Cheshire and Merseyside Integrated Care Board

3. Mrs B complains about Cheshire and Merseyside Integrated Care Board (ICB) on behalf of her late mother, Mrs C.

4. She says the ICB did not acknowledge and apply the Covid-19 emergency legislation. Its continuing health care (CHC) suspension letter dated 27 May 2020 made no reference to this. It was not until 5 May 2023 when the ICB finally agreed that their mother qualified for retrospective funding through the Covid-19 emergency legislation.

5. Mrs B is unhappy with the time it took the ICB to progress the PUPoC assessment of her mother’s needs. She says the ICB did not provide timely information between 27 May 2020 and 29 March 2021. It did not clarify how it was going to progress with the review following the suspension.

6. She is also unhappy that the ICB’s CHC team sent her process concerns about the delay in the PUPoC assessment to the patient experience team (PET). She says the family could not access the link to access the PET portal and were stuck in two complaint systems. They had to repeat all the information.

7. Mrs B says the ICB’s contradictory process and lengthy delays were stressful and had a deep impact on the family’s wellbeing. It traumatised them. The failure to apply emergency Covid-19 legislation resulted in unnecessary assessments and years of grief for the family. It delayed natural closure for the loss of her mother. The two-tier complaints system caused them additional distress. The family had to relive their mother’s healthcare episodes when they completed the information gathering tools for assessment. They were left helpless and have lost faith in the ICB.

8. Mrs B wants the ICB to acknowledge its failings and apologise for the impact they had on the family. She wants it to make service improvements in the way it keeps families updated about CHC assessments and applies funding legislation for patients. She also wants a financial remedy for the distress caused.

9. The ICB was Cheshire CCG until July 2022. We refer to it as the ICB throughout for ease of reference.

10. For several years Mrs C was cared for and supported by family at home. Her dementia diagnosis also required the services of privately funded support.

11. On 13 May 2020 the family contacted the GP to understand how to get a package of care as their mother’s dementia needs were getting more complex. They requested a referral for continuing health care funding. This is where some people with long-term complex health needs qualify for free health and social care arranged and funded solely by the NHS. The GP signposted them to the council.

12. On 20 May the social worker had declined and sent Mrs C back to the GP. It was felt she required two carers twice a day for 1 hour and the family should progress with self funding her care. On 22 May a district nurse completed a positive checklist at Mrs C’s home. A checklist is a screening tool used to help practitioners identify individuals who may need a referral for a full assessment of eligibility for CHC. On 27 May 2020 CHC funding assessments were suspended due to the pandemic.

13. On 8 June 2020 Mrs C was admitted to a nursing home as the family could no longer manager her needs.

14. On 3 August 2020 the GP visited the nursing home and noted Mrs C required palliative care.

15. On 1 September 2020 CHC services resumed.

16. Mrs C died on 4 September 2020 at the nursing home.

17. On 22 November 2020 Mrs B sent an email request to the CHC team to complete a PUPoC assessment. This is where the ICB can look back at a past period of care to see if the person should have been eligible for CHC, as long as they had not had an assessment during that period.

18. Between November 2020 and July 2022, the ICB gathered the records to complete the PUPoC assessment.

19. On 8 July 2022 a clinician began work on Mrs C’s needs portrayal document (NPD). The ICB sent the NPD to Mrs B for comments and feedback on 7 September. In September 2022 Mrs B raised concerns about the PUPoC assessment. She also set out some Covid legislation that was in place around the time of her mother’s original checklist, and complained that the ICB should have applied this.

20. The ICB prepared a second draft NPD, which it shared on 26 January 2023. But it also addressed her complaint about the Covid legislation. On 28 April the ICB held an exceptional circumstances consideration panel and gave the outcome on 5 May. It agreed to reimburse the costs of Mrs C’s care between 22 May 2020 and 4 September 2020 on the basis that she would have been eligible for funding under the Covid legislation in place at the time.

21. After Mrs B sent the ICB the evidence of those case costs, the ICB reimbursed those.

24. 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 found the ICB has put right the impact of what it got wrong in the complaints process, PUPoC assessment and Covid-19 emergency legislation.

The ICB did not apply the Covid-19 emergency legislation sooner

25. Mrs B says the ICB did not acknowledge and apply the Covid-19 emergency legislation. It incorrectly said that only a social worker could have access to admission avoidance funding during the Covid-19 funding period. It was not until 5 May 2023 when the ICB finally agreed that their mother qualified for retrospective funding through the Covid-19 emergency legislation.

26. The senior patient experience manager said the ICB dealt with this case as an exceptional circumstance as it appeared to be an isolated case. It did this to ensure the family were treated appropriately and put in a position they would have been if the pandemic did not interrupt their mother’s CHC assessment pathway. The ICB used the exceptional circumstances process as it did not have any other local processes that were appropriate at that time. It provided a reimbursement for the period between 22 May 2020 and 4 September 2020.

27. The Covid-19 Hospital Discharge guidance in place in May 2020 said the Government agreed the NHS would fully fund the cost of new or extended out of hospital health and social care support packages. This applied for people being discharged from hospital or who would otherwise be admitted into it, for a limited time, to enable quick and safe discharge and more generally reduce pressure on acute services.

28. On 22 May 2020 a district nurse completed a positive checklist for Mrs C at home. The ICB wrote to the family on 27 May 2020 saying there would be a delay in doing the full CHC assessment due to the pandemic.

29. On 8 June 2020 Mrs C experienced an acute medical episode which required an emergency admission to a nursing home as the family could no longer manage her at home. The GP documented that in usual circumstances, she would have gone into hospital.

30. So there is evidence Mrs C met the criteria for the Covid-19 emergency funding at this point. We have thought about whether it should have realised this sooner than it did.

31. First, when the ICB paused Mrs C’s CHC assessment after the positive checklist, she had not experienced the medical episode that led to her emergency admission to a nursing home. It was that medical episode that provided objective evidence that she would have been eligible for the emergency funding. So it could not have realised at the time it paused the assessment. As we explain later, the ICB was not aware that Mrs C’s GP later arranged her admission to the care home.

32. On 1 September 2020 CHC assessments resumed. But Mrs C sadly died just three days later, before the ICB could do the full assessment. Therefore there was no reason for the ICB to have done anything further at that point.

33. Mrs B asked for reimbursement of care costs in November 2020. The ICB started to manage this via a PUPoC assessment. We can see why it did this. Mrs C had a positive checklist before the suspension of CHC assessments and was not funded or assessed during after this. So the ICB managed the case via what it felt was the appropriate process. These were unprecedented times when Covid-19 guidance was revised multiple times over a short period of time. A piece of guidance applied in Mrs C’s case because of a change in the clinical situation after the ICB had got her positive checklist. We cannot reasonably have expected the ICB to have realised this. What it did was not incorrect.

34. Once the ICB was on the PUPoC assessment pathway, we can understand why it focused on this and did not consider whether any other guidance might have applied. We know Mrs B is not happy with how long the ICB took to process this, and we look at that later in this decision.

35. In September 2022 Mrs B wrote to the ICB about Covid-19 emergency funding. We know the family say they mentioned Covid-19 emergency legislation earlier in a letter dated 8 April 2021. We have seen that letter. Mrs B wrote, ‘somehow the process of progressing the application of CHC funding and the introduction of Emergency Covid19 guidelines/legislation delayed facilitating an eligibility outcome’.

36. We can see this letter was focused on the delays in completing the retrospective review. It mentioned the Covid legislation in passing, in the middle of a sentence. We do not think the ICB could have reasonably picked up on this at this point. Whereas the September 2022 letter referenced the Covid legislation in more detail and the family’s understanding of it.

37. The ICB responded in November 2022. The ICB said emergency Covid-19 funding was only for patients in hospital who needed to be discharged into a care home or their own home with a care package. It said it did not apply to Mrs C, who was already in a care home.

38. Mrs B wrote to the ICB about this again in February 2023. She did not get a response.

39. On 6 March 2023 the ICB told the family that the emergency funding relied on a social worker involved in arranging an emergency admission into 24-hour care to also arrange the funding. The ICB said this was a local arrangement, it was not explicitly in the legislation. The ICB said Mrs C’s GP arranged her care home admission so the ICB was not informed.

40. The family maintained that Mrs C should have been eligible for the emergency funding. On 28 April 2023 the ICB held an exceptional circumstances consideration panel. They believed the period between May and September 2020 should be funded.

41. On 5 May 2023 the outcome of the exceptional circumstances appeal was that the ICB agreed to fund for the period between 22 May and 4 September 2020. They felt Mrs C would have been eligible under normal circumstances. If the family had a different social worker, they would have made arrangements that would have led to Mrs C getting the emergency funding. The ICB reimbursed the care costs with interest.

42. When we weigh up the evidence, we cannot reasonably criticise the ICB for not realising Mrs C was eligible for the emergency funding before the family raised this with it in September 2022.

43. But when they did, we think the Trust should have put things right sooner. The situation was very different from September 2020, so the ICB had more time to carefully consider the information the family provided. We can see the ICB gave incorrect information in its first few responses.

44. It said funding was only applicable to patients leaving hospital, which was not the case. It said hospital avoidance was not a criterion for emergency Covid funding until phase 3 of the NHS guidance, set out in a letter on 31 July 2020. When we compare this to the phase 1 guidance in place in May 2020, they both say the same thing – that the funding was available to avoid hospital admission. We appreciate Mrs C’s care home admission had not been arranged by a social worker in line with local guidance. But this did not stop the ICB from retrospectively applying the funding after the exceptional circumstances panel. So we think the ICB could have established the facts and put things right sooner after September 2022. We recognise this would not have happened immediately.

45. Because it did not do that, and the family had to continue to pursue it, this caused them extra work, worry and frustration.

46. The NHS Complaint Standards state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

47. We asked the ICB if it would be happy to write to Mrs B to acknowledge it should have applied the correct legislation when it first replied to the complaint in November 2022 and offer an apology for the extra work, worry and frustration the family experienced getting this sorted out. The ICB has agreed to do this.

48. We have thought about whether the impact warrants a financial remedy. Mrs B has described how frustrating and traumatic the process was for them. We also know this is because it took a few years to get her mother’s care costs reimbursed. We must consider the impact only of what the ICB got wrong – that after the family raised concern relating to the emergency Covid legislation, it took several months to realise this applied. So this accounted for only a small part of the time they waited, and we can see it involved the family sending just a couple of further letters to the ICB. We do not think the majority of the time they waited was because the ICB got things wrong.

49. We looked our ‘Our guidance on financial remedy’ and we think this is a level 1 impact. A case will generally be level 1 if we consider the person affected has experienced a low impact injustice such as annoyance, frustration, worry or inconvenience. This would typically arise from a single (one-off) incidence of maladministration or service failure, where the effect on the person complaining is of short duration, and where there are no other adverse effects or ongoing wider impact. We usually consider an apology to be an appropriate remedy for these cases.

50. We discussed this with the family’s advocate and asked if the apology resolved the complaint. They told us the family are understandably disappointed that we have not asked the ICB to pay a small financial remedy, they are happy to receive the apology.

51. Finally, the ICB’s associate director also confirmed the ICB has addressed all cases that were stood down during Covid-19 and completed assessments where appropriate. The ICB continues the recovery work taking place since the pandemic which has led to closer working relationships with hospital discharge teams, working to remove barriers and the prioritisation of work with the aim to meet the 80% target of assessments completed within 28 days of referral. As the Covid-19 legislation is no longer in place, the same situation should not occur. But we are pleased to see the ICB has taken learning from this.

52. We are satisfied the ICB has now done enough to put things right in line with the NHS complaint standards. There is nothing further we need to ask it to do.

The ICB did not progress the PUPoC assessment quickly

53. Mrs B feels the ICB did not provide timely information and clarify how it was going to progress with the PUPoC assessment following the suspension of CHC assessments. We Here were are specifically looking at how long it took the ICB to progress this once it had started on that pathway, and before the ICB changed to considering the Covid legislation.

54. We know in November 2020 Mrs B sent the ICB a PUPoC assessment request. The ICB acknowledged this request in February 2021.

55. In March 2021 the ICB sent Mrs B the relevant form. On 8 April Mrs B completed the application.

56. Between June 2021 and March 2022, the ICB gathered the relevant records for the review. In June 2022 it sent a letter to Mrs B apologising for delay. In July 2022 a clinician began work on Mrs C’s NPD. In September 2022 the ICB apologised for distress the outstanding matter caused. It sent Mrs B the NPD for comments.

57. Our Principles of Good Administration, ‘Getting it right’, says that public bodies should follow policies and procedures, act in line with establish good practice, and provide effective services.

58. The PUPoC guidance in place at the time did not specify a timeframe for when a PUPoC assessment should be completed. When we weigh up what the ICB was doing, we do not think the delay was because of something it did wrong. It had a backlog of cases, with fewer staff than usual as CHC staff were redeployed to other roles to help manage the pandemic. It needed to gather evidence to complete the PUPoC assessment and it made timely referrals to third party providers for records. Ultimately, the ICB could not prioritise a PUPoC assessment over unpaused assessments for those who needed consideration of their current needs at the time.

59. We are satisfied there is no indication of a failing here. We think the ICB acted in line with our Principles. The ICB progressed the assessment as quickly as it could, gathering the information it needed in line with the PUPoC policy. We appreciate this was still a long timeframe and we are pleased to see the ICB recognised this when it apologised to the family for the distress they felt during the progression of the review.

ICB complaint process

60. Mrs B is unhappy the ICB sent her process concerns about the delay in the PUPoC assessment to the patient experience team (PET). She says the family could not access the Egress link (a secure email system) to access the PET portal, so they were stuck in two complaint systems. They had to repeat all the information.

61. The ICB said it only has one complaints policy, and this is publicly available on its website.

62. The ICB’s complaints process says a formal complaint should always be sent immediately to the PET for initial acknowledgment. The PET log all complaints received and agree timescales for response.

63. Once the PET has reviewed the complaint, they will liaise with the complainant to confirm that the information received about the complaint is accurate and covers all their concerns and seek consent. Once they have consent they will acknowledged the complaint within three working days. This includes a timescale for responding to the complaint– usually within 35-40 working days.

64. The Trust was responsible for making sure it responded to the complaint, regardless of how it did that. We can see the ICB’s CHC team sent the complaint to the PET team (although not when). The PET sent Mrs B an Egress link to sign into. She could not access it, so she did not know what PET were investigating. Mrs B told the CHC team on 23 January and 10 March 2023 that she could not log into the Egress link, but got no response. The family later learned that PET had already investigated and responded on 20 February.

65. Our Principles of Good Administration, ‘Being customer focused’, say public bodies should communicate effectively and be helpful.

66. We can see no evidence that the CHC team told Mrs B it was sending her complaint to the PET. And there is no evidence that did anything about Mrs B’s difficulties accessing the Egress system. So we do not think the ICB acted in line with our Principles here.

67. The NHS Complaint Standards, ‘Promoting a learning culture’ says that effective complaint handling promotes a culture that is open and accountable when things go wrong. Organisations use learning to improve their services and make sure every member of staff knows their role in promoting a learning culture. Organisations demonstrate how they use learning to improve services.

68. We can see the ICB has already acknowledged that it missed opportunities to identify and explore the issues Mrs B experienced with accessing the PET response and correspondence via the Egress link.

69. It said the CHC team are working closely with the PET to develop refresher training for staff about complaints procedures. This is so they can identify specific concerns or issues and understand how to respond and escalate those issues effectively. This training took place on 21 October 2024. The ICB will also work together to review the referral process between the CHC team and PET. This will improve communication with individuals about such referrals.

70. We noted the ICB had not yet offered the family an apology for the frustration they experienced because of what it got wrong here. The ICB has now agreed to do this, and the family has accepted.

71. We think this enough to put things right and there is nothing further we need to ask the ICB to do.

72. We appreciate how difficult the family found this process. We hope what the ICB has agreed to do gives them some closure on the matter.

1. We have carefully considered Mrs B’s complaint about Cheshire and Merseyside Integrated Care Board (ICB). The ICB has agreed to acknowledge it should have applied the correct legislation in November 2022 and offer an apology for the emotional impact it had. It will also apologise to the family for the frustration caused and difficulties experienced in the complaint handling process. We can also see the ICB has already apologised for the delays in progressing the previously unassessed period of care (PUPoC) assessment. There is nothing more we need to ask it to do.

2. We were sorry to hear about the distress the events have had on the family and the loss of faith it has caused. We hope our decision reassures you that the ICB has and will put things right in line with the NHS Complaint Standards.