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The value of instructing an Advocate from Compass CHC to attend CHC assessments
Introduction: Compass CHC often receive instructions to act for clients that have experienced significant delays from Health Boards (as is the format in Wales) and CCGs (in England). Delays are often experienced from the point at which the family first initiated a Continuing Healthcare (‘CHC’) assessment, and a full assessment being completed. In cases with an eligible outcome, this inevitably causes a delay in relation to when the individual will be considered to have been entitled to CHC funding.
In a recent case, Compass CHC were instructed due to the family experiencing significant delay in a DST assessment being completed by a Welsh Health Board.
When Compass CHC attended the DST in March 2020, several problems arose…
The unnecessary delay: The family had already experienced a five-month wait, from when they initiated a CHC assessment to the DST scheduled for March 2020. Within that time, a nurse assessor had reviewed the patient (hereinafter ‘Mrs M’) and concluded that it was inappropriate to conduct a DST assessment until Mrs M’s weights were more stable. Mrs M was continuing to lose weight and was considered at risk of malnutrition when the nurse assessor conducted a review. His reasoning for delaying a DST was so that Mrs M’s weight could become stable before an assessment is scheduled.
This same nurse assessor attended the March 2020 meeting where an Advocate from Compass CHC was present. The nurse assessor introduced the meeting as being a further review and stated that he would not be conducting a DST.
The Advocate from Compass CHC explained to the nurse assessor that he had unjustifiably delayed the CHC assessment of Mrs M, had not acted in the best interests of Mrs M and had acted negligently. There is no provision in the framework or other supplementary documentation stating that a patient’s weight must be stable before conducting a DST assessment. Mrs M was at risk of malnutrition and required a dietician referral at his previous review, and this was the same at the meeting in March 2020, where she had lost a further 5kg. Given that there was no justification for delaying a DST assessment, the Advocate submitted that a DST assessment should have taken place during, or immediately following, his review.
The nurse assessor continued to state that he was only instructed to complete a review in the March 2020 meeting and did not have the authority to complete a DST. After much persuasion from the Advocate, and a refusal for the meeting to conclude without a DST being completed given that we had been instructed by the family and costs had been incurred, the nurse assessor eventually agreed to conduct a DST assessment.
The impact on CHC funding: It is normal practice that, where an individual is deemed eligible for CHC, the eligibility period runs from the date of the CHC assessment. As such, it appeared that the Health Board were attempting to delay a CHC assessment by conducting ‘reviews’ of Mrs M and providing the family with unjustified reasons for further delay, i.e., her weights needing to become stable before an assessment.
This means that, if Mrs M was considered eligible at the DST in March 2020, the funding period would commence from the date of the DST meeting. However, had the nurse assessor not caused unnecessary delays leading up to and following his previous review, Mrs M should have been considered eligible from October 2019, given that:
a. The family of Mrs M requested a CHC assessment in October 2019;
b. Mrs M’s care needs in October 2019 were fundamentally the same in March 2020; and
c. There was no reasonable justification for the delay in a DST assessment.
The nurse assessor rejected the Advocate’s submissions in relation to the funding period during the March 2020 meeting, and so the Advocate made a detailed argument to the Health Board on this point within the post DST representations that Compass CHC submit to Health Board’s following a DST assessment.
No multidisciplinary team: Given that the nurse assessor had intended for the March 2020 meeting to simply be a review, and was not expecting to conduct a DST assessment, there was no multidisciplinary team present at the meeting. Specifically, no social worker had been invited to form part of the multidisciplinary team to determine Mrs M’s eligibility for CHC funding. Due to the provision set out in the framework for a multidisciplinary to be present at DST assessments, the Advocate from Compass CHC did not want a procedural issue to arise after the meeting where the decision may be deemed unsound by the Health Board due to the lack of a multidisciplinary team.
As such, the Advocate ensured that:
a. The manager of the care home, who was a registered nurse, was involved in the DST assessment, offered levels of need and made a CHC eligibility decision; and,
b. The nurse assessor submitted the DST documentation to a social worker within 5 days of the March 2020 meeting for a social worker to make an eligibility decision and to sign and date the document.
By doing so, the Advocate was able to ensure, as far as possible, that the DST assessment was procedurally correct. The Advocate followed this up with the nurse assessor the day after the meeting until he confirmed that a social worker had agreed with the eligibility decision and had signed and dated the documentation.
Eligibility criteria – the care domains: At the meeting in March 2020, the Advocate submitted that Mrs M had a Severe level of need in Mobility and a Severe level of need in Cognition, with several High and Moderate needs in other domains. While the nurse assessor had initially suggested that Mrs M had a Moderate level of need in Mobility, after persuasive submissions from the Advocate, the nurse assessor and care home manager agreed with a Severe level of need.
As the multidisciplinary team had agreed that Mrs M had two Severe levels of need, when the Advocate asked them to consider Mrs M’s eligibility for CHC, the Advocate reminded them of the provision in the national framework where it states:
“A clear recommendation of eligibility to NHS continuing healthcare would be expected in each of the following cases:
• A level of priority needs in any one of the four domains that carry this level.
• A total of two or more incidences of severe needs across all care domains.”
Accordingly, the nurse assessor and care home manager recognised they were required to follow this provision and so, concluded that Mrs M was entitled to CHC funding.
Conclusion: This case illustrates the value of instructing an Advocate from Compass CHC. Had Mrs M’s family not had an Advocate attend the meeting in March 2020, no DST would have been completed, the nurse assessor would have conducted a review of a review, likely giving a further unjustified, procedurally unsound reason for delaying a CHC assessment again.
By having an Advocate from Compass CHC, a DST was completed without procedural error and thorough post DST representations were submitted to the Health Board, including all relevant care records and detailed submissions requesting for the CHC eligibility decision to be backdated. Additionally, the Advocate maintained correspondence with the nurse assessor following the meeting to ensure a social worker signed the documentation and to confirm when the documentation was submitted to the Health Board. This meant that the family of Mrs M did not have to attempt to contact the Health Board and, rather, received regular updates from their Advocate.
Overview: Retrospective Welsh Case
This case illustrates the drastic failures of Health Boards to accurately apply the national framework, such that they grossly undermined the care needs of the patient to the extent that Compass CHC successfully appealed 8 disputed care domains and secured Continuing Healthcare funding.
Details of the case:
This was a retrospective case concerning a patient with vascular dementia, frequent agitation and challenging behaviour. Compass CHC were instructed by the patient’s son, who was seeking to recover the cost of six months of care fees.
As this was a Welsh case, it had been assessed by Health Boards prior to it reaching the appeal stage. Specifically, three separate Health Boards had assessed the patient’s needs and concluded that the patient did not have a primary health need and therefore, did not qualify for Continuing Healthcare funding. Each Health Board that reviewed this case had significantly and grossly undermined the care needs of the patient. The third and final Health Board that reviewed the case had awarded 4 High levels of need, 4 Moderate levels and 3 Low levels of need. When appealing the decision, Compass CHC submitted that the patient had 4 Severe levels of need, 4 High levels, 2 Moderate levels and 1 Low level of need. As such, 8 care domains were disputed, illustrating the extent to which the Health Boards had dramatically undermined the patient’s care needs and failed to conduct an objective and accurate assessment.
While Compass CHC successfully appealed 8 care domains, we wish to outline the arguments for 3 of the care domains that encapsulate the frequent misapplication and oversight of the national framework that takes place at Continuing Healthcare assessments.
The care domains:
The most notable failures of the Health Boards related to the Mobility domain, the Psychological & Emotional domain and the Communication domain.
The Health Boards had each maintained that the patient had a Moderate level of need in Mobility, whereas Compass CHC submitted that a High level of need was satisfied. The Advocate from Compass CHC that attended the appeal noted that the Health Boards had misapplied the national framework in a way that frequently transpires at assessments nationally.
The dispute was concerning the patient’s falls history, risk assessment, and subsequent level of need; with the Health Boards awarding a Moderate level, whereas Compass CHC submitted a High level of need. In this domain, a High level of need relates to a patient who (a) has been assessed as being at high risk of falling, and; (b) has a history of falls. Often, assessors will attempt to apply their own broad, unsupported interpretation of the national framework, force a comparative approach and attach artificial brackets to descriptors by alleging, as they did so in this case, and attempted to maintain at the appeal, that an individual that is frail and cognitively impaired will always have a high falls risk assessment, but that it does not necessarily mean they are at a high risk of falling. Further, it was alleged by assessors in this case that the falls were not frequent, severe, did not cause significant injury and so do not satisfy a High level of need.
This unsupported, broad, comparative approach at assessments leads to significant disparity and variation across England and Wales in terms of how the national framework is applied. There is no provision in the national framework, practice guidance or any other form of supplementary documentation encouraging assessors to neglect risk assessments. Similarly, there is no provision that states a patient must be falling monthly, weekly or daily or must have sustained significant injury. Rather, a falls risk assessment assessing a patient as being at high risk of falls, coupled with a history of falls, is all that needs to be satisfied for a patient to qualify as having a High level of need.
Psychological & Emotional domain:
In this care domain, the Health Board had supported their contention that a Low level of need was satisfied by stating that the patient did not “require anything other than general support and reassurance”. Compass CHC disputed the Low level of need in this domain and submitted that a High level of need was satisfied. The Health Boards had blatantly disregarded that this patient was prescribed Lorazepam on an ‘as required’ basis to manage agitation and care staff were required to provide close supervision when the patient was experiencing periods of distress. The evidence of the medication for agitation and the care plan relating to the management of the patient’s mood disturbance was outlined clearly in the care records. Yet, these records were disregarded by the Health Boards. As such, Compass CHC submitted at appeal that the Health Boards rationale for the level of need in this domain was unjustified and contradicted the records that illustrated that the patient rarely responded to reassurance.
This care domain was significantly disputed, given that the Health Boards had maintained that a Low level of need was satisfied, whereas Compass CHC were successful in submitting that a High level of need should have been awarded in this domain.
The Communication domain is frequently misinterpreted at local level. Communication, for the purposes of the Continuing Healthcare assessment, seeks to assess an individual’s ability to “reliably” communicate their “needs”. Instead, as was the case in this appeal, assessors had concluded that because the individual was able to speak, in that they could say words, albeit out of context, and referred to their long-term memories, the patient was able communicate, but just required some support. At appeal, Compass CHC disputed this on two points. Firstly, that there is a very clear and important distinction between speech and reliable communication. While the patient could speak, the patient did not communicate any basic care needs, including pain, hunger or thirst, in a way that was or could have been deemed reliable.
Our second point when disputing this level of need related to the Cognition domain. Specifically, at this stage of the appeal, it had been agreed that the patient had a Severe level of need in the Cognition domain. Accordingly, we highlighted that an individual with severe cognitive impairment is deemed, by the national framework, as being “dependent on others to anticipate their basic needs”. As such, we made the submission that a patient considered to be severely cognitively impaired is unable to communicate reliably for the purposes of the national framework, given that they have no insight into or awareness of their basic needs. Both of our points in this domain were accepted at appeal.
This case highlights the unfortunate reality wherein numerous separate Health Boards repeatedly upheld an unjustified, procedurally incorrect decision, illustrating the necessity to have expert knowledge of the national framework and eligibility criteria to ensure that an objective, thorough and accurate assessment of a patient’s care needs is completed
The patient, who had been diagnosed with Parkinson’s Disease and Dementia, had a number of severe health issues and required constant supervision during waking hours. She lived at home with full-time care provided by live-in carers and paid for privately by the family.
BaNES (Bath & North East Somerset) Clinical Commissioning Group outsource their services to external company Sirona Care & Health to undertake clinical assessments for continuing healthcare funding.
Compass CHC was brought in by the family to oversee the appeal process after BaNES Clinical Commissioning Group deemed that the patient didn’t have primary health needs and denied the family access to NHS continuing healthcare funding
The family of the patient thought her needs were sufficiently complex, intense and unpredictable in their nature to be considered a ‘primary health need’ which would have entitled her to NHS continuing healthcare funding to pay for the cost of her care in full. This is entirely separate to social care funding and the fact that she had assets over the threshold of £23,250 was irrelevant.
Accordingly, the patient’s family requested that an assessment of their relative’s care needs be undertaken. These services are commissioned to an external company, Sirona Care & Health, in Bath.
An assessment took place in the spring of 2015 following an initial checklist assessment 3 months earlier.
The first issue here is that the National Framework for continuing healthcare funding states that the entirety of the process should be completed within 28 days of the date of the initial checklist. In this instance, it was some 3 months before the secondary assessment, the Decision Support Tool (DST) assessment, was undertaken.
Secondly, and separately, there was not a representative from the local authority in the form of a social worker in the DST assessment, it is set out in the National Framework that there must be a multi-disciplinary team panel of individuals involved in the assessment to look at matters from both a clinical and social care perspective. Clearly the absence of the social care representative meant this was not possible in this case.
Despite the recommendations of the nurse assessor present at the Decision Support Tool assessment, Sirona Care & Health – the company acting on the CCGs behalf – down scored and downgraded the levels of need the nurse assessor had awarded at the initial assessment and the patient was deemed ineligible for funding.
It was at this point that the family contacted Compass CHC who instigated an appeal of this assessment.
As part of the appeal process an independent panel must be convened to review the initial recommendation and afford the family an opportunity to explain why they disagree with the outcome and how the evidence contradicts the negative decision. This took place in early 2016 (a year after the initial checklist assessment) and Tim Davies of Compass CHC represented the family’s interests as the advocate.
From the outset, the appeal meeting was farcical in that the ‘independent’ chairperson was a Director of Sirona Care & Health. The attitude of the chairperson was unprofessional and bordering on aggressive and the whole process was entirely unsatisfactory from the perspective of the family. Despite presenting the panel with clear evidence of the incorrect scores in relation to levels of need provided throughout the initial assessment and the clear primary health need that warranted the funding, the outcome of the appeal panel was that the initial decision stood.
Therefore, the family advanced through Compass CHC to an appeal at NHS England level. This took place in late 2016 where Mr Davies again represented the families’ interests and presented matters to the NHS England panel.
Examples were provided of issues which occurred when the CCG scored the patient’s needs as merely moderate in rather than high across a number of domains (or categories).
The evidence and the view of Compass CHC was that as a minimum the level of need for the behaviour domain was in fact high because the restless behaviour and the need for constant supervision presented a predictable risk of harm to the patient. In the domain of nutrition, the level of need was recorded as being ‘moderate’ by the BaNES Clinical Commissioning Group but the evidence, in Compass’ view supported a higher classification. It was highlighted that the patient satisfied the requirement of being nutritionally at risk given that she was on a fortified diet requiring dietary supplements to keep her weight at a stable level. Further, there was a risk of aspiration of food associated with the Parkinson’s Disease and the fact she had swallow function issues. In light of the fact the patient had a BMI of less than 18 and a malnutrition universal screening tool scoring of 2 which indicated she as at high risk of malnutrition, the only conclusion which could be reached was that the patient was at high risk of malnutrition and a high – not moderate – level of need was the appropriate assessment.
In the domain of drug therapies, the Clinical Commissioning Group scored the level of need as being moderate whereas Compass CHC thought the evidence supported a high domain. Indeed, the nurse assessor at the original assessment recorded a high level of need and this was downgraded by Sirona and BaNES CCG to ‘moderate’. Due to the Parkinson’s medicine needing to be administered at very set timeframes and monitored for its effectiveness and symptom control, Compass CHC reviewed that these potential fluctuations of condition meant that the only sensible outcome was a ‘high’ level of need. Further, Compass CHC argued that in light of these increased issues the needs were sufficiently complex, intense and unpredictable in their nature to warrant the consideration that the needs were primarily health needs and there was a funding entitlement.
The NHS England panel agreed and continuing healthcare funding was awarded and backdated to the date of the original Decision Support Tool assessment 21 months previously. In totally Compass CHC managed to secure c£90,000 for the family.
This goes to show that unfortunately when the National Framework is ignored, incorrect decisions can be made at every stage of the continuing healthcare funding process and even when the initial appeal process has been exhausted there is justification to pursue matters further to ensure that an individual receives the funding they should be entitled to.
When Mr CF contacted us to instigate the continuing healthcare funding process, Mrs JF (his mother) was living at home with agency carers attending 4 times a day. In 2016, Mrs JF suffered from ulcers on her leg which did not respond to treatment. Consequently, she required a leg amputation in May 2016 which brought with it many challenging needs. For example, Mrs JF is now unable to weight bear and refuses hoisting due to her level of pain and impaired cognition. Mrs JF suffers with severe pain which is not responding to medication. She is also allergic to antibiotics and some pain relieving medication which further complicates matters. Such a high level of pain and the inability to walk has had a direct impact on Mrs JF’s psychological and emotional status. Mrs JF has also lost a significant amount of weight. In addition, Mrs JF has a cognitive impairment which has an impact on her behaviour (due to lack of understanding) and her ability to reliably communicate her needs.
We gathered and reviewed the records in the case and drafted detailed representations to support our case for continuing healthcare funding. We then submitted representation to the CCG (Clinical Commissioning Group) and requested a date for the CHC Checklist (the first stage of the continuing healthcare process).
Our advocate, Natasha, attended the Checklist in January 2017. It was evident that the recent carer’s notes where not in sufficient detail at the Checklist stage, however we were able to argue the levels of need. We obtained a positive Checklist which triggered for a full assessment. Natasha advised the care agency to re-write their Care Plan to ensure that it accurately reflects Mrs JF’s needs and asked carers to write in the daily notes when Mrs JF was suffering from pain, refusing care and when she was tearful and upset. Additionally, Natasha advised Mr CF (who also cared for his mother) to keep a detailed diary regarding his mother’s pain, behaviour and psychological and emotional state.
Due to our attendance at the Checklist, we were able to ensure that the levels of need were not underscored (which could put a halt on the entire process). Further, we could make sure that the supporting evidence was in place for the DST stage. Supporting evidence is crucial, as the DST is an evidence based exercise. Natasha presented the case for funding at the DST in March 2017and secured continuing healthcare funding for Mrs JF.
The Compass CHC team was approached by a lady whose mother was in hospital following a serious fall. The hospital was seeking to discharge her home with a care package of 4 carers a day however the lady was completely immobile with a number of severe, complex health conditions, including a diagnosis of terminal cancer.
Her daughter felt that the care package offered was completely insufficient and her mother required 24 hour care but the hospital discharge team and social services were adamant that her mother should be discharged home. We intervened and drafted a letter to the discharge team outlining why the patient’s requirement for care was a significant health need and how the individual was entitled to NHS continuing healthcare funding to meet the cost of her care. Further, we explained that a “fast track assessment” was appropriate.
Following receipt of our representations the hospital discharge team reviewed the position and fast track funding was provided. The patient was discharged to a nursing home with the full care cost being met via continuing healthcare funding.
We can assist at every stage of the process. It is not necessary to wait for a negative outcome before contacting us for assistance; we can provide support and assistance from the very outset and help influence assessments in the patient’s favour where they ought to be receiving continuing healthcare funding.
In this case we assisted in successfully influencing the outcome of our client’s assessment for continuing healthcare funding prior to their discharge from hospital. Whilst in hospital, the patient was advised they were not well enough to return to their own home and required nursing care but, due to owning their own home, they would have to meet the cost of care themselves.
The Compass CHC team were instructed to take on the case by the patient’s power of attorney. We secured the hospital records and, having reviewed them and cross referenced the patient’s condition to the National Framework criteria for continuing healthcare, it was clear that the patient satisfied the eligibility for NHS continuing healthcare funding.
We drafted detailed representations explaining the basis for the patient’s entitlement to the funding and highlighting the independent evidence contained in the hospital records that supported this. The assessment team agreed with our representations and the funding was awarded, despite the fact that a matter of weeks earlier they had attempted to discharge the patient on a fully self-funding basis without any NHS funding to meet her care costs.
This is another example of how we were able to assist at a very early stage in the process, while the patient was still in hospital and before discharge.
The Compass continuing healthcare team were contacted by the spouse of a patient who was in hospital and suffering from severe issues with their mental wellbeing and behaviour as a result of dementia.
The hospital had advised the family that the patient would need to be discharged to a nursing home and that they would have to pay these costs in full. The family researched the point and contacted the Compass CHC team for advice.
Having reviewed the position in terms of the patient’s health needs, we were able to advise that they met the NHS criteria for continuing healthcare funding. We intervened on their behalf and took over dealing with the hospital team. The hospital discharge team had incorrectly applied the continuing healthcare funding process, for example the family were not involved or afforded an opportunity to contribute to the assessment process. We requested that a new assessment be carried out where the procedures were correctly adhered to and we drafted representations detailing what the scorings for the assessment should be based upon the needs of the patient.
We worked closely with the family ensuring that they were fully prepared for the assessment and armed with our representations when attending the meetings. NHS continuing healthcare funding was awarded and the patient was discharged to a nursing home with the full cost met by NHS continuing healthcare.
Mr B was admitted to a care home after being discharged from hospital. Despite clear guidance that at such a time it is good practice to assess someone’s eligibility for Continuing Healthcare funding prior to discharge, no assessments were done. The care home was costing Mr B £1000 per week and so his family got in touch with us. We were able to secure both the hospital records and those from the care home, draft detailed representations and instigate the NHS assessment process. We were soon able to organise a Checklist assessment. Although there were some obvious attempts to down score at the Checklist, our advocate was able to ensure that Mr B’s case progressed to the next stage of the assessment process where the Decision Support Tool (DST) is completed. Again, our advocate attended the DST and although there were some attempts to underscore and downplay the health needs of the patient contrary to the independent evidence, we were able to secure full NHS Continuing Healthcare funding.
Mr M was living in a care home for 4 years prior to Compass CHC being instructed. Compass CHC were contacted by his family as his funds were running low and they felt that he shouldn’t be paying for his care as his needs were primarily health needs. On securing the available care records we drafted detailed representations supporting the contention that the needs were primarily health needs. Thereafter we instigated the NHS assessment process.
The Clinical Commissioning Group (CCG) initially, incorrectly, refused to complete a Checklist as they stated it was not their responsibility to do so. On referring them to the National Framework they eventually agreed to complete the assessment. With our advocate in attendance we were able to ensure that Mr M progressed on to the Decision Support Tool (DST) assessment. Even though he more than met the threshold the CCG were reluctant to compete the DST and wanted to put it on hold. They then wanted to complete a further checklist. With our persistence and knowledge of the National Framework we were able to get them to agree that the mistake was theirs. They then completed a DST with our advocate in attendance and we were able to secure full funding. This decision was reviewed after 3 months, again with our advocate in attendance, we were able to ensure the funding would be in place for a further 12 months.
We were contacted by Mrs P’s family after she had moved from home into a nursing home. On securing the available care records, we drafted detailed representations supporting the contention that the needs were primarily health needs. Thereafter, we instigated the NHS assessment process. A few days before the checklist, Mrs P fell and fractured her pubic rami, which meant she went from being able to mobilise independently to being nursed in bed or a chair. She was also in significant pain due to the fracture. With the assistance of our advocate, Mrs P passed the checklist and a full assessment was triggered.
Around three weeks later, a full assessment was completed. A multi-disciplinary team was present, with a nurse assessor and social worker. Mrs P had an over-arching diagnosis of dementia, but she also had significant psychological and emotional needs caused by paranoid hallucinations which meant she would not leave her room and would often not engage with care staff. In addition, she was still immobile and experiencing pain from her fracture pubic rami which meant she could no longer independently mobilise or reposition. Given her cognitive impairment and significant psychological and emotional needs, there was significant complexity in Mrs P’s care. With the assistance of our advocate, the most appropriate levels of need were secured during the assessment and the complexity and intensity of Mrs P’s care was highlighted, which led to funding being secured. Click here to read the client testimonial
Prior to instructing Compass CHC, Mrs IB had been a resident in the care home for over 4 years. During which time, no Continuing Healthcare assessments had been completed, despite it being good practice for an assessment to be completed when somebody enters a care setting.
Compass were contacted by Mrs IB’s son and on receipt of instructions, were able to secure the care homes records in support of an application. Having reviewed the records we were able to draft a detailed letter of representations setting our why we were of the view that Mrs IB should be in receipt of full NHS Continuing Healthcare funding. These were then submitted to the CCG to instigate their assessment process.
On receipt of our letter, the CCG stated that we should contact the community nursing team, who would be able to complete the Checklist assessment, as the initial screening tool. The community nursing team denied responsibility and referred us back to the CCG, who in turn passed the responsibility on to the care home, who they stated needed to ask the District Nurses to complete the assessment. The care home initially refused to make such a request to the District Nurses, as they believed that they could meet IB’s needs and so a Checklist was not necessary. However, CHC funding is not about whether the patients’ needs can be met and so we persevered with our claim. Eventually, the CCG wrote to the District Nursing team requesting that they complete the Checklist. Despite this instruction from the CCG, the District Nurses claimed they could only complete the assessment if they received a referral from the GP. We therefore contacted the GP requesting the referral. The referral was eventually made and the District Nurses arranged the Checklist. However, they failed to inform the relevant parties until 10 days after the proposed date of completion. This clear lack of communication was unsatisfactory and so a request was made for a further date, to allow all those involved to attend. Despite their involvement so far and further correspondence from the District Nurses, they eventually and rather out of the blue, wrote to the CCG informing them that they were refusing to complete the Checklist assessment.
When we challenged the CCG on the above point, we were informed that they would accept a Checklist from either a nurse at the care home or a social worker. The issue was that the care home was residential only and so they had no registered nurses working at the home and the local authority confirmed they would only send a social worker for the final DST assessment and not the Checklist.
The above was clearly not acceptable and so we made a formal complaint to the CCG, setting out that under the National Framework for NHS Continuing Healthcare, they were the body with overall responsibility for ensuring that everybody who should be assessed, is. We also offered an alternative option at this point, which was for Compass to arrange for an independent nurse assessor to complete the Checklist assessment. The CCG eventually agreed to this plan and so the nurse, along with one of our advocates attended the care home.
IB passed the Checklist and this was duly submitted to the CCG, who in turn arranged for the final assessment, the Decision Support Tool (DST), to be completed. With the assistance of one of our expert advocates at the DST, Mrs IB was assessed as being eligible for full NHS continuing Healthcare.
This case illustrates the obvious complexities of the CHC process and the minefield that must be navigated even just to arrange the first assessment. Not one of the professionals involved in her care wanted to step up and take responsibility for completing the assessment. Neither did those professionals deemed responsible for the CHC process by the Department of Health, through the National Framework. This would have left IB in a veritable ‘no-man’s land’, whereby although she was clearly eligible for the funding, it would not have been put in place as the process was simply not completed. However, with our tenacious approach and knowledge of the National Framework, as well as the eligibility criteria, Compass were able to find a workable solution to the problem and secure full funding on an ongoing basis.
We were initially instructed in May 2016, where we looked to pursue a standard case to secure funding in place going forward for Mrs Seddon. Unfortunately, however, Mrs Seddon passed away in February 2017 and so we then proceeded with the case with a view to claim back previously incurred care costs. We gathered and reviewed medical records to cover the period that Mrs Seddon was in Brendoncare care home, which was from April 2014 up until her passing in February 2017. We then drafted comprehensive representations outlining evidence to support the contention that Mrs Seddon was eligible for full CHC funding throughout this period.
On the basis of our letter of representations alone, the CCG agreed that Mrs Seddon was eligible for CHC funding throughout the entire period from 01/04/2014 – 27/02/2017. This will result in an approximate reimbursement of just below £150,000, as the care fees were approximately £4,400 per month.