Norfolk and Waveney Integrated Care Board

8. Mr P complains about the decision made about his father, Mr B’s care and treatment from Norfolk and Waveney Integrated Care Board (the ICB). Mr P specifically complains about the following:

• one-to-one funding was revoked without any prior consultation with the family • the ICB failed to complete a mental capacity assessment or a risk assessment prior to ending the one-to-one support • the ICB failed to complete a second review in which the family were involved • the ICB did not seek any advice from the appropriate professionals before it made it decisions.

9. By removing this one-to-one funding, Mr P states this has severely limited his mother’s ability to safely visit her husband, as the care home are regularly not sufficiently staffed to provide support.

10. Mr P says this decision has had a negative impact on his mother’s mental health, as well as father’s own welfare. It has restricted his right to family life. By failing to complete an assessment of risk to his mother, Mr P says this is a massive oversight, and are proceeding with its plan despite their complaints.

11. His mother feels unsafe to visit her husband alone and is regularly unable to visit him because of these changes. Mr P says his father has less interaction throughout the day and is in more regular distress.

12. As a result of his complaint, Mr P wants processes to be followed in terms of the MentalCapacity Act, family consultation to be guaranteed in all CHC reviews to prevent thishappening to other families, an acknowledgement the ICB completely failed to appreciate the level of risk present or the distress it has caused.

13. Mr B had a brain aneurysm (a weak spot in the wall of a blood vessel in the brain that can balloon and fill with blood) several years ago. This led him to develop Othello's syndrome, (also known as delusional jealousy, is a rare psychiatric disorder characterized by intense, and irrational jealousy).

14. Mr B moved from one care home to another in July 2024, and one to one care for 24 hours daily was agreed to be continued by the ICB to allow for a settling in period of him. The plan was to complete weekly reviews for his needs.

15. Mr B had a review of his one-to-one care in November 2024. Following the review, Mrs B was sent an email to inform her the overnight provision of one-to-one care was not indicated when reviewing care documentation. Assistive technology and overnight checks were agreed with the care home.

16. Mrs B emailed the ICB to report her anxieties and advised she wanted to be included in future reviews, and possible reductions of one-to-one care.

17. The ICB emailed Mrs B in May 2025 to advise following a review of care records, discussions with the home manager and deputy, there was no reason for the daytime one-to-one care to continue. As such, one-to-one care was stopped the following day.

18. Three days later the CHC team did a welfare check on Mr B, and the family were assured there had been no untoward incidences/near misses to suggest one-to-one care was still required.

19. In June, a further call was made by the CHC team lead and there was no indication one-to-one care required reinstating.

20. Eight days later, a senior CHC nurse emailed the care home manager requesting the stopping of the one-to-one care. There were no concerns raised in the response from the care home manager.

21. The ICB decided not to reinstate the one-to-one care for Mr B as there is no clinical reasoning for doing so.

22. A less restrictive options has been trialled and to date, the ICB feels it is meeting Mr B’s assessed needs for support.

One-to-one funding and communication 26. Mr P complains in the ICB conducted a CHC review of his father’s care, and during this review the ICB failed to communicate with the family at any point. He also states the ICB failed to assess his father’s capacity to contribute towards the review of his care or assess the risk he still poses prior to revoking the funding.

27. Mr P complains the ICB took the decision to revoke the one-to-one funding without any consultation.

28. Following Mr B’s move to the new care home in July 2024, the ICB states one-to-one care for 24 hours daily was agreed to be continued by the ICB to allow for a settling in period for Mr B.

29. It also says in the complaint response, the plan was to complete weekly reviews for his needs. The response states he had a review in November and following the review Mrs B was informed via email the overnight provision of one-to-one care was not indicated, and instead assistive technology and overnight checks were agreed with the care home.

30. At the start of May 2025, Mrs B was informed via email following a review and discussions with the home manager, there was no justification for the daytime one-to-one to continue. This was stopped the following, and a welfare check was conducted three days later.

31. At the start of June, the care home informed the CHC team on two separate occasions, there were no concerns raised in stopping the one-to-one care.

32. The response acknowledges, Mr B was no longer mobile and risks to himself and others had been reduced. The response also states it recognises the past trauma Mrs B has experienced, and the care home had put in steps to assist with her visits.

33. The ICB states it will not be reinstating the one-to-one care for Mr B as there is no clinical reasoning for doing so. A less restrictive option has been trialled and to date has been meeting Mr B’s assessed needs for support.

34. We considered whether the ICB made the appropriate decision to stop the one-to-one funding.

35. The evidence shows prior to stopping the one-to-one funding, the ICB requested the Antecedent, Behaviour and Consequence (ABC) records from the care home. An ABC chart is an observational tool which allows practitioners to record information about what happened before, during, and after the behaviour. This allows practitioners to identify underlying causes and allows them to develop effective management strategies.

36. The ABC records are dated across seven days April 2025. While the records show Mr B was unsettled and shouting on most days, he was not aggressive or a danger to staff or others.

37. For example, between the seven days in April, the notes state ‘showed repetitive behaviour’, ‘shouting and screaming’. There were occasions where he was unsettled and trying to get out of his chair. The notes also show the staff tried to reassure him and made him comfortable.

38. Our adviser says there is no evidence to support the additional one-to-one provision was clinically necessary and even with it in place, the records show Mr B would still scream and shout. He could not be distracted or reassured.

39. The care home staff were also confident they could provide the required support for Mr B and his wife with a chaperone present.

40. This approach is consistent with National Institute for Health and Care Excellence (NICE) guideline of ‘Violence and aggression: short-term management in mental health and health and community settings’. It states restrictive interventions must be ‘used for no longer than necessary’ with regular reviews and reduction where they are no longer effective.

41. Our adviser also comments the ICB were commissioning a ‘Tier 3’ package of care, which included 13 hours of direct one-to-one care per day and one and half hours of direct registered nurse care as part of the provision. As such, the additional 12 hours of daytime one-to-one care in place meant the ICB were in effect paying twice for the care.

42. Our adviser states as a public body, the ICB must consider its spending as it is considered as guardians of the public purse and are bound by the NHS Financial Standing instructions.

43. NHS England in ‘NHS financial framework: integrated care board and system finance business rules’ says ‘ICBs also have a duty to act with a view to ensuring that they deliver financial balance individually (section 223GC of the [National Service Act 2006]). This is to promote careful financial management and to reflect legislation that requires NHS England and ICBs to manage within a fixed budget’.

44. In conclusion, the decision to withdraw one-to-one funding was appropriate, and proportionate. With continuous supervision, Mr B’s shouting and distress persisted regardless of whether one-to-one support was present. This demonstrated the intervention was not effective in managing Mr B’s presenting behaviour.

45. We also understand the ICB acted within its limit as it was already commissioning a package of care to meet Mr B’s assessed needs, and the continuation of one-to-one support would have resulted in a duplication of provision, which would not meet the ICB’s financial obligations. As such, we do not find an indication of a failing.

46. We recognise the concerns raised by Mr P regarding the withdrawal of the one-to-one support, especially given the complexity of Mr B’s condition and the distressing nature. These concerns have been carefully considered with input from our adviser.

47. We will next consider the communication aspect raised by Mr P.

48. The records show Mrs B was invited to the review of Mr B’s one-to-one in November 2024, which includes an email inviting her to participate in a review of the one-to-one provision .

49. Mrs B replied to the email on the same day stating she was happy with the provision and she will decide to attend when she knows the time of the review meeting.

50. Later in November, Mrs B was informed it was decided her husband no longer required the one-to-one night provision, and the care home would have safety measures put in place to replace this. She was also informed he would still be in receipt of the daytime one-to-one.

51. The evidence shows an email from Mrs B sent to the ICB at the start of December 2024 saying she agreed with the ICB’s plans, although she was anxious about the removal of the one-to-one provision at night. She also accepted it was a fair decision, and she asked to be involved in any further reviews of her husband’s care.

52. While there is evidence the ICB contacted Mrs B about the removal of the one-to-one night provision, there is no evidence to suggest the family were invited to participate in any discussion regarding the reduction in one-to-one during waking hours.

53. The evidence suggests the decision to remove the one-to-one during waking hours was made following a review of behaviour records and a discussion with the manager at the care home, but it did not involve the family.

54. The National Framework states ‘Individuals being assessed for NHS Continuing Healthcare are frequently facing significant changes in their life and therefore a positive experience of the assessment process is crucial. The process of assessment of eligibility and decision-making should be person-centred. This means placing the individual at the centre of the assessment and care-planning process.’

55. It also goes on to say:

‘69. There are many elements to a person-centred approach, including:

• ensuring that the individual and/or their representative is fully and directly involved in the assessment process; • taking full account of the individual’s own views and wishes, ensuring that their perspective is incorporated in the assessment process; • addressing communication and language needs; • obtaining consent to any physical intervention/examination as part of the assessment process (where the individual has capacity to give this); • obtaining consent to the sharing of personal data with third parties (e.g. family, friends, advocates, and/or other representatives) (where the individual has capacity to give this); • dealing openly with issues of risk; and • keeping the individual (and/or their representative) fully informed.

56. Our adviser says while the provision of one-to-one is not a function of the National Framework, the principles above are a good guideline of involving the individual and or their representative.

57. As there is no evidence to show the family were involved in the review of the daytime one-to-one funding, we consider this falls short of what we would expect from an organisation.

58. We have looked at what actions the ICB has taken since Mr P raised his complaint.

59. In its response of 1 July, the ICB recognises it would have been best practice to involve Mrs B in the review of her husband’s care and apologises this did not take place. It said moving forward, steps have been taken to ensure the CHC team do invite representatives to reviews of one-to-one care when appropriate to do so.

60. In its email response to us on 13 January 2026, the senior lead for the patient experience team at the ICB provided reassurances to us about the family’s involvement in future annual CHC reviews in line with the ICB’s processes.

61. The NHS Complaint Standards set out how organisations providing NHS services should approach complaint handling. They apply to NHS organisations in England and independent healthcare providers that deliver NHS-funded care.

62. We can see the actions of the ICB are in line with the complaint standard of ‘giving fair and accountable responses’. These state ‘organisations openly identify instances when things have gone wrong, or where services have had an unfair impact, and take responsibility for these. They make sure staff can offer a range of ways to put things right for the individual.’

63. As such, we consider the ICB has taken appropriate and remedial action in line with NHS Complaint Standards to address the concerns raised by Mr P. We also consider the reassurance from the senior lead reflects a commitment to improvement, and we are satisfied the steps taken are sufficient to address the issues identified, and to help prevent these issues happening again. We find the ICB has taken reasonable steps to put matters right for the family.

64. We also want to acknowledge the distress caused by the lack of family involvement with the withdrawal of Mr B’s one-to-one care during waking hours. We recognise being excluded or feeling insufficiently involved in discussions about a loved one’s care can be frustrating. We understand family members play an important role, and their perspectives are important. We are sorry this was not fully reflected in Mr P’s and Mrs B’s experience and understand the impact this may have had on them.

Assessments

65. Mr P complains the ICB failed to complete a mental capacity assessment or a risk assessment prior to ending the one-to-one support.

66. He says there are still risks to his mother, such as his father regularly grabs her arms and will not let go. He says the ICB did not consult with the family, and it did not factor this into its decision making.

67. While the ICB has not directly responded to the complaint point about assessments, the ICB explains one-to-one care is commissioned only after other options have been considered and exhausted. It states in line with the Mental Capacity Act (MCA) 2005, it is not a less restrictive option for individuals who lack capacity about their care and support needs if other options are appropriate to trial.

68. The ICB goes on to say where one-to-one care is commissioned, it is expected reviews will be scheduled to determine the ongoing need for this high level of restrictive care and support.

69. In terms of risks, the ICB states Mr B is no longer mobile and risks to himself and others have reduced. The CHC team also recognises the past trauma Mrs B has experienced, and the care home has put in steps to assist with her visits.

70. The care home manager has advised the ICB when Mrs B visits Mr B which is approximately three times a week, the care home staff will be able to facilitate supervised visits. The ICB explains if Mrs B feels at risk or is anxious, she should raise this with the home directly and they can support her.

71. NICE guideline of ‘Violence and aggression: short-term management in mental health and community settings’ sets out risk assessment is a dynamic process which requires regular review and ongoing consideration of the individual’s current mental state and observed behaviour.

72. For example, on section 1.4.16 the guidance states ‘At least once during each shift a nurse should set aside dedicated time to assess the mental state of, and engage positively with, the service user. As part of the assessment, the nurse should evaluate the impact of the service user's mental state on the risk of violence and aggression and record any risk in the notes.’

73. Our adviser explains by requesting the behaviour charts, the ICB carried out a risk assessment at this evidence was considered by the ICB panel.

74. In Mr B’s case, we can say the behavioural monitoring charts formed part of the wider dynamic risk assessment process, which informed care planning and ensured Mr B’s changes in his behaviour were appropriately captured.

75. We also considered whether the ICB should have completed a mental capacity assessment prior to ending of the one-to-one support.

76. Our adviser comments mental capacity assessments had been conducted previously for Mr B, and it was known he had a lack of capacity. Our adviser explains a further assessment would not have added any useful information to assist the ICB’s decision making process.

77. As such, the mental capacity assessments had already been appropriately undertaken previously, and there was no new information to suggest a deterioration or change in capacity at the relevant time. We consider a further formal reassessment would not have altered the care decision making process, which informed by ongoing behavioural observation as noted in the behaviour charts. We do not find anything went wrong in this complaint aspect.

78. We recognise Mr P’s concerns as he did not feel a risk assessment or a mental capacity assessment was carried out at the time. In practice, the ongoing behavioural charts and observational records demonstrate these were being utilised to monitor Mr B’s behaviour. We recognise how the lack of formal risk assessments may have been a source of significant worry and concern for the family.

Second review

79. Mr P states the ICB decided about his father’s care without consulting the family, and this decision has had a hugely negative impact on his mother’s mental health, as well as his father’s own welfare, as well as restricting his right to family life. He states the ICB failed to complete a second review in which the family were involved.

80. The ICB states it would have been best practice to involve Mrs B in the review of Mr B’s care and apologises this did not take place. It says moving forward, steps have been taken to ensure the CHC team do invite representatives to care reviews of one-to-one care when appropriate to do so.

81. We considered whether the ICB should have considered doing a second review which involved the family.

82. Our adviser states the evidence shows Mrs B was anxious about visiting her husband without support because of his previous comments to her. There is also evidence to show the ICB and the care home were aware Mrs B required a chaperone when she visited her husband because of his past behaviour towards her. Our adviser adds Mr B’s general condition and mobility had deteriorated significantly and as such, Mrs B was safe when visiting.

83. While it is acknowledged the family were not appropriately involved in the original decision-making process, we have already established the ICB’s decision to remove the one-to-one funding was appropriate based on the information available at the time.

84. We can see the ICB has recognised this shortcoming and has taken steps to address this. For example, confirming the family will be involved in future reviews of Mr B’s care, and appropriate arrangements such as a chaperone from the care home will be in place to support safe involvement, and mitigate any risks towards Mrs B.

85. In an email to us on 13 January 2026, the senior lead informed us ‘it was made clear that if any issues occur as a result of this change one-to-one care could be reconsidered. However, this was not necessary and the change was successful.’

86. Given the above, we consider it would not be proportionate to undertake a further review solely based on involvement, as this would be unlikely to change the outcome already reached by the ICB. As such, we do not find anything went wrong here.

87. We understand the family’s concerns about Mrs B’s wellbeing when visiting her husband, and the impact this decision has had on her. We appreciate not being fully involved in the process may have added to Mr P and Mrs B’s worry and uncertainty, particularly given the importance of the decision made.

Professional advice

88. Mr P complains the ICB failed to seek any advice from appropriate professionals such as a psychiatrist before it made its decision. He says as his father’s condition is unique, it should have warranted advice and guidance to help support the ICB’s decision.

89. While the ICB has not responded to the above complaint point, it would be useful to consider this point as part of the investigation for Mr P’s assurance.

90. Our adviser explains it is not normal practice for the ICB to involve specialists in the decisions made regarding the provision of one-to-one care.

91. Our adviser also says while the ICB could have asked for a report from a clinician involved in the treatment of Mr B, the ICB followed standard practice in requesting the behaviour charts and considering the nature and severity of the presenting behaviours.

92. NHS England in ‘NHS continuing healthcare’ states the underlying principle of NHS continuing healthcare (CHC) as noted by is identifying a person’s healthcare needs as they present and the assessments are not based on diagnosed conditions.

93. Our adviser adds the ICB had a robust, evidence-based rationale for reducing the one-to-one provision for Mr B.

94. This is in line with the National Framework which states ICB’s should ensuring ‘eligibility decisions are based on thorough, accurate and evidence-based assessments of the individuals’ needs’. As such, we cannot say anything went wrong here.

95. We recognise Mr P’s view about obtaining specialist advice and understand from his perspective this may have provided further reassurance and confidence in the decision-making process. We acknowledge how important it is for families to feel all possible expertise has been considered when decisions are made about their loved one’s care. As identified by our adviser, this was not required in Mr B’s case as the ICB had the evidence to support its decision.

96. We understand how important this complaint is for Mr P and his mother. We also recognise this decision will be disappointing for Mr P. We hope our consideration of his complaint reassures him we have taken his complaint seriously and have undertaken a thorough consideration of the issues.

1. We have carefully considered Mr P’s complaint about Norfolk and Waveney Integrated Care Board (the ICB) and we thank Mr P for his patience during this time.

2. We are very sorry to hear about the distress caused by the ICB’s removal of one-to-one funding for his father, Mr B and the additional concerns raised by the family. We recognise this was a difficult and upsetting experience, and the process caused Mr P and his mother, Mrs B additional distress.

3. We understand the experience has had an impact on Mr P and especially his mother who has experienced distress by the ICB’s decision. We appreciate Mr P bringing his complaint to us for further consideration.

4. We found there is no indication of a failing in relation to the ICB revoking the one-to-one funding, and there is no evidence to suggest it was necessary to complete a mental capacity assessment or a risk assessment prior to ending the support.

5. Having carefully reviewed the available evidence and expert advice sought, we found while the family were not sufficiently involved in the process, this was recognised by the ICB. We consider sufficient steps have been taken to address this issue.

6. We also consider a second review was not required as the original decision to remove the one-to-one funding would still stand and no further specialist input was required.

7. We understand our decision will be disappointing for Mr P. We would like to reassure Mr P we have looked at his complaint independently and impartially with advice sought from an experienced clinician.