Claim for retrospective continuing healthcare funding was unreasonably refused

What happened

Mrs Y suffered from Alzheimer's and had lived in a care home since autumn 2008. In Late 2008, a social worker carried out a continuing healthcare needs checklist assessment to determine whether Mrs Y should be referred for full consideration of continuing healthcare. (a package of care that is funded and arranged by the NHS). The record of the checklist noted that the social worker explained to Mrs Y, in the presence of her carer, what the checklist assessment was for. The social worker also noted that Mrs Y was able to make her own decisions when she underwent the checklist assessment. The checklist assessment showed that Mrs Y was not eligible for full continuing healthcare and Mrs Y agreed with the outcome.

The social worker and care home also carried out a single assessment and community care service review and care plan for Mrs Y in spring 2010. Her family was also present at this review and were given a copy of the review document but did not raise any concerns. The review considered continuing healthcare but decided that a checklist assessment was not required because Mrs Y's needs had not changed significantly. Mrs Y died in autumn 2010.

Ms P was unhappy that the CCG did not tell her a continuing healthcare assessment was undertaken for her mother, or that she had the right to appeal the assessment, and so was not in a position to challenge or appeal the decision. She also complained about delays in the CCG responding to her retrospective request, lost records and the CCG's handling of her complaint. She wanted the CCG to assess her mother for retrospective continuing healthcare funding and refund the amount paid to the care home between autumn 2008 and autumn 2010.

What we found

Mrs Y was considered able to make her own decisions at the time of the continuing healthcare needs checklist assessment in autumn 2008, and the outcome of the assessment was explained to her. There was therefore no requirement to inform the family and there was no official 'right' of appeal to the findings of a checklist assessment. The assessment was in accordance with the National Framework in place at the time.

The single assessment and community care service review appropriately considered whether Mrs Y might have been eligible for funding and found a checklist was not required. Mrs Y's daughter was given a copy of the review document and had the opportunity to raise concerns about the provision of care but did not.

However, we found there was an unassessed period of care from spring to autumn 2010.

Putting it right

The CCG agreed to undertake an assessment for the period spring to autumn 2010 to determine whether Mrs Y met the eligibility criteria for fully funded NHS continuing healthcare. Following that assessment, the CCG paid Mrs Y's family £1,600.