Retrospective review
24. The family complain the ICB refused to complete a review of Mrs Q’s needs for the period from 20 November 2018 to 21 March 2019.
25. The family say it understands the ICB refused to complete a review of this period due to the decision support tool (DST) assessment of 20 November 2018. The family explain the refusal to complete the review is not compliant with national guidance, namely the National Framework.
26. In its complaint response of 2 April 2025, the ICB refers to the Department of Health and Social Care and NHS England’s guidance, ‘Dealing with requests for assessments of previously unassessed periods of care from 1 April 2012’ (Published 14 December 2023). It says, ‘If an ICB finds evidence that the individual has previously been found not eligible for NHS CHC following a full assessment, the period is already assessed, and no further assessment is necessary.’
27. The ICB says Mrs Q did have a full assessment on 20 November 2018 to determine her eligibility for NHS CHC funding. As such, a retrospective review would not be undertaken for the period of 20 November 2018 to 21 March 2019 as this is not an identified previously unassessed period of care.
28. The Department of Health and Social Care in its guidance of Dealing with requests for assessments of previously unassessed periods of care from 1 April 2012 explains ‘a request for a PUPoC assessment refers to a request for an ICB to consider NHS CHC eligibility where the ICB had responsibility for an individual, for a specific past period of care, where:
• there was no consideration of NHS CHC eligibility by the relevant ICB for that individual during the past period of such care • that individual had funded that past period of care in full or in part • there is appropriate, objective evidence that the individual should have been considered for eligibility for NHS CHC in accordance with The National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012 (as amended) and the national framework’.
29. Our adviser explains if the family requested an assessment of the time frame which was the same as a PUPoC, then the ICB are correct in stating Mrs Q had already undergone a full consideration of care needs to establish whether there were a Primary Health Need and eligibility for CHC funding.
30. Our adviser also explains the period of care in question for Mrs Q cannot be considered as previously unassessed period of care (PUPoC) as the evidence shows she had undergone an assessment of eligibility in line with the National Framework and was not eligible for CHC funding.
31. As such, we can say the ICB are correct in declining a PUPoC assessment as there was a full consideration of Mrs Q’s health needs on 20 November 2018 and there was no period of unassessed care.
32. We recognise it can be frustrating to have an assessment declined, and we acknowledge the family feel national guidance (the National Framework) was not followed in this matter. After careful consideration, there are no indications of failings in the ICB’s decision to not carry out a PUPoC assessment, in line with the National Framework.
Assessment format, consideration of domains, and key characteristics 33. The family complain DST was completed by a third party and was not in the standard format. They complain by failing to complete the appropriate documentation, the ICB has provided no evidence to support the care domains, or four key characteristics were adequately considered, or the National Framework was followed.
34. The ICB explains the Strata document is a full DST but presented in a different format, and it was the digital recording management document used by NHS Morecambe Bay CCG at that time. It says due to an encryption, it does not print the whole document, only the sections of the document the family have received.
35. It also apologises to the family for feeling the document does not have sufficient information recorded within the assessment.
36. A review of the documentation dated 20 November 2018 has been carried out as part of its investigation. This has evidenced a detailed summary containing at least one to two paragraphs of which outlines a detailed recommendation capturing the levels of nature, intensity, complexity, or unpredictability of Mrs Q’s care needs.
37. The National Framework (2012) states,
‘69. Standing Rules Regulations make it clear that if the CCG is to use any screening tool, that tool must be the NHS Continuing Healthcare Checklist. They may, if they wish, directly move to a full MDT assessment for an individual without using a Checklist. However, a CCG cannot use a different tool or method for screening for NHS continuing healthcare’.
38. The National Framework (2018) states,
‘83. The Standing Rules require a CCG to take reasonable steps to ensure that individuals are assessed for NHS Continuing Healthcare in all cases where it appears that there may be a need for such care. These regulations also state that if an initial screening process is used to identify where there may be a need for such care, then the Checklist is the only screening tool that can be used for this purpose.
2.The purpose of the Checklist is to encourage proportionate assessments of eligibility so that resources are directed towards those people who are most likely to be eligible for NHS Continuing Healthcare, and to ensure that a rationale is provided for all decisions regarding eligibility’.
39. Our adviser explains an ICB cannot change the documentation prescribed by the Department of Health (DOH) for NHS Continuing Healthcare (CHC) assessments. The DOH has established clear guidelines and frameworks which ICBs must adhere to when making eligibility decisions for CHC funding. Our adviser further explains any changes to the documentation or guidelines would require a formal amendment process and approval from the DOH. As such, ICBs are expected to follow these guidelines to ensure consistency and fairness in the assessment process.
40. While we recognise the Strata document used was not in line with the National Framework, this relates to an issue with the process rather than the accuracy of the information recorded in the document. Our adviser states, the details entered on the document appropriately reflects Mrs Q’s needs, which provides clear evidence of the identified healthcare requirements.
41. We raised this concern with the ICB on 15 January 2026 via email in line with our complaint standards, specifically the principle of ‘welcoming complaints in a positive way’, and ‘being through and fair’. These standards require consideration of whether an error has resulted in injustice or affected the outcome for individuals. While the correct process was not followed, we cannot see any evidence it compromised the quality of Mrs Q’s assessment of health needs or led to an incorrect outcome.
42. We also informed the ICB the importance of sharing the above information to ensure learning is taken from this to ensure consistency, and adherence to the National Framework going forward. We asked the ICB to consider our concerns and to highlight what steps will be taken to ensure all future assessments are completed using the prescribed documentation which is fully compliant with the National Framework.
43. The ICB confirmed in an email on 21 January 2026 to us it has discontinued the usage of the Strata document, and it acknowledges the requirement to meet the National Framework standards.
44. The actions of the ICB are in line with the NHS Complaint Standards of Giving fair and accountable responses which say ‘Organisations empower staff to identify suitable and appropriate ways to put things right for people who raise a complaint. They provide guidance and resources to make sure any proposed action to put things right is consistent.’ As such, we can see the ICB has taken sufficient steps to put things right, and we will not consider this issue further.
45. We recognise the family feel disadvantaged because of the incorrect document was used to complete Mrs Q’s health needs. The evidence confirms this did not impact the overall outcome, and the ICB has confirmed it is no longer using the document. We do not find any indications of failings in this complaint aspect.
Written correspondence
46. The family says the ICB failed to provide proof that the outcome was adequately communicated to the patient, giving them the right to appeal. The ICB says while it is unable to locate hard copies, there are notes on its case management system dated 22 February 2019 which shows the team leader at the time requested the decision outcome letter to be sent.
47. The ICB also says within the records on its system a discussion took place with the patient’s Next of Kin (NOK). It states as this is a historical case, and records have been transferred to several record management systems over the years; the team is unable to evidence the request was completed.
48. The ICB also says the All Age Continuing Care (AACC) service acknowledges as part of the service transfer following the decommissioning of CCGs, poor document and record management practices where inherited from organisations that no longer exist, it has impacted its ability on this occasion to provide all the information the family require and apologise for the frustration.
49. The Strata document notes ‘They were informed regarding the panel process. They were informed that the decision will be sent to them via post. An information leaflet was not given as they have previously been given a leaflet at previous assessments’.
50. Further in the document, it is also recorded the following, ‘… [Mrs Q] has undergone a vast physical change since her CVA and her family cannot understand how it means she does not have a primary health need… advised that they could submit their own evidence to panel if they wished, however, they declined. They were informed of the post ratification appeal process’.
51. The National Framework (2018) notes in paragraph 159 ‘Once the eligibility decision is made by the CCG, the individual should be informed in writing as soon as possible (although this could be preceded by verbal confirmation where appropriate).’
52. From the above, we can see the ICB informed the family of the outcome at the time of the decision verbally and informed of the post-ratification appeal. This is in line with the National Framework.
53. In the complaint response to the family, the ICB and AACC firstly indicated they could not provide the outcome letter as they were unable to locate the hard copies. We requested the ICB and AACC team to consider locating the hard copies again, and as a result were able to provide the outcome letter to us on but were able to send the evidence to us on 18 December 2025.
54. While the outcome letter is dated 23 February 2018, which indicates an error in the year date, as the assessment took place on 22 November 2018, it is considered as evidence. It is addressed to Mrs Q’s daughter and shows the ICB informed the family of the outcome and of their right to appeal the decision. We can see the letter also discusses the four key characteristics and explains why a Primary Health Need was not identified.
55. The ICB also provided an extract from its data base which supports a telephone conversation took place with Mr Q and a discussion was held about his mother’s assessment, and the outcome.
56. We recognise how important it is for families to feel informed and supported throughout the assessment process. The ICB communicated directly with the family at the time so they understood what the outcome was, and what the next steps would be in the case. While we understand the situation may have felt challenging, the evidence demonstrates the ICB followed the National Framework and took reasonable steps to keep the family informed. As such, we cannot fault the ICB’s actions.
57. We understand how important this complaint is for Mr Q and his family. We also recognise this decision will be disappointing for Mr Q. We hope our consideration of his complaint reassures him we have taken his complaint seriously and have undertaken a thorough consideration of the issues.