Cumbria Partnership NHS Foundation Trust (17 011 029a)

Category : Health > Hospital acute services

Decision : Closed after initial enquiries

Decision date : 23 Mar 2018

The Ombudsman's final decision:

Summary: The Ombudsmen will not investigate Mrs D’s complaint about flaws in her mother’s hospital discharge and assessment of eligibility for NHS continuing healthcare (CHC). The Council and Trust have already accepted some flaws in their actions and have apologised to Mrs D. The CCG has agreed to accept a late request for a review of CHC eligibility. An investigation by the Ombudsmen is unlikely to achieve more for Mrs D and her mother.

The complaint

  1. The complainant, whom I shall call Mrs D, complains about flaws by the Council, Trust and Clinical Commissioning Group (CCG) in
    • the discharge from hospital of her mother, Mrs M,
    • the assessment of Mrs M’s eligibility for NHS continuing healthcare (CHC)
    • communication with Mrs D.

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The Ombudsmen’s role and powers

  1. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
  2. 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).
  3. 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
  • the fault has not caused injustice to the person who complained, or
  • the injustice is not significant enough to justify their involvement, or
  • they cannot achieve the outcome someone wants, or
  • it would be reasonable for the person to ask for a review or appeal,
  • they are satisfied with the actions (or proposed actions) of the Council or NHS organisation.

(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

  1. I have considered information Mrs D has provided in writing and by telephone. I have also considered written information provided by the Council, Trust and CCG. Mrs D, the Council, Trust and CCG have had an opportunity to comment on a draft version of this decision.

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What I found

  1. NHS Continuing Healthcare (CHC) is a package of ongoing care arranged and funded by the NHS, where an assessment concludes a person has a ‘primary health need’. CHC funding can be used to pay for a person’s residential nursing home fees in some circumstances.
  2. NHS-funded nursing care (FNC) is the funding provided by the NHS to residential care homes with nursing, to support the provision of nursing care by a registered nurse.
  3. A person’s local Clinical Commissioning Group (CCG) is responsible for assessing their eligibility for CHC or FNC and providing the funding. CCGs sometimes commission other NHS organisations to carry out the assessments on their behalf.
  4. This usually means a nurse co-ordinates a multidisciplinary assessment and completes a Decision Support Tool (DST) form. The DST is a record of the relevant evidence and decision-making for the assessment.
  5. If a person disagrees with the CCG’s decision that they are not eligible for CHC, they can ask the CCG to review its decision. If they disagree with the outcome of the review, they can appeal to an Independent Review Panel (IRP) organised by NHS England.

What happened

  1. Mrs M has vascular dementia. She was detained by the Trust for assessment under Section 2 of the Mental Health Act 1983 in January 2017. The Trust completed a DST on 15 February 2017 and concluded that Mrs M was not eligible for full CHC funding but that she qualified for the Funded Nursing Care (FNC) element of a residential nursing care placement.
  2. Mrs M was discharged from hospital to a residential nursing home in February 2017 and paid for her own care in full until June 2017 when her assessed contribution dropped to just over £150 per week.
  3. Mrs D says that
    • despite asking repeatedly, the Council gave her no support or information for finding residential care for Mrs M;
    • the Trust did not invite her to attend Mrs M’s CHC assessment;
    • the assessment and its conclusion, that Mrs M was eligible for FNC but not CHC, were flawed. Mrs D believes that, as a result of this decision, Mrs M has had to pay for residential care which should have been fully funded through CHC;
    • the CCG did not tell her of the outcome of Mrs M’s CHC assessment, despite her holding financial power of attorney for Mrs M. This meant she could not appeal the decision;
    • the person doing a later assessment told her that Mrs M should have been eligible for CHC when first assessed;
    • despite upholding most of Mrs D’s complaints, the Council has not refunded Mrs M’s care fees.
  4. The Council sent Mrs D a joint response to her complaint, on behalf of itself and the Trust, in October 2017. This response
    • acknowledged the Council social workers’ communication with Mrs D was not adequate;
    • apologised for this and said it would address this direct with the social workers;
    • accepted that Mrs D should have been invited to the CHC assessment;
    • said that in future, measures will be put in place for families to be invited to CHC assessments and for this to be documented.
  5. However, this response did not offer a financial remedy.
  6. In response to my preliminary enquiries, the Trust sent me a copy of Mrs M’s DST and the CCG’s decision letter stating that Mrs M was not eligible for CHC. This letter is addressed to Mrs M at her residential nursing home. It is dated March 2017 and asks for an appeal to be made within six months of that date.
  7. Mrs D says she did not receive this letter and only became aware of it after complaining to the Ombudsmen. Mrs D says the letter was addressed to her mother, who lacks the capacity to make decisions about finance.
  8. The CCG has now agreed to accept a late appeal from Mrs D.

My analysis

  1. The Trust and Council have already accepted there were flaws in the way they communicated with Mrs D around her mother’s discharge from hospital. This includes how they involved Mrs D in the assessment of Mrs M’s eligibility for CHC funding. My view is that they have already taken appropriate action by acknowledging flaws, apologising to Mrs D and agreeing to improve their practice in the future.
  2. Mrs D considers
    • Mrs M has suffered a financial loss as a result of a flawed CHC assessment;
    • Mrs M should have been in receipt of CHC from the point she entered residential nursing care;
    • had this happened, Mrs M would not have had to pay the full fees herself between February and June 2017.
  3. Where the Ombudsmen investigate and find flaws in assessments, they usually recommend that this is remedied through a review or a re-assessment. The CCG has already agreed to review its decision on Mrs M’s CHC eligibility. Following review, if the CCG decides that Mrs M was in fact eligible for CHC from February 2017, it can refund her residential care fees accordingly. An investigation by the Ombudsmen at this point is not going to achieve more for Mrs M or Mrs D in this respect.
  4. If Mrs D remains dissatisfied with the CHC decision when the CCG has completed its review, she will have a right of appeal to an IRP. If she continues to remain dissatisfied after the IRP has considered her appeal, she can then complain to the Parliamentary and Health Service Ombudsman about this.

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Final decision

  1. The Ombudsmen will not investigate this complaint. The Council and Trust have accepted there were flaws in communication with Mrs D around Mrs M’s discharge from hospital. They have apologised and agreed to improve their practice. The CCG has agreed to accept a late review of its decision that Mrs M was not eligible for CHC funding. I consider this appropriate action in response to Mrs D’s complaint. An investigation by the Ombudsmen is unlikely to achieve more for Mrs D or Mrs M.

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Investigator's decision on behalf of the Ombudsman

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