Summary: We will not investigate Mr C’s complaint about NHS continuing healthcare funding because there is not enough evidence of fault to justify investigating.

The complaint

1. Mr C says the Council failed to complete a checklist for NHS continuing healthcare funding. Mr C says his wife may not have received nursing care because of this. Mr C wants the Council to retrospectively complete the checklist and forward it to the NHS for full assessment.

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The Ombudsman’s role and powers

2. The Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start or may decide not to continue with an investigation if we decide:

• there is not enough evidence of fault to justify investigating, or
• any fault has not caused injustice to the person who complained, or
• we could not add to any previous investigation by the organisation, or
• further investigation would not lead to a different outcome, or
• we cannot achieve the outcome someone wants.

(Local Government Act 1974, section 24A(6))

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How I considered this complaint

3. I considered information provided by the complainant.
4. I considered the Ombudsman’s Assessment Code.
5. I considered the ‘national framework for NHS continuing healthcare and NHS-funded nursing care’ issued by the Department of Health and Social Care.

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My assessment

6. Mr C’s wife, Mrs C, was privately funding residential care. Mr C contacted the Council when their funds fell below the threshold and asked the Council for help.
7. The Council completed an assessment of Mrs C’s care and support needs under the Care Act 2014. The Council assessed residential care was the correct care setting to meet Mrs C’s care and support needs.
8. Some people with long-term complex health needs qualify for free social care arranged and funded solely by the NHS. This is known as NHS continuing healthcare.
9. The first checklist assessment can be completed by a nurse, doctor, other healthcare professional or social worker. Depending on the result of the checklist, you'll either be told that you do not meet the criteria for a full assessment of NHS continuing healthcare and are therefore not eligible, or you'll be referred for a full assessment of eligibility. Being referred for a full assessment does not mean you'll be eligible for NHS continuing healthcare. The checklist is to enable anyone who might be eligible to have the opportunity for a full assessment.
10. The guidance states where there may be a need for NHS continuing healthcare, a checklist should normally be completed. The guidance states whenever an individual needs a long-term care home placement with nursing or has significant support needs, a checklist would be expected to be completed.
11. Mr C thinks the Council should have completed a checklist. The Council did not complete a checklist because it did not assess Mrs C needed nursing care or had significant support needs. The Care Provider and Mr C agreed with this care needs assessment, and the Care Provider said it would contact the Council if Mrs C’s needs changed. Without evidence Mrs C was receiving, or in need of, nursing care the Ombudsman could not say it was fault of the Council not to complete a checklist or that not doing so has caused any significant injustice.
12. Mr C says Mrs C might not have received nursing care because the Council did not complete the NHS checklist. However, the reason Mrs C did not receive nursing care was because the Council did not assess she needed it. The Council made that decision following a care needs assessment undertaken under the Care Act, with input from Mr C and the Care Provider. Mrs C had lived at the residential care home for several years so the Care Provider would have a good understanding of her needs and how best to meet them. It is therefore unlikely the Ombudsman would find fault in how the Council made the decision residential care met Mrs C’s needs.
13. If Mr C feels Mrs C had a primary health need that would qualify her for continuing healthcare, he can ask the NHS to complete a retrospective assessment, without the need for the Council to complete the checklist.

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Final decision

14. We will not investigate Mr C’s complaint because there is not enough evidence of fault to justify investigating.

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Investigator's decision on behalf of the Ombudsman