3. Mrs E complains about Norfolk and Waveney Integrated Care Board (the ICB) decision following a Continuing Healthcare (CHC) Checklist on 21 September 2023.
4. Mrs E says as a result her and her husband’s finances have been affected and they have had to pay for care.
5. Mrs E is seeking the ICB to reconsider its decision.
6. In May 2022 Mr E was placed into a care home. In June 2023 the ICB say it received its first referral from the local authority regarding Mr E. On 20 September the ICB completed its first Checklist.
9. Mrs E complains about the ICB’s decision following its checklist on 21 September 2023. The ICB completed a checklist for Mrs E’s husband, Mr E. The checklist was negative and there was no further action taken.
10. In her complaint to the ICB on 5 February 2024, Mrs E explained there were inaccuracies in the checklist. She noted • Mr E breathing issues for 30 years had not been taken into account • Mr E had mobility issues • Mr E made inappropriate advances to members of staff and patients.
11. The ICB explained Mr E had been assessed by its NHS Continuing Healthcare (CHC) team and was provided with a negative checklist. The ICB stated information and evidence gathered for the checklist was provided by the care home and taken from his care records. It was satisfied the checklist had been completed in line with the National Framework.
12. Whether or not an individual is eligible for NHS continuing healthcare funding is a discretionary decision. It is our role to decide if the ICB made its decision in line with the National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care (National Framework) 2022.
13. We cannot question discretionary decisions when they have been made without maladministration (fault) and we can only uphold a complaint about an eligibility decision if there is some specific fault in the way the ICB reached its decision. Such decisions are based on clinical judgements and opinions. The fact that someone else has a different opinion does not mean that there must have been a fault in the decision making process.
14. We have considered the National Framework. It says:
‘111. The Checklist is the NHS Continuing Healthcare screening tool which can be used in a variety of settings to help practitioners identify individuals who may need a full assessment of eligibility for NHS Continuing Healthcare.
113. The Checklist has 11 care domains broken down into three levels: A, B or C (where A represents a high level of care need, and C is a low level of care need). The outcome of the Checklist depends on the number of As, Bs, and Cs identified.
115. Completion of the Checklist is intended to be relatively quick and straightforward. It is not necessary to provide detailed evidence along with the completed Checklist.’
15. Firstly, we considered who completed the checklist.
16. The National Framework says:
‘122. The Checklist can be completed by a variety of health and social care practitioners, who have been trained in its use. This could include, for example: registered nurses employed by the NHS, GPs, other clinicians or local authority staff such as social workers, care managers or social care assistants’
17. The checklist was completed by a senior carer at the care home. It is recorded Mrs E was invited to attended but did not do so. The checklist was completed by an appropriate person.
18. Next, we considered how the checklist was completed. The National Framework says:
‘127. The Checklist requires practitioners to record a brief description of the need and source of evidence used to support the statements selected in each domain. This could, for example, be by indicating that specific evidence for a given domain was contained within any relevant patient care records on a stated date. This will enable evidence to be readily obtained for the purposes of the MDT if the person requires a full assessment of eligibility for NHS Continuing Healthcare.’
19. We have reviewed the checklist. We have seen the senior carer has noted a description of each need and provided evidence to support each statement. The following are examples:
‘Mr E has normal consistency food and fluids. Mr E is reported to take under thirty minutes at mealtimes. Mr E is reported with a weight of 75kg in August and a weight of 76kg in September, with a MUST score of 0.’
‘Mr E’s skin is reported as intact at present. Mr E has a Waterlow score of 11’
20. We have reviewed the records. We have not seen any clear and obvious errors regarding descriptions in the checklist. The records confirm for example his weight was 76Kg in September. There is no indication of a failing in the ICB’s decision making.
21. Mrs E raised three inaccuracies with the checklist. We will now consider these in turn.
22. Mr E says Mr E breathing issues for 30 years had not been considered. She explains Mr E’s breathing issues resulted in a hospital admission. There were also several occasions where Mr E was treated by paramedics.
23. The checklist says Mr E did not report any breathing concerns, was not prescribed any inhalers or nebulisers and did not report any recent chest infections. It was recorded Mr E scored a C in this domain.
24. The descriptors for a score of C says normal breathing, no issues with shortness of breath. Or 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.
25. We have not seen the ICB got anything wrong in its description of Mr E’s breathing needs. We acknowledge Mr E does have a history of some breathing issues but he did not receive ongoing care for these. The ICB have accurately reflected Mr E condition at the time of the checklist using his medical records.
26. Mrs E says Mr E had mobility issues. She explains for a long time he experienced falls which included one hospitalisation. She explains his mobility issues led to a double hip replacement.
27. The checklist says Mr E is independently mobile with a Zimmer frame. He is reported to become wobbly on his feet at times but usually when he is unwell. Mr E has not been reported with any recent falls. It was recorded Mr E scored a C in this domain.
28. The descriptors for a score of C say, ‘Independently mobile. Or able to weight bear but needs some assistance and/or requires mobility equipment for daily living’.
29. There is no evidence of a fall in the records. We have considered if the ICB’s description is supported. As an example on 23 August 2023 it is noted, ‘help with walking, needed little or no help but help was on hand if needed, used a Zimmer frame’. There are no clear and obvious errors with the ICB’s decision here.
30. Mrs E explains Mr E made inappropriate advances to members of staff and patients. This was considered in the behaviour domain.
31. The ICB explained in this domain Mr E is compliant with his care needs. He can be sexually inappropriate at times. A safeguarding issue was raised, and GP informed on the 8 September due to Mr E inappropriately touching another resident. The senior carer said this behaviour was out of character. Mrs E did not agree with this statement. The ICB considered Mr E scored a B in this domain.
32. The descriptors for a score of B says, ‘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.’
33. The ICB did include Mr E’s behaviour in its consideration. We cannot see this was inaccurate. We acknowledge Mrs E does not agree with the view this behaviour was out of character. We have not seen evidence in the records Mr E’s behaviour posed a risk to self, others or property. As noted above, Mr E was compliant with his care. We cannot say the ICB got anything wrong here.
34. Mrs E says the ICB have not acknowledged Mr E’s unpredictable and confrontational behaviour which resulted in two black eyes. The records for the relevant time period have no record of an incident where Mr E had two black eyes. We do not dispute Mrs E recollection of events.
35. We recognise it would be distressing to witness her husband with black eyes. We do not have any other details of this incident or when it occurred. We have seen the ICB considered the relevant records and available information in reaching its decision in the behaviour domain could be consider inaccurate. This one-off incident would not mean the overall decision for this domain was inaccurate. We will therefore will not take further action on this complaint.
36. We acknowledge how important this complaint is to Mrs E. The CHC process can be frustrating and stressful. We consider the ICB completed the checklist in line with the National Framework. We have seen no indications of a failing in its decision making.
1. We have carefully considered Mrs E’s complaint about Norfolk and Waveney Integrated Care Board (the ICB). We acknowledge it has been ongoing for a long time and how challenging continuing healthcare appeals can be.
2. We have not found the ICB got anything seriously wrong in its decision making. Our decision is not intended to detract from Mrs E’s account or experience.