Summary: Mr and Mrs A complain about the handling of their son, B’s Continuing Healthcare assessments by the Council. We will not investigate as the Council has responded appropriately and we would not recommend any further action on its part.

The complaint

1. Mr and Mrs A complain on behalf of their son, B about how Coventry City Council (the Council) has assessed his needs in relation to eligibility for Continuing Healthcare (CHC) funding. Specifically, Mrs A complains the Council has not properly applied the National framework for NHS continuing healthcare and NHS-funded nursing care (the National Framework) when assessing B’s needs.
2. Mrs A says this has led to B not having CHC funding for his care home placement since 2016. Mr and Mrs A would like for their son to be found eligible for CHC funding and for fees they paid for his care to be refunded.
3. Mr and Mrs A would also like more training for Council staff in assessing people for CHC.

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The Ombudsman’s role and powers

4. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
5. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
6. The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start or continue with an investigation if they believe:

• it is unlikely they would find fault, or
• it is unlikely they could add to any previous investigation by the bodies, or
• they cannot achieve the outcome someone wants

(Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

7. I considered information provided by the Mrs A and the Council.
8. I considered the Ombudsman’s Assessment Code.
9. I considered Mrs A’s comments on my draft decision before making this final decision.

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My assessment

10. CHC is a package of ongoing care that is arranged and funded by the NHS where a person has been assessed as having a ‘primary health need’. CHC funding can be provided in any setting and can be used to pay for a person’s residential nursing home fees in some circumstances.
11. NHS-funded nursing care (FNC) is the funding provided by the NHS to residential nursing homes that also provide care by registered nurses. FNC funding is set at a weekly rate.
12. A person’s local Clinical Commissioning Group (CCG) is responsible for assessing their eligibility for CHC or FNC and providing the funding. Social care professionals can contribute to these assessments before the CCG make the decision on eligibility.
13. B has learning difficulties and lives in a residential care home. He was assessed in 2017 for CHC funding and found not to be eligible. The Council contributed to the assessment.
14. A joint package of care was put in place involving funding from the CCG and the Council.
15. Mr and Mrs A complained in May 2021 about the Council’s assessment and stated it had not properly taken into account the National Framework when making its assessment.
16. The Council responded to the complaint and explained its role in the CHC process and how it adhered to the National Framework. It also encouraged Mrs A to appeal the decision to the CCG.
17. The Council is correct in its analysis that Mr and Mrs A’s best avenue if they disagree with assessments and the decision on eligibility is the CCG, not the Council.
18. It would not be proportionate for us to investigate the Council as its response is reasonable and ultimately the decision lies with the CCG.

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Final decision

19. We will not investigate this complaint. This is because the Council has given a reasonable response and we could not achieve anymore for Mr and Mrs A in this complaint.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman