Derby and Derbyshire Integrated Care Board

3. Mrs A complains about the ICB’s decision that Mr O did not screen in for an NHS continuing health care assessment for the period 27 January 2017 to 9 April 2018. She disputes the ICB’s scores in the domains for behaviour, cognition, psychological/emotional, communication and mobility. She also complains the ICB did not consider her comments on the domains and Mr O’s hospital records.

4. Mrs A says the ICB’s decision has caused her considerable distress. She says Mr O’s estate has been financially disadvantaged.

5. Mrs A wants an apology, care fees to be paid back and compensation for her distress. She also wants service improvements.

6. In November 2016 Mr O was admitted to hospital. In December he was discharged to a nursing home. He became a permanent resident of the home.

7. By April 2017 Mr O experienced a general decline in his physical abilities. He became reliant on staff to help with transferring him from one place to another. Mr O was able to make his needs known. He was reliant on staff to help with his hygiene needs. He had a long-term catheter in place and was incontinent. Medication was given to him which he took. He had a low body mass index and his nutrition and weight were monitored by staff.

8. On 12 September 2017 Mr O was awarded funded nursing care.

9. On 29 March 2018 he was admitted to hospital with pneumonia. He was started on intravenous antibiotics (into the vein). On 3 April he was discharged to the care home. He had fast track CHC funding from 10 April and died in early September.

10. On 9 May 2019 Mrs A sent the ICB her completed application form to request a review for a previously unassessed period of care. On the same day the ICB noted her application.

11. On 29 October 2020 the ICB completed a CHC checklist. It covered the period from 27 January 2017 to 9 April 2018. On the same date the clinical support unit, on behalf of the ICB, sent Mrs A its decision outcome letter. It said Mr O did not screen in for a CHC assessment.

14. In our primary investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. When we see there is a sign something went wrong, we go on to consider whether the organisation had done enough to put right the impact this had on the complainant.

ICB’s checklist decision

15. CHC describes care provided over an extended period of time to meet physical or mental health needs as a result of disability, accident or illness. If someone meets the criteria to receive CHC funding, their care will be funded by the NHS. A ICB is responsible for CHC funding decisions, but sometimes commissions other organisations to do this work.

16. The ICB should carry out an assessment for CHC funding in all cases where it appears there may be a need for it. To decide whether a full CHC funding assessment is required, the ICB can use a screening process, known as the checklist.

17. A domain describes a subset of care needs, for example, nutritional needs. There are 11 domains in the checklist. The checklist contains three separate columns. Column A describes the highest rating for care needs. Column C describes the lowest needs and column B describes average needs.

18. The checklist says a full assessment for NHS continuing healthcare is needed if there are:

• two or more domains selected in column A • five or more domains selected in column B, or one selected in A and four in B, or • one domain selected in column A in a priority need, with any number of selections in the other two columns.

19. It is not our role to question clinical judgment. Instead, our role is to consider whether the evidence matches the checklist descriptors and the ICB’s scoring in the domains being challenged.

20. The checklist does not determine eligibility for CHC so there is no consideration of the primary health need test or the eligibility criteria (four key characteristics). We can only consider the checklist and rationale alongside the information available to the person completing the checklist at the time (once we have decided the right information was gathered).

21. Mrs A disputes the ICB’s scoring in the domains for behaviour, cognition, psychological and emotional, communication and mobility. We will consider each domain below.

Behaviour

22. The ICB assessed the level of need in this domain as C. Mrs A disagrees and says it should have been B. The checklist describes C as:

• ‘No evidence of ‘challenging’ behaviour.

OR Some incidents of ‘challenging’ behaviour. A risk assessment indicates that the behaviour does not pose a risk to self, others or property or a barrier to intervention. The person is compliant with all aspects of their care’.

23. It describes B as:

• ‘‘Challenging’ behaviour that follows a predictable pattern. The risk assessment indicates a pattern of behaviour that can be managed by skilled carers or care workers who are able to maintain a level of behaviour that does not pose a risk to self, others or property. The person is nearly always compliant with care’.

24. Mrs A said Mr O had no particular challenging behaviour, but he did have behaviour that made it difficult to look after him safely, particularly when Mrs O had been caring for him at home. She said Mrs O was 85 years old at the time and had to employ a carer to help. Mrs O had been using a mobility scooter to take Mr O to the bathroom. Mrs A when Mr O lost strength in his legs, Mrs O would drag him off the scooter by his belt. Mrs A says Mr O did not accept anything was wrong. She says he insisted Mrs O wash him before the carers arrived and then refused to let them put him to bed.

25. The ICB says there was no evidence of any behavioural concerns.

26. We note Mrs A’s account mainly referred to Mr O’s behaviour when he was being cared for at home. This was before the period the checklist covered and Mrs A accepted his behaviour improved when he moved into the nursing home. This is the period the checklist covered. The detail about his earlier needs was helpful background information, but could not influence the checklist decision.

27. Our adviser says the evidence supports the ICB’s score of C, but for the wrong reason. We note it referred to the wrong part of the descriptor. It said there was no evidence of challenging behaviour but there is evidence to show Mr O had occasional episodes of challenging behaviours that continued throughout the assessed period. Mrs A’s account refers to Mr O’s behaviour improving when he went into the care home and that while he could still be difficult, staff could manage that.

28. On the checklist, the ICB should have highlighted, ‘some incidents of ‘challenging’ behaviour. A risk assessment indicates that the behaviour does not pose a risk to self, others or property or a barrier to intervention. The person is compliant with all aspects of their care’.

29. While the ICB did not explain its rationale well, the decision was in line with the evidence. We cannot the ICB’s scoring was wrong.

Cognition

30. The ICB assessed the level of need in this domain as C. Mrs A disagrees and says the score should be B. The checklist describes C as:

• ‘No evidence of impairment, confusion or disorientation.

OR Cognitive impairment which requires some supervision, prompting or assistance with more complex activities of daily living, such as finance and medication, but awareness of basic risks that affect their safety is evident.

OR Occasional difficulty with memory and decisions/choices requiring support, prompting or assistance. However, the individual has insight into their impairment’.

31. It describes B as:

• ‘Cognitive impairment (which may include some memory issues) that requires some supervision, prompting and/or assistance with basic care needs and daily living activities. Some awareness of needs and basic risks is evident.

The individual is usually able to make choices appropriate to needs with assistance. However, the individual has limited ability even with supervision, prompting or assistance to make decisions about some aspects of their lives, which consequently puts them at some risk of harm, neglect or health deterioration’.

32. Mrs A says Mr O had cognitive impairment expected for the final stages of normal hydrocephalus. Hydrocephalus is a build-up of fluid in the brain. She says he had difficult with thinking, rationalising, reasoning, decision making and he could get very confused. She said he needed assistance with all but minor decisions. He had lost interest in daily activities and he had short term memory loss.

33. The ICB said there are limited records. It said on 31 January 2018 the records show Mr O was able to remember information to make decisions independently. He showed he knew where he lived and could make his thoughts and wishes known. He had insight into his communication, such as his lack of motivation to eat on 9 May 2021. On 31 January 2018 he requested bed rails following a fall from his bed. The ICB said there is an entry on 3 April 2018 that Mr O was improving but was confused when he was being treated in hospital for a chest infection.

34. Our adviser says the evidence supports the ICB’s score of C. The nursing assessment completed on 25 July 2017 shows Mr O had no cognitive impairment. He was alert and orientated although his family said he could be ‘muddled at times’. Mr O realised he had some difficulties with his short-term memory. The care plan dated 31 January 2018 shows he was fully orientated, able to keep information and make decisions for himself. On 31 January 2018 the GP records say Mr O had no cognitive problems. On 29 March Mr O was admitted to hospital and treated for a chest infection. On 3 April the records show he had improved but was still confused. On 5 April the record shows he felt low the day before his mood but it had picked up.

35. We note again that the ICB did not correctly highlight the rationale in the checklist. It highlighted both the first two of the criteria in the descriptor for C set out above. However, the evidence supports the third criterion, referring to occasional difficulty with memory and decisions, needing support and having insight.

36. The ICB did not explain its rationale clearly, but the decision was in line with the evidence. We cannot say the ICB’s scoring was wrong.

Communication

37. The ICB assessed the level of need in this domain as C. Mrs A thinks the scoring should be C. However, we think this is a mistake, as she says she disputes the ICB scoring. We think she means the score should be B. The checklist describes C as:

• ‘Able to communicate clearly, verbally or non-verbally. Has a good understanding of their primary language. May require translation if English is not their first language.

OR Needs assistance to communicate their needs. Special effort may be needed to ensure accurate interpretation of needs or additional support may be needed either visually, through touch or with hearing’.

38. It describes B as:

• ‘Communication about needs is difficult to understand or interpret or the individual is sometimes unable to reliably communicate, even when assisted. Carers or care workers may be able to anticipate needs through non-verbal signs due to familiarity with the individual’.

39. Mrs A says towards the end of his life Mr O had very limited use of his hands, which made writing impossible for him. She says he could talk articulately but a lot of what he said could be confused. This meant he could not always make his needs known or understood. She said he had a call button but would forget to use it.

40. The ICB said the records indicate Mr O was able to make his needs known verbally and there were no issues with communication.

41. Our adviser says the evidence supports the ICB’s score of C. For example, the nursing assessment says Mr O had no difficulty in his communication. The GP records say on 3 July 2017 Mr O felt unwell but he ‘could not put his finger on what it is…’. We note Mrs A’s own account of Mr O’s communication difficulties towards the end of his life remain in line with the descriptor for C. It captures that effort may be needed to understand the person’s needs, which is what she describes.

42. We are satisfied the ICB considered the available evidence in line with the domain descriptor. We have not seen any failings with the ICB’s scoring.

Psychological/Emotional

43. The ICB assessed the level of need in this domain as C. Mrs A disagrees and says the score should B. The checklist describes C as:

• ‘Psychological and emotional needs are not having an impact on their health and well-being.

OR Mood disturbance or anxiety or periods of distress, which are having an impact on their health and/or wellbeing but respond to prompts and reassurance.

OR Requires prompts to motivate self towards activity and to engage in care planning, support and/or daily activities’.

44. It describes B as:

• ‘Mood disturbance or anxiety symptoms or periods of distress which do not readily respond to prompts and reassurance and have an increasing impact on the individual’s health and/or well-being.

OR Due to their psychological or emotional state the individual has withdrawn from most attempts to engage them in support, care planning and/or daily activities’.

45. Mrs A says Mr O experienced depression and was treated with antidepressants. This varied from mild in the earlier stages and frequently became worse. He could be low for days and sometimes weeks at a time. During his time at the care home he had expressed a desire to be dead.

46. The ICB said there is very limited evidence available for this domain and it is from the GP records. On 28 February 2017 the GP prescribed Mr O’s sertraline medication was increased to 100mg. The records indicate the increased medication improved his mood.

47. The evidence supports the ICB’s score of C for this domain. The records show Mr O had a long history of depression and had been on antidepressant medication for several years. The nursing assessment says Mr O thought that his emotional state was stable. But the care staff felt he was in a low mood and was disengaged with staff and his care. The carers mention that his low mood could be related to ongoing family matters.

48. The GP records say on 28 February 2017the GP assessed Mr O and decided to increase his sertraline medication from 50mg to 100mg per day. On 10 July the GP records say Mr O’s mood was ok. He said he got a little bored at times but was generally content. On 12 July the GP records say someone (the name of the person had been removed) was concerned about his low mood and weight loss, they accepted he was very unmotivated but said things had improved a little. On 13 July the GP records show again the GP discussed Mr O’s recent weight loss, low mood and recent urinary tract infection. The record says Mr O was quite tearful the other day but had since improved. It said he was trying out fortisip drinks (supplement drinks) and trying to eat more. The GP offered a consultation but this was declined and the person was happy to see how things went.

49. The nursing assessment dated 25 July 2017 says Mr O thought that his emotional state was stable, with no issues. But the care staff felt he was in a low mood and was disengaged with staff and his care. The carers mention that his low mood could be related to ongoing family matters. On 10 August the GP records say he was now eating much better. On 2 September Mr O said he felt well in himself. On 13 March 2018 the GP records show Mr O was in good spirits and did not appear to be confused. On 29 March the GP record says he was confused but could answer simple questions. On the same day he was admitted to hospital to treat his chest infection. The records show he had shown understanding of his care plan and gave verbal consent. On 3 April he was discharged. On 5 April the records showed he felt very low the day before but his mood picked up today.

50. We are satisfied the ICB considered the available evidence in line with the domain descriptor. Mr O did have low mood and periods of distress, but he did respond to prompts and was engaging with care planning. This agrees with the descriptor for C in this domain. We have not seen evidence of a failing here.

Mobility

51. The ICB assessed this domain as C between 31 January and 2 April 2017. Between 3 April 2017 and 9 April 2018 it said it was B. Mrs A disagrees and says it should have been assessed as B for the first two months and then A. The checklist describes C as:

• ‘Independently mobile.

OR Able to weight bear but needs some assistances and/or requires mobility equipment for daily living’.

52. It describes B as:

• ‘Not able to consistently weight bear.

OR Completely unable to weight bear but is able to assist or cooperate with transfers and/or repositioning.

OR In one position (bed or chair) for majority of the time but is able to cooperate and assist carers or care workers.

OR At moderate risk of falls (as evidenced in a falls history or risk assessment)’.

It describes A as:

‘Completely unable to weight bear and is unable to assist or cooperate with transfers and/or repositioning.

OR Due to risk of physical harm or loss of muscle tone or pain on movement needs careful positioning and is unable to cooperate.

OR At a high risk of falls (as evidenced in a falls history and risk assessment).

OR Involuntary spasms or contractures placing the individual or others at risk’.

53. Mrs A says Mr O had huge mobility issues. She says when he was discharged from hospital he was transferred briefly via a banana board. She says both his feet had dropped and he could not weight bear. She said he needed two carers to hoist and help him to the bathroom. She said he used a wheelchair for limited periods. She says as his health deteriorated, he became bed bound and needed regular turning and repositioning. Mrs A says for many months he could not move his legs and arms. She says before he died, he could not move his legs at all. He was unable to move himself and was dependent on others to do this for him.

54. The ICB said until 3 April 2017 the evidence indicates Mr O was able to transfer from one place to another with the help of two staff and the use of mobility aids. It says there is no evidence of unreliability in transferring and no falls were documented. Between 3 April 2017 and 9 April 2018 the records says Mr O had reduced power in his quadriceps muscles. A slide board or full hoist was advised for transfers. However, it seems he was mainly transferred via a hoist. The ICB says during the whole period Mr O did not walk around freely due to his poor mobility. On 16 January 2018 Mr O was found half hanging out of bed. On 31 January he rolled out of bed. Mr O requested a bed rail and no further incidents occurred. On 17 February 2018 he was assessed as having a high risk of falls.

55. The ICB said from 3 April 2017 to 9 April 2018 Mr O’s mobility declined further. He was dependent on staff to use a hoist for transfers. Records do not suggest he was not compliant with moving and handling interventions. It said although Mr O had a fall it did not amount to a significant fall history. He was being assessed as at moderate risk and there were no further incidents after bed rails were used.

56. Our adviser says the evidence supports the ICB’s score of C for the period between 31 January 2017 and 2 April 2017. There is evidence that on 30 January 2017 Mr O was able to transfer with help and he was using mobility aids. This agrees with the descriptor for C. However, the ICB recognised after this date Mr O’s mobility declined and he became more dependent on staff to use a hoist to transfer him. The ICB file shows Mr O was assessed by a physiotherapist on 3 April 2017. He was no longer safe to transfer with a rotunda or stand aid. He could manage a slide board and it was recommended he would benefit from chair raisers. The evidence supports the ICB’s increased score of B for the period between 3 April 2017 and 16 February 2018.

57. But there is evidence to show from 17 February to 9 April 2018 Mr O’s mobility needs were greater. The ICB pack shows the fall risk assessments between 17 February and 3 April 2018 often assessed Mr O as being at high risk of falls. A high risk of falls is one of the criteria for a score of A in this domain. The IRP did not find this.

58. This suggests a failing, as we cannot say the ICB considered the evidence in line with the domain descriptor for the whole period. It appears to have got this wrong from 17 February 2018.

Impact

59. We recognise Mrs A disagrees with the ICB’s decision. We do not wish to take away from her account or what she has told us about Mr O’s needs.

60. We can see the evidence does not support the ICB’s scoring in the mobility domain from 17 February 2018 to 9 April 2018. If Mr O had a score of A in the mobility domain this would have made a difference to the overall decision for this period. A full assessment is indicated if an individual scores any of the following:

• 2As • 5Bs • 1A and 4Bs or • 1A in a priority domain (behaviour, breathing, drug therapies and medication, and altered states of consciousness).

61. If the ICB had from 17 February 2018 scored the mobility domain as A in line with the descriptor, this would have changed the decision. As from 17 February 2018 Mr O would have had two As (nutrition and mobility) and he would have screened in for a full CHC assessment.

What we have asked the ICB to do

62. We do not think the ICB has fully considered the evidence for the mobility domain. As a result, we have concerns about its scoring in this domain.

63. Our Principles for Remedy, ‘Getting it right’ (our principles), say that public bodies should acknowledge when things have gone wrong and put things right.

64. We asked the ICB if it would be willing to reconsider this case and carry out a full CHC assessment for the period from 17 February to 9 April 2018. The ICB has agreed to do this.

65. We are satisfied this is enough to put right Mrs A’s complaint in line with our principles. It will make sure the ICB properly considers all the evidence. We think this resolves the matter and there is nothing more we could achieve if we investigated the complaint.

Procedural issues

66. Mrs A says the ICB did not consider her comments on the domains and Mr O’s hospital records.

Hospital records

67. Mrs A says the ICB asked her for details of the hospitals Mr O had stayed at. She says she provided the ICB with this information but it did not consider these records.

68. The records show in November 2016 Mr O was admitted to hospital. He was discharged in December 2016. Between 29 March and 3 April 2018 he was admitted to hospital and diagnosed with pneumonia.

69. The records show the ICB got Mr O’s hospital records and included this in its file. We can see the hospital records do not include records from Mr O’s hospital admissions in November 2016 and 29 March to 3 April 2018. However, Mr O’s first admission was in December 2016, this was several weeks before the period under review. Our adviser said it would only have provided a record of progress Mr O made in hospital, any ongoing issues and his needs at that time. While the records would have been considered as background information, they would not have shown what Mr O’s needs were during the period under review.

70. We know that had the ICB got Mr O’s records from his hospital stay between 29 March and 3 April 2018, these records could have given further details of his needs during the last week of the review period, after his discharge and before he got fast track funding. This would have given limited further evidence. However, the ICB has agreed to carry out a full CHC assessment from 17 February 2018 anyway. In doing so the ICB will consider Mr O’s needs from this date, which includes the period he was admitted to hospital. Because of this there is no need to consider this part of the complaint further.

Consideration of Mrs A’s comments

71. The National Framework 2018 says:

• ‘97. The Checklist requires practitioners to record a brief description of the need and source of evidence used to support the statements selected in each domain’.

72. The records show Mrs A gave the ICB her written comments. We can see the ICB included Mrs A’s comments on each domain in the checklist and the needs portrayal document.

73. Our adviser says the nurse assessor gave very little comments in the checklist and did not show how they had considered Mrs A’s information. The assessor did not say where they got their sources of information to support their clinical decision. The nurse assessor did not give a clear rationale to support the recommendations given in the checklist. There suggests a failing, as this is not in line with the National Framework. This says the assessor should record a brief description of the need and evidence of the source used. It is also not in line with practice guidance 23 of the National Framework 2012 to give a clear rationale to support the recommendations given in the checklist.

74. However, we are satisfied the ICB made the right decision in the majority of the domains. We do not think the ICB correctly considered the evidence in the mobility domain from 17 February to 9 April 2018. But this is not because it did not properly consider Mrs A’s comments. We can see the ICB itself noted Mr O was at high risk of falls from 17 February 2018. It ignored its own evidence here, not Mrs A’s.

75. We realise the ICB could have given a better rationale and more comments to explain its decisions in the checklist. However, we cannot say its decision in the mobility domain was wrong because it did not properly consider Mrs A’s comments. We therefore do not think this had an impact on the decision.

1. We have carefully considered Mrs A’s complaint about Derby and Derbyshire Integrated Care Board’s (ICB – formerly CCG) decision that her father, Mr O, did not screen in for (need) an NHS continuing healthcare (CHC) assessment. There is evidence that the ICB did not properly consider the evidence in the mobility domain from 17 February to 9 April 2018. The ICB has agreed to look at the complaint again and carry out a full CHC assessment for this period.

2. We are sorry to hear the ICB’s decision caused Mrs A’s distress. We are satisfied with the actions the ICB has agreed to take to put things right in line with the Parliamentary and Health Service Ombudsman’s (our) Principles for Remedy.