12. Before we decide if we should conduct 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 has gone wrong when NHSE made its decision.
13. Whether or not an individual is eligible for NHS continuing healthcare funding is a discretionary decision. 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 (July 2022) when it considered whether Mr E 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. To help us reach a decision, we have carefully considered the information Mr E provided alongside the file the IRP considered. When we look at a complaint about an IRP, we consider if it took into account all the relevant information when it made its eligibility decision. Mr E has told us he disagrees with the IRP’s consideration of the skin and behaviour domains and the four key characteristics.
Care domains
Skin
17. Mr E says his mother’s needs in this domain were high.
18. The DST sets out the descriptors for the weightings in each domain. The DST descriptor for high says:
‘Pressure damage or open wound(s), pressure ulcer(s) with ‘partial thickness skin loss involving epidermis and/or dermis’, which is not responding to treatment OR Pressure damage or open wound(s), pressure ulcer(s) with ‘full thickness skin loss involving damage or necrosis to subcutaneous tissue, but not extending to underlying bone, tendon or joint capsule’, which is/are responding to treatment.
OR Specialist dressing regime in place; responding to treatment.’
19. The ICB said Mrs A’s needs in this domain were moderate and the IRP weighted it as moderate too.
20. The DST descriptor for moderate says:
‘Risk of skin breakdown which requires preventative intervention several times each day without which skin integrity would break down.
OR Pressure damage or open wound(s), pressure ulcer(s) with ‘partial thickness skin loss involving epidermis and/or dermis’, which is responding to treatment.
OR An identified skin condition that requires a minimum of daily treatment, or daily monitoring/reassessment to ensure that it is responding to treatment.’
21. We can see from the IRP the panel had a discussion about Mrs A’s skin needs. Mr E gave an account of his mother’s needs. The IRP weighed up her needs to see whether a higher weighting may be appropriate.
22. At the IRP Mr E said his mother would get skin tears because she lashed out. He said she suffered a lot of these and still did at the point of the IRP hearing. They took a long time to heal. He was concerned bandages were needed because she would take plasters off. He said picking at her wounds meant they would take a long time to heal.
23. The IRP said Mrs A’s skin was fragile, vulnerable and at a high risk of breakdown. She needed regular prompting to move and reposition. She slept on a pressure relieving mattress as her pressure areas were at risk. Her skin remained intact at the time of the DST.
24. The IRP acknowledged Mrs A skin was prone to frequent minor skin trauma from skin tears, bruising and abrasions. This was because of the general frailness of her skin. Mrs A picked at her skin tears, scabs and dressings, this extended the healing time for her skin breaks. The IRP acknowledged she needed regular monitoring of her skin integrity and moisturising and barrier creams were applied each day.
25. The IRP said staff were able to carry out all necessary interventions and treatments to help with her skin integrity. Mrs A did not require a referral to the tissue viability nurse. It said the measures in place were standard care arrangements and no specialist dressing or treatments were required.
26. Our clinical adviser said the clinical evidence supports the IRP’s weighting in this domain.
27. We can see the IRP with the help of the clinical adviser took the time to explain the difference between someone with fragile skin that is susceptible to skin tears, bruising which heal and they then get another tear or bruise in a different place on their body and someone who has a wound that causes destruction to underlying tissue and despite treatment it does not heal, a wound that is usually open and is in the same place.
28. The IRP looked at the available evidence and said why it could not say Mrs A’s needs in this domain were high. It said her skin integrity was responsive to pressure relieving aids and the planned interventions and protective measures in place, this included dressings and treatment needed for her skin breaks. This is line with the descriptor for the moderate weighting.
29. We recognise Mr E disputes the weighting in this domain. We consider the IRP acted in line with the National Framework and DST descriptors when it considered Mrs A’s needs in this domain. We can see no indication of a failing.
Behaviour
30. Mr E says his mother’s needs in this domain were severe.
31. The DST descriptor for severe says:
‘‘Challenging’ behaviour of severity and/or frequency that poses a significant risk to self, others or property. The risk assessment identifies that the behaviour(s) require(s) a prompt and skilled response that might be outside the range of planned interventions.’
32. The ICB said Mrs A’s needs in this domain were high and the IRP weighted it as high too.
33. The DST descriptor for high says:
‘‘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.’
34. We can see from the IRP the panel had a discussion about Mrs A’s needs in this domain. Mr E gave an account of his mother’s needs. The IRP weighed up her needs to see whether a higher weighting may be appropriate.
35. At the IRP Mr E said the care records showed his mother shouting, spitting at staff, calling out and would occasionally be aggressive. Mr E recalled an incident at Christmas lunch where his mother would go to hit the carer after every mouthful. He explained once his mother went for him when he was trying to straighten her blanket. He told the IRP his mother had been physically aggressive since February 2021 when she was in hospital. At a previous care home his mother tried to assault another resident. He said mental health services had been asked to come to the home but his mother had left before this could take place.
36. The IRP acknowledged said there was no disagreement as to the form of the challenging behaviour. It looked at how Mrs A’s needs were managed. It acknowledged Mrs A was not always compliant with care and some of her behaviour might have presented a risk but this was managed by staff who knew her. It said there were incidents where Mrs A had episodes of anxiety around personal care. She could be resistance to care staff and would attempt to hit or slap them.
37. The IRP said Mrs A would respond to distraction and/or a retreat and return approach. In response to Mrs A’s shouting staff provided her with company and reassurance. Staff were able to complete personal and hygiene care to a satisfactorily level. Any risks were managed by staff using practical measures. The IRP said no behaviour management plans, or ABC charts were completed. There was no involvement from mental health services. Mrs A required no medication to manage or control her behaviour. Care staff did not require additional skills or training to meet Mrs A’s needs in this domain.
38. The IRP said Mrs A’s needs in this domain were improving and a moderate level of need could apply. However, it acknowledged there was still a potential risk to self and therefore said a higher weighting was appropriate.
39. The records show care staff personal care interventions could trigger aggressive and resistive behaviour from Mrs A and this posed a challenge to delivery of care. Our adviser said care staff were able to manage this behaviour by using a calm approach, offering a calm voice and explanations to Mrs A. Where she was agitated or if aggression arose, staff would ensure Mrs A was safe and walk away and return minutes later to attempt the intervention or complete it. There were no occasions where staff could not meet Mrs A’s needs because of her behaviour. Care plans showed it was important for Mrs A to be comfortable and settled than to have a wash. This approach was a planned intervention and resulted in Mrs A receiving the care she needed.
40. The care home records do not hold behavioural care plans or behavioural charts. Mrs A did have a 1:1 presence at night as there were times where she was unsettled and would call out and require reassurance. Staff were aware one of the triggers for Mrs A being unsettled or agitated was a lack of good sleep and possible infection.
41. There was no evidence Mrs A’s behaviour needed a skilled response above what carers could provide. There is no evidence in the records her behaviour indicated a severity or frequency to present a significant risk of harm that would suggest her needs in this domain were severe. This is what the IRP would have needed to see to give a severe weighting in this domain.
42. We recognise Mr E disagrees with the IRP’s weighting in this domain. It appears the IRP considered this domain in line with the National Framework and DST descriptors when it considered Mrs A’s needs in this domain. We can see no indication of a failing.
Four key characteristics
43. The IRP applies an eligibility test to help it make a decision about an individual’s CHC eligibility. This is what we refer to as the ‘primary health need’ test. 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 an individual’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.
44. 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 A’s needs.
45. Mr E disagrees with the IRP’s consideration of the four key characteristics. The four key characteristics are fundamental to the decision making, so we have looked at how the IRP considered these.
Nature
46. Section 3.3 of the practice guidance within the National Framework describes nature as ‘the characteristics of both the individual’s needs and the interventions required to meet those needs’.
47. In line with paragraph 59 of the National Framework, in the IRP’s consideration of nature we would expect to see analysis of: ‘The particular characteristics of an individual’s needs (which can include physical, mental health or psychological needs) and the type of those needs. This also describes the overall effect of those needs on the individual, including the type (quality) of interventions required to manage them’.
48. Section 3.3 also lists questions prompts for factors that should be considered (though not specifically and individually answered) for the nature indicator:
• How does the individual or the practitioner describe the needs (rather than the medical condition leading to them)? What adjectives do they use?
• What is the impact of the need on overall health and well-being?
• What types of interventions are required to meet the need?
• Is there particular knowledge/skill/training required to anticipate and address the need? Could anyone do it without specific training?
• Is the individual’s condition deteriorating/improving?
• What would happen if these needs were not met in a timely way?
49. The IRP report shows the panel considered Mrs A’s needs and how this impacted her. It’s decision in the nature indicator is clear and presents a full picture of how Mrs A’s needs were met. The IRP focussed on Mrs A’s individual needs rather than her diagnosed medical condition.
50. The IRP looked at the types of care Mrs A needed to keep her safe and well. The report set out the nature of Mrs A’s needs. The IRP acknowledged in the Psychological and emotional needs and drug therapies and medication domain, Mrs A could take time to respond to respond to approaches like reassurance and distraction. The IRP said there was no adverse consequences from Mrs A’s initial refusal of care interventions and personal care could be completed satisfactorily.
51. The IRP said Mrs A did not have a diagnosed respiratory condition or suffer from breathing difficulties or shortness of breath. She did not have any routine medication. She did not need any specific interventions such as an inhaler or oxygen. There were no implications for her daily care needs. It acknowledged she was at risk of aspiration and chest infections and these were treated by her GP.
52. The IRP said Mrs A needed supervision and assistance with eating and drinking. She required lots of prompting and encouragement during mealtimes. It said at the time of the DST Mrs A had a BMI of 18.9 and a MUST score of 2 indicating her weight was borderline low and she was at high risk nutritionally. Mrs A was not prescribed supplements. Care staff gave her fortified milkshakes and snacks in between her meals to increase her diet. She had recent SALT reviews and no notable changes to her diet were made and she was discharged from its services.
53. The IRP acknowledged Mrs A was doubly incontinent and her needs were managed by care staff. She needed monitoring and her pads changing. The IRP acknowledged she could sometimes be resistant to continence care. Staff would provide Mrs A would reassurance, explanation or retreat and return. Staff would check and change her pads every two to four hours. Mrs A was prescribed laxatives for her constipation.
54. She had occasional UTIs. In order to reduce her risk of UTIs staff would encourage her to have frequent intake of oral fluids. The IRP said there was no complications to routine care arrangements monitor and manage Mrs A’s double continence and hygiene needs. The IRP acknowledged Mrs A would have episodes of anxiety with personal care. This could sometimes cause a delay in carrying out her personal care, however, Staff were able to provide to satisfactorily provide personal care to Mrs A.
55. The IRP acknowledged Mrs A’s skin was at high risk of breakdown because of her advanced age, loss of weight bearing ability, nutritional risk and double incontinence. It said her skin integrity responded to pressure relieving aids, planned and protective measures. Mrs A needed prompting to move and reposition in bed. Care staff were able to protect and promote Mrs A’s skin integrity. She did not require any specialist dressing or treatments and measures provided were part of standard care arrangements.
56. The IRP said Mrs A was not able to weight bear and staff needed to deliver care to her whilst she was in bed. It used full body hoist for transfers. She required support and supervision from two staff members for transfer, movement, repositioning and using suitable aids. She had a history of falls and need one on one support when in hospital and when discharged to the care home. The IRP said there was no recorded falls in the home and her one to one supervision had been removed.
57. Mrs A had Alzheimer’s dementia. The IRP said as she did not have awareness of risk she needed support and assistance from staff to keep her safe and for all activities. The IRP said due to Mrs A cognitive impairment she was unable to reliably express herself of communicate. Staff would use their familiarity with Mrs A to anticipate or interpret her needs at all time or look for cues in her facial expressions or body language.
58. The IRP said Mrs A care could be met by care staff, her skin care needs and administration of medication were overseen by a registered nurse. The IRP said the vast majority of care Mrs A needed was for daily activities.
59. We can see the IRP considered the care plans in respect of the Mrs A’s identified needs and found she had variable needs including some challenging behaviour and fragile skin. It said her care interventions to meet these needs could be met by planned intervention and were not unusual or require highly specialised skill to meet her needs.
60. We think the IRP considered all the relevant factors, including the family’s evidence when it decided the nature of Mrs A’s needs did not indicate she had a primary health need. We are satisfied it acted in line with the National Framework.
Intensity
61. Section 3.4 of the practice guidance within the National Framework says intensity ‘is about the quantity, severity and continuity of needs.’
62. In line with the National Framework, we would expect the IRP’s consideration of the intensity indicator to ‘relate 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’)’.
63. Section 3.4 also lists questions prompts for the intensity indicator:
• How severe is this need?
• How often is each intervention required?
• For how long is each intervention required?
• How many carers/care workers are required at any one time to meet the needs?
• Does the care relate to the needs over several domains?
64. We can see the IRP looked at the right things. It had a discussion about the intensity of Mrs A’s needs. The IRP said Mrs A had needs in ten out of the twelve care domains. She had severe level of need in the cognition domain. She had a high level of needs in four domains, these were nutrition, mobility, communication and behaviour domains. She had a moderate level of need in continence, skin, psychological and emotional needs, and drug therapies and medication domains.
65. The IRP said the care needs Mrs A’s needed were consistent with standard skills required of care home staff under supervision of a registered nurse and with access to a GP. It acknowledged she needed daily care and treatment for her skin integrity and to manage minor skin trauma. It said these interventions did not involve complex dressings or additional time from a GP. There was no referral to a TVN. It said there was no indication her skin tears and breaks were not healing or responding to treatment. Mrs A’s continence care was routine. She had no particular breathing difficulties limiting her daily activities or altered state of consciousness which had implications for her daily care. It said she had borderline nutritional risk but she did not require or need prescribed supplements.
66. The IRP acknowledged Mrs A was very unsettled when she moved into the care home. She had challenging behaviour but she had become calmer and less anxious or agitated. Where she still presented with challenging behaviour such as refusing of rejecting personal care, the IRP said she did respond to care staff providing distraction, encouragement or reassurance. Staff would sometimes leave and return to provide her with care which was provided to a satisfactory level. Her challenging behaviour was not a barrier to providing her with a personal and hygiene care.
67. The IRP said Mrs A required support and assistance with activities of daily living. All her care needs could be anticipated by staff and were of a routine nature. Care staff did not view Mrs A’s needs as exceptional in terms of the daily routine for her care. Her needs were managed with the available resources of the care home. Her needs did not require highly skilled or lengthy interventions with extra staff needed to provide her with care.
68. Our adviser said Mrs A’s needs were not intense in nature. We can see the IRP considered all the available evidence when making its comments regarding the intensity of Mrs A’s needs. Mrs A’s care needs could be delivered by carers following a care plan that had been assessed and monitored by a registered nurse and carers within the care home. A GP was consulted when required.
69. We think the IRP considered all the relevant factors, including Mr E’s evidence when it decided the intensity of Mrs A’s need did not suggest she had a primary health need. We are satisfied it acted in line with the National Framework.
Complexity
70. Section 3.5 of the practice guidance within the National Framework says complexity ‘is about the level of skill/knowledge required to address an individual need or the range of needs and the interface between two or more needs.’
71. In line with the National Framework, in the IRP’s consideration of complexity indicator we would expect to see analysis of: ‘how the needs present and interact to increase the skill required to monitor the symptoms, treat the condition(s) and/or manage the care. This may arise with a single condition, or it could include the presence of multiple conditions or the interaction between two or more conditions. It may also include situations where an individual’s response to their own condition has an impact on their overall needs, such as where a physical health need results in the individual developing a mental health need.’
72. Section 3.5 lists the question prompts for the complexity indicator:
• How difficult is it to manage the need?
• How problematic is it to alleviate the needs and symptoms?
• Are the needs interrelated?
• Do they impact on each other to make the needs even more difficult to address?
• How much knowledge is required to address the needs?
• How does the individual’s response to their condition make it more difficult to provide adequate support?
73. We can see the IRP looked at the available evidence. It had a discussion about the complexity of Mrs A’s needs. It acknowledged there was potential and actual interactions between various domains. It said Mrs A’s impaired cognition and lack of capacity were constant factors. As were the physical characteristics of the risk to her skin breakdown, nutritional risk, loss of weight bearing ability, her double incontinence and her resistant behaviour and anxiety.
74. The IRP acknowledged Mrs A required assistance and support with all aspects of her personal and hygiene care because of her cognition and physical limitation. The IRP said at the time of the DST there was no increase in the level or type of care interventions required by staff beyond the normal actions of prompting, encouraging, monitoring, interpreting, anticipating and responding to her care needs. It said all Mrs A’s needs could be addressed by care home staff. Her skin needs were met by monitoring and daily care interventions.
75. The IRP said Mrs A was at risk nutritionally but evidence showed she received satisfactory nutritional intake and did not need prescribed supplements. She did need monitoring to promote her nutrition and a plan was in place to manage risk around her swallowing and coughing. The IRP found no complicating factors or risk to Mrs A continence needs, her needs could be met by care home resources.
76. The IRP said Mrs A’s potential interactions of her needs did not increase components of her care or the support she required above the standard care provided and expected by a care home. The IRP said Mrs A’s needs were not complex or complicated. Her needs did not require additional skills or knowledge to be met.
77. Our adviser said Mrs A’s needs were not complex in nature. We can see the IRP acknowledged there was interaction between the domains, this was influenced by her underlying conditions. Her carers could deliver care to her by following a care plan that had been assessed, planned and monitored by a registered general nurse. The IRP found no evidence to support that Mrs A’s care was difficult or complex to manage. She did not require regular, intensive input from a specialist team.
78. The IRP considered and weighed up the evidence before making its decision. We consider the IRP considered all the relevant factors, including Mr E’s evidence when it decided the complexity of Mrs A’s needs did not suggest she had a primary health need. We are satisfied it acted in line with the National Framework.
Unpredictability
79. 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.’
80. Section 3.6 of the practice guidance within the National Framework says unpredictability ‘is about the degree to which needs fluctuate and thereby create challenges in managing them. It should be noted that the identification of unpredictable needs does not, of itself, make the needs ‘predictable’ (i.e. ‘predictably unpredictable’) and they should therefore be considered as part of this key indicator.’
81. Section 3.6 lists the question prompts for the unpredictability indicator:
• Is the individual or those who support him/her able to anticipate when the needs might arise?
• Does the level of need often change? Does the level of support often have to change at short notice?
• Is the condition unstable?
• What happens if the need isn’t addressed when it arises? How significant are the consequences?
• To what extent is professional knowledge/skill required to response spontaneously and appropriately?
• What level of monitoring/review is required?
82. The IRP report shows the IRP considered the unpredictability of Mrs A’s needs. We can see it had the unpredictability prompts in mind to inform its discussions. The IRP acknowledged the gradual deterioration in cognition or mobility were consistent with what would be expected given Mrs A’s medical history, advanced age and presentation. It said there were no sudden changes or rapid deterioration in her condition at the time of the DST. The IRP said her care needs were known and predictable to deal with through planned care arrangements and it said all care was carried out satisfactorily. It found no sudden or critical changes in care responses required for Mrs A.
83. The IRP said Mrs A’s day to day needs were not unpredictable in terms of the arrangements she needed to provide her with care. Her care needs were known to staff and were straightforward to plan and respond to. It said there was no implication she required changes at short notice to provide her with care.
84. Our adviser has said there was no evidence Mrs A’s care was unpredictable to manage. We can see the IRP considered the available evidence and acknowledged there was interaction between domains but these were influenced by her underlying conditions and did not fluctuate daily. Her care plans were not required to change suddenly. Her carers and nurses were aware there would be days when a leave and return approach was required to complete interventions and Mrs A required support at night when she would call out for reassurance. Mrs A’s care followed a natural format, appropriate to meet her needs arising from her underlying conditions.
85. If a person has unpredictable needs, we would expect to see their care needing frequently or sudden changes. That was not the case for Mrs A. The IRP clearly described why her needs were not unpredictable.
86. We think the IRP considered all the relevant factors when it decided the predictability of Mrs A’s needs did not indicate she had a primary health need. We are satisfied it acted in line with the National Framework.
Summary
87. The IRP showed it applied the National Framework when it considered Mrs A’s CHC eligibility.
88. We recognise Mr E’s account and that he disagrees with the IRP’s decision. We do not wish to take away from his account or what he has told us about his mother’s needs.