Summary: Mrs X complained about delays by the Council and NHS Integrated Care Board (ICB) in assessing her late mother Mrs Y’s eligibility for an NHS contribution to her care costs, leading to a missed period of funding. She also complained about the ICB’s decision to fund fewer than 24 hours a day of one-to-one support for Mrs Y. Mrs X complained to us late, more than 12 months after becoming aware of the problem. There are no good reasons for us to investigate the complaint now.

The complaint

1. Mrs X complained about the actions of North Yorkshire Council (the Council) and NHS Humber and North Yorkshire Integrated Care Board (the ICB). She complained that:
1. the Council delayed referring Mrs Y’s case to the ICB, and the ICB then delayed assessing Mrs Y’s eligibility for NHS funding towards the cost of her residential care;
2. when the ICB concluded its assessment, it did not backdate its payments far enough; and
3. the ICB agreed Mrs X needed one-to-one support 24 hours a day, but decided not to fund four hours within that 24-hour period.
2. Mrs X says the delays under a) above meant the NHS contribution to Mrs Y’s residential care was not backdated as far as it should have been. She also says Mrs Y lost out on 4 hours a day of funding that she was entitled to, for the whole period that she needed one-to-one support. Mrs X says that the faults meant Mrs Y unnecessarily paid for some of her care that should have been free of charge. She says this has caused a financial loss to Mrs Y’s estate. Mrs X would like the organisations to reimburse Mrs Y’s estate for the loss.

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The Ombudsmen’s role and powers

3. The Local Government and Social Care Ombudsman (LGSCO) and Parliamentary and Health Service Ombudsman (PHSO) have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA). The two Ombudsmen would not investigate jointly, where a complaint was about matters that fell solely within one Ombudsman’s remit.
4. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something an organisation has done. (Local Government Act 1974, sections 26B and 34D, as amended, and Health Service Commissioners Act 1993, section 9(4).)

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How I considered this complaint

5. I considered evidence provided by Mrs X, the Council and the ICB, as well as relevant law, policy and guidance.
6. Mrs X had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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My assessment

7. NHS Continuing Healthcare (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’. The Government has issued CHC guidance for ICBs, called the National framework for NHS continuing healthcare and NHS-funded nursing care (the National Framework).
8. A person’s local ICB is responsible for assessing their eligibility for CHC and providing the funding. 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. In some cases, an ICB may decide a person is not eligible for CHC for all their care needs, but that it should contribute towards a portion of them. This was the case for Mrs Y, where the ICB decided it would only fund the additional cost of one-to-one support in her residential care setting, rather than her full residential care fees.
9. For most people who may be eligible for CHC, the first step in assessment is for a health or social care professional to complete a CHC Checklist. In Mrs Y’s case, a Council social worker started a CHC Checklist in mid-June 2023 and sent it to the ICB in late July 2023. The ICB completed its assessment in late September 2023, deciding to fund Mrs Y’s one-to-one support. Mrs Y died the following month. In mid-November 2023, the ICB sent an outcome letter to Mrs X. This stated the ICB would pay for Mrs Y’s one-to-one support from mid-August 2023. Around the same time, Mrs X found out direct from the care provider that the ICB was only funding 20, rather than 24, hours a day of one-to-one support.
10. Mrs X was aware of all the issues she complains about from mid-November 2023. The Ombudsmen received Mrs X’s complaint in late March 2025, more than 12 months later. This means her complaint is ‘late’. I have considered whether there are good reasons for us to investigate, despite the lateness.
11. Mrs X complained promptly to the ICB following its decision in November 2023. She did not receive a response from the ICB until July 2024. Mrs X told us she originally posted her complaint to PHSO in November 2024 and only found out that we had not received it in March 2025, after calling to check on the complaint’s progress. Had we received the complaint in November 2024, it would not have been late. These are compelling explanations for why we received the complaint late. However, they are not enough to persuade me to investigate despite the lateness, for the reasons set out below.
12. The ICB has already apologised for the delayed assessment. It has also backdated its funding as far as the National Framework allows, based on the date it received the completed CHC checklist from the Council. These are sufficient remedies for any frustration and financial loss caused directly by the ICB’s delay, following receipt of the completed CHC checklist in July 2023.
13. The Council has also apologised for its delay in submitting the completed CHC checklist to the ICB. This is an appropriate remedy for any non-financial injustice, such as frustration caused by the Council’s delay.
14. Mrs X says Mrs Y’s estate suffered additional financial loss, not remedied by the ICB backdating funding. She says this is because the ICB:
• could not backdate funding to the beginning of August 2023 due to the delay in receiving the completed checklist; and
• paid the care home for 20, rather than 24, hours a day of one-to-one care. Mrs X says this led to higher costs to Mrs Y for the portion of her residential care that she was paying for herself.
15. Another, more appropriate route, is still available to Mrs X to achieve her desired outcome of having the NHS funding backdated to the beginning of August 2023. The ICB has backdated Mrs Y’s funding as far back as the National Framework allows,but ICBs can also consider previously unassessed periods of care (PUPoCs). Mrs X can request a PUPoC for the dates in August 2023 that the ICB has not yet funded. If the PUPoC confirms Mrs Y should have had NHS-funded one-to-one support for the whole of August, her estate can receive a refund. This would resolve any remaining financial injustice from the delay Mrs X complains about.
16. The ICB says it commissioned the one-to-one support direct with the care provider, so Mrs Y should have received 24 hours of one-to-one support at no extra charge to her, regardless of how much the ICB paid the provider. An investigation by the Ombudsmen is unlikely to find the ICB acted with fault or achieve a reimbursement for Mrs Y’s estate from the ICB. If the care provider charged Mrs Y extra for one-to-one support during the period funded by the ICB, Mrs X should complain about this to the provider. If she remains dissatisfied following the care provider’s response, she can complain to PHSO.

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Decision

17. We will not investigate Mrs X’s complaint about care funding assessment delays and decisions. Mrs X complained to us late and there are no good reasons for us to investigate the complaint now.

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Investigator's decision on behalf of the Ombudsman