s IRP acted in line with the National Framework when it considered whether Mrs A 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.
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.
17. When as ICB makes a CHC eligibility decision or an IRP reviews it, they first look at the person’s needs in 12 care domains. Each domain is given a weighting from no needs to high, severe or priority (the highest level of need is different for different domains). The ICB or IRP then applies an eligibility test. It looks at the four key characteristics of those needs: 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.
18. Mr A did not challenge the weighting of any of the care domains at the IRP. He, the ICB and the IRP agreed on all of these. So we have focused on the key characteristics.
19. 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 B’s needs.
20. Mr A has told us he disagrees with the IRP’s consideration within the four key characteristics.
21. Mr A says the Deprivation of Liberty Safeguard (DOLS) assessment and social worker’s rationale report highlighted that an independent social worker recognised that his mother should have been eligible for CHC funding. She received and required 24-hour nursing care and skilled medical intervention.
22. The registered nurse at the care home also felt his mother should have been eligible. Nurses provided daily care and intervention, as well as advice for carers about effective feeding, skin care, transfers and managing specific issues of communication and dementia.
23. Mr A says his mother needed help with feeding, mostly taking 30-40 minutes and at times for over 60 minutes. She had a detailed end of life care plan which was an indicator of her frailty. She had advanced cognitive decline, challenging behaviour, and was always nursed in bed. She was completely unable to weight bear, unable to assist or cooperate with transfers. Due to the loss of muscle tone and pain on movement, she needed careful positioning and was unable to cooperate.
24. There was an increase in the incidents of skin integrity breakdown with tears and blistering to her skin that required regular nursing treatment. Her Waterlow score showed she was very high risk of developing skin tissue damage. She therefore needed close monitoring to reduce the risk of further damage occurring.
25. She moved to a pureed diet and significantly thickened fluid (such that it needed to be spooned out of the cup). In early 2020, the care home made a referral to the speech and language therapy team (SALT) for an assessment of his mother’s eating and swallowing. Mr A says the registered nurse reported that staff would often seek her intervention to assist and advise with feeding as they were unable to feed his mother successfully.
26. His mother had uncertain deterioration. Her physical wellbeing was unstable. Her feeding was unpredictable and required regular nursing skills, direct input and advice to carers to ensure that it maximised her nutritional and liquid intake. This was also important for maintaining good skin integrity. It was clear that without this nursing role, her continued weight loss would have seriously compromised her fragile state of health.
Nature
27. The National Framework says nature 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.’
28. The nature section of the IRP report gives a detailed explanation of Mrs A’s needs. It acknowledged she had limited insight into her condition and day to day care needs due to her significantly impaired cognitive function. She was dependent on carers and needed support with all her activities of daily living within the care home.
29. We can see the IRP presented a clear picture of how Mrs A’s needs were met. They describe the nature of her condition. The report sets out a consideration of the types of care Mrs A needed across each of the care domains to keep her safe and well. It noted these were routine interventions, including being fed using thickened food and regular repositioning every two hours to stop her skin from breaking down.
30. She was unable to mobilise, so was looked after in bed. Lifting her with a hoist was discouraged as she was frail. Her carers had to interpret and anticipate all her needs. Section 7 in the report drew out that she was doubly incontinent during the review period. She did not display challenging behaviour and mostly cooperated with her care. There were occasional periods of agitation around care interventions, but the risk of harm was low. She had a straightforward medication regime. Her care needs were met with care support.
31. We looked at the levels of training Mrs A’s carers needed. They were knowledgeable and well-trained in older person’s care for physical and mental health needs. We know Mrs A needed support to make choices and carers would monitor her needs. There was access to her GP if needed. She was prescribed anticipatory medication which required administration from a registered nurse, but this was not used and did not involve further oversight or intervention.
32. Mr A feels the range, interaction and frequency of his mother’s needs and the frequency of her need for assistance required knowledgeable and skilled carers, without which she could not cope. We can see the evidence supports the IRP’s conclusion. They show Mrs A did need care to ensure all her needs were met. But it was routine interventions that did not take time to complete.
33. We think the IRP weighed up the things the National Framework PG3 says it should. It is very clear Mrs A needed a lot of care with all daily living activities. But we cannot see she needed any specific knowledge, skill or training beyond that a local authority carer could provide.
34. We think the IRP’s decision about the nature of Mrs A’s needs was in line with the guidance set out in the National Framework.
Intensity
35. 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’). It sets out that assessors should look at how severe a person’s needs are, how often an intervention is and how long it takes, how many carers are needed, and whether the care is needed over several domains.
36. The IRP’s report shows a detailed account about the intensity of Mrs A’s needs. It set out the domains where her needs were greatest and that the combination of these required consistent care throughout a 24-hour period. It set out that she needed support with repositioning and her nutritional needs. She also needed support with continence care, skin monitoring and administration of medication. It noted she had the occasional outburst, but this was not problematic, and her care needs could be met. There was no evidence of a complicated medication regime.
37. There were no barriers to providing the care. Her support and interventions were managed successfully, with oversight when needed.
38. The evidence shows the IRP looked at the amount of time needed to provide the care, how much planning was involved and how many carers were needed. These are the considerations PG3 advises to look at. Mrs A’s care could be delivered with no increase of frequency of support. She needed care 24 hours a day, as Mr A says, but this alone does not indicate a primary health need. At different times of the day, she needed more or less help.
39. The IRP recognised Mrs A had a level of need in many of the care domains. We note it concluded the levels of care and monitoring required in these domains were what local authority carers could be expected to provide and were not intense enough to determine a primary health need. There is no indication that the majority of her interventions took a long time. They were straightforward to meet.
40. We think the IRP’s decision about the intensity of Mrs A’s needs was in line with the guidance set out in the National Framework.
Complexity
41. 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.’ It sets out that assessors should think about how difficult it is to manage the need and alleviate the symptoms, how the needs impact on each other, how much knowledge and skill is needed, and whether the person’s response makes it difficult to provide support.
42. The IRP report shows a good account about the complexity of Mrs A’s needs. It detailed her care was not difficult to deliver. It recognised her poor level of cognition impacted her communication to help staff identify her needs, nutrition, skin and continence. Her prescribed medication did not become difficult or need adjusting on a regular basis.
43. The IRP thought about the knowledge and skill needed to care for Mrs A. Carers anticipated Mrs A’s needs through familiarity and understanding of her care. It thought about whether the needs combined to create complexity and set out why it thought they did not.
44. We think IRP considered the factors PG3 says it should. It saw Mrs A’s care interventions were not difficult to manage and did not need specific skill or knowledge beyond that which a well-trained carer would have. There were no interactions or difficulties with Mrs A’s response that meant it was more complex to provide her care. Her needs were not difficult to plan or provide for. She did not require intervention from specialist care teams such as SALT and did not have frequent hospital admissions during the review period.
45. We think the IRP’s decision about the complexity of Mrs A’s needs was in line with the guidance set out in the National Framework.
Unpredictability
46. 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.’
47. The National Framework says an assessor should think about whether it is possible to anticipate the person’s needs, whether the needs or support change at short notice, if the person’s condition is stable, what level of knowledge or skill is needed for a spontaneous response, and what would happen if the need was not met.
48. The IRP report shows the panel considered the unpredictability of Mrs B’s needs. It noted that her needs were stable throughout the review period. When there were incidents of challenging behaviour and resistance to receive care at times, there were clear actions expected of staff to respond.
49. The IRP noted her health needs did not fluctuate. Her care interventions were routine. The IRP noted having an end of life care plan was not evidence of unpredictability. There was no rapid deterioration or sudden change in the level or type of support Mrs A required. These are key pieces of evidence in this characteristic. If a person had unpredictable needs, we would expect to see frequently changing care plans, or carers having to take action outside of the care plans to meet those needs.
50. We can see no emergency interventions were needed. She did not require constant 1:1 supervision nor did she require the completion of behaviour charts. There were no safeguarding alerts raised.
51. We think the IRP’s decision about the unpredictability of Mrs A’s needs was in line with the guidance set out in the National Framework.
52. Mr A says an independent social worker and registered nurse recognised that his mother should have been eligible. We know there was a disagreement between the senior nurse and social worker at the MDT. This led to the case proceeding to a verification panel who decided she was not eligible.
53. CHC funding is not based on an opinion from a specialist worker or consultant. The totality of the needs and the effects of the interaction of needs should be carefully considered before deciding if someone has a primary heath need. If a person meets the criteria for CHC funding, this means their care needs are above and beyond what can be provided routinely by appropriately trained care staff. Therefore, they require a higher level of skilled interventions. A primary health need is based on a person’s day to day care needs and the level of input and skill needed to meet their needs and anticipate and plan for changes in their condition. We can see local authority care staff could meet Mrs A’s need through routine approaches and care procedures.
54. Mr A says a social care and wellbeing assessment detailed that a DOLS was in place. A DOLS indicates a person who lacks mental capacity is unable to leave a place of residence and is under what amounts to ‘continuous supervision’. This would apply to a large number of care home residents in similar scenarios, and this is not of itself indicative of a primary health need.
55. When we weigh up the evidence, we are persuaded the IRP considered the social care and wellbeing assessment as we would have expected it to have done.
56. Our decision does not take away from the account the family has given us, or the challenges Mrs A faced. We appreciate she was reliant on the care she received at the care home. The IRP’s conclusion that her care did not indicate a primary health need and fell within the remit of the local authority appears to be in line with the National Framework.