Summary: Ms X complained that a Care Provider failed to maintain up to date records and care plans for her mother and it failed to refer her mother for a Continuing Healthcare (CHC) checklist to establish if she qualified for CHC. We found there was fault by the Care Provider. We recommended the provider allocated a single point of contact to help Ms X resolve the matter, made an apology and a payment and reviewed its policies.

The complaint

1. Ms X complains that:
2. The care provider failed to maintain up to date records and care plans concerning her mother (referred to in this statement as Mrs Y) while she was resident in Tandy Court.
3. When she asked the care provider to assess Mrs Y for CHC eligibility in or around April 2021, staff did not do this. They wrongly determined that because the care home could still meet Mrs Y’s needs, a CHC assessment was not appropriate.
4. There was a delay in updating Mrs Y’s care plan between April and October 2021.
5. Mrs Y’s care plan was still not accurate by December 2021 and needed further amendment prior to a full assessment for CHC which took place in January 2022.
6. Ms X complains that the inaccuracies in the care planning meant her mother’s needs were not likely to have been met properly between March 2020 and December 2021 and the failure to assess Mrs Y for CHC eligibility led to a delay in this funding being provided for her. The issues also caused Ms X time and trouble and concern.

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The Ombudsman’s role and powers

7. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
8. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
9. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)
10. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

11. I spoke to Ms X and considered the information she provided. I asked the Care Provider for information and considered its response to the complaint. I considered national government guidance.
12. Ms X and the Care Provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Care Provider Policies

13. The Care Provider stated its policy was to review care plans monthly and the resident or their relatives should be included in this review.

Continuing Healthcare (CHC) Assessments

14. Some people with long-term complex health needs may qualify for Continuing Healthcare (CHC). If an individual is found to have a ‘primary health need’ as set out in the National Framework for NHS Continuing Healthcare and NHS-Funded Nursing Care, the NHS will fund some or all of their care needs.
15. An initial assessment for CHC (a checklist) can be completed by a nurse, doctor, other healthcare professional or social worker. The checklist is intended to be relatively quick and straightforward. The outcome would either be that someone does not meet the criteria for a full assessment, and are therefore not eligible, or that a full assessment of eligibility should be carried out. The professional(s) completing the checklist should record in writing the reasons for their decision, sign and date it and give the individual a copy.
16. The National Framework for NHS Continuing Healthcare and NHS-Funded Nursing Care states there will be many situations where it is not necessary to complete a checklist. These include where it is clear to practitioners working in the health and care system that there is no need for CHC at that time. If this is their decision, the reasons for it should be recorded. If there is any doubt between practitioners, a checklist should be completed.
17. We asked the care provider what its policy was for completing CHC assessments. It stated it had no policy as it did not carry out CHC Assessments.

What Happened

18. Mrs Y has vascular dementia and has been a resident of Tandy Court residential care home since 2018. Ms X wrote the content for a detailed care plan for her mother at that time.
19. Mrs Y was unwell with suspected COVID-19 at the end of March 2020. She went into isolation. Visits to the home also ceased at that time.
20. In April 2020, when Mrs Y was well enough to see Ms X via a window visit, Ms X says there was a noticeable progression of her mother’s dementia and significant worsening of her health.
21. Ms X stated her mother was not responding to verbal prompts, was not engaging in activities or speaking in her mother tongue. She was not walking independently, watching the television or making choices for herself. Mrs Y’s behaviour changed significantly, including swearing, shouting and throwing things. She was refusing medication and her GP had advised that medication be given covertly.
22. Ms X had not been aware of the full extent of Mrs Y’s worsening health until March 2021 when the care home allowed visiting to recommence.
23. On reviewing Mrs Y’s care plan she found that it had not been updated, so it did not reflect the changes in her presentation or her needs. As a result, Ms X was concerned about how the care home staff were supporting Mrs Y’s current needs when the care plan did not accurately reflect the changes in Mrs Y’s presentation.
24. Ms X asked for a review of her mother’s care plan and had several meetings with the care home. Due to the change in her mother’s needs, she also asked the care home to carry out a CHC checklist to see if Mrs Y would qualify for CHC.
25. The care provider told Ms X that because they could meet Mrs Y’s needs, and she did not need nursing care, there was no need for a CHC referral. We asked the care provider to explain the apparent confusion between the care home being able to meet Mrs Y’s needs and Mrs Y’s potential eligibility for CHC. The care provider did not expand on its position beyond what it told Ms X in its complaint response.
26. Ms X disagreed with the care home’s reasons for not completing a CHC checklist, but because Mrs Y’s care plans were out of date, she told us that it proved difficult for her to arrange for a separate referral for a CHC assessment. Ms X complained that it took from April 2021 to October 2021 for the care home to update Mrs Y’s care plans.
27. In October 2021 Ms X referred her mother to her GP. The GP carried out a CHC checklist, which Mrs Y passed. The GP referred Mrs Y for a full CHC assessment. Further work was still needed to update Mrs Y’s care plans.
28. A full CHC assessment took place in January 2022. In September 2022 Ms X was hospitalised due to her worsening mobility. She was discharged in October 2022 to an enhanced assessment bed at a different care home. Ms X has been supporting her mother there.
29. Ms X noted that following a delay in the NHS decision, they agreed in October 2022 to grant full CHC for Mrs Y, backdated to 29 November 2021.
30. Ms X considered that, but for the issues with the care plans and the care home’s refusal to carry out a CHC checklist in April 2021, Mrs Y would have been granted CHC much sooner. She explained that the ongoing correspondence with the care provider to get Mrs Y’s care plans updated correctly has been stressful while she was also working and supporting Mrs Y.

Ms X’s complaint

31. In response to Ms X’s complaint, the Care Provider acknowledged that staff at the care home had removed the detailed care plan that Ms X drafted in 2018. Staff had replaced that with a new care plan which lacked detail. The care provider made revisions to Mrs Y’s care plans in January, April, August and November 2021. The response indicates that the revised care plans were not detailed enough and did not properly reflect the changes in Mrs Y’s behaviour, mobility, communication or personal care.
32. Several other issues were noted such as the wrong ‘crash mat’ being used, several medication errors, the way Mrs Y’s hearing aids were managed and a lack of recording in other areas such as fluid charts and distressed behaviours.
33. The complaint response initially stated that the care provider would make a referral for a CHC assessment when significant changes meant the care home cannot meet someone’s needs. In the care provider’s further response it accepted that a CHC referral could be made for any person with long term complex health needs. This was often when a care provider could no longer meet someone’s needs, but not always. The care provider accepted that care plans were insufficiently detailed and had not been properly updated in a timely way to reflect Mrs Y’s changed needs.

What should have happened

34. Government guidance sets out the process for deciding whether someone qualifies for CHC. I found the care provider was at fault when it declined to refer Mrs Y for the completion of a checklist in or around April 2021. I found the care provider’s reasons for not making a referral were flawed. Its staff suggested a checklist could only be completed when a care home can no longer meet someone’s needs. This is incorrect. To qualify, an individual needs to have a ‘primary health need’. An initial checklist considers various areas of someone’s health and behaviour to determine whether a full CHC assessment should be done. Although the care provider’s staff may not complete the checklist themselves, there had been significant changes in Mrs Y’s needs and presentation which may have made her eligible for CHC at that time. The care provider has not provided a proper explanation of its grounds for dismissing the request.
35. To compound the flawed reasoning for not making a referral, the care provider acknowledged that Mrs Y’s care plan and other documents had not been properly updated to set out the changes in her health and behaviour. When they agreed to update the care plans, this was not done thoroughly and it took too long to achieve. This is likely to have delayed Ms X’s ability to make a CHC referral through Mrs Y’s GP or other medical professionals between May 2021 and October 2021.
36. The Care Providers actions caused injustice to Ms X and Mrs Y so I have made recommendations to remedy the injustice caused.

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Agreed action

37. Within four weeks of our final decision:
38. The Care Provider agreed to provide Ms X with a single contact point who was suitably senior and who could liaise with the staff and managers at Tandy Court and provide her with information to support an application to backdate CHC further to April 2020.
39. The Care Provider agreed to provide Ms X with a written apology and make a payment of £250 to Ms X to recognise the distress caused by the fault we have identified. Our website contains guidance on making effective policies. The care provider’s apology should adhere to this guidance.
40. The Care Provider agreed to create a policy for all its staff detailing the actions they should take if a CHC checklist is requested. Its policy should reflect the guidance within the National Framework for NHS Continuing Healthcare and NHS-Funded Nursing Care.
41. The Care Provider agreed to ensure that staff at Tandy Court conduct monthly reviews of care plans in line with its policy. It agreed to reiterate the need to update care plans and other documents with sufficient detail when changes to a resident’s needs are identified at a review.
42. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

43. We found there was fault by the Care Provider. The Care Provider agreed to meet our recommendations and I have now completed my investigation and closed my file on the basis the agreed actions are taken by the Care Provider.

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Investigator's decision on behalf of the Ombudsman