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At Beacon we understand that families and friends can often bring highly valuable insight to an assessment – if they have been involved in the care of the individual being assessed they are often able to provide the coordinating assessor with information about the ‘person’ which cannot be gleaned from the care records alone. This is particularly useful when it comes to helping the multidisciplinary team to understand whether a particular behaviour is out of character and a result of disability or illness.
The coordinating assessor should explain the assessment process and criteria to you and you should be invited to share your views and opinions about your care needs during the completion of the Decision Support Tool. This includes having an opportunity to provide information about every care domain, to select the level of need you feel is correct in each domain, and to provide an overall view as to the totality of your needs.
If the multidisciplinary team disagree with a level of need you have specified in a particular domain they should discuss it with you and record your viewpoint in writing.
Sometimes CCGs will invite you or your representative to attend the decision-making panel if they have one, but they are not required to do this. Once a final decision has been made by the CCG they should write to you to explain the outcome and provide a full detailed rationale. This letter should refer to the key indicators, demonstrating that the CCG have carefully considered the nature, intensity, complexity and unpredictability of your needs in reaching their decision. The letter should explain how you can access the dispute resolution process if you disagree with the decision.
Once the multidisciplinary team have made a recommendation regarding eligibility the Clinical Commissioning Group should accept that recommendation in all but exceptional circumstances. Exceptional circumstances are not clearly defined but the implication is that this is where a quick decision is required. Some CCGs choose to use a panel to help them make the final decision. However any decision-making panel is acting for the CCG and must also accept the recommendation of the multidisciplinary team in all but exceptional circumstances.
We are aware of situations in which NHS trusts have overturned multidisciplinary recommendations or instructed MDTs to change their recommendations. We have successfully appealed a high number of cases where such procedural failings have been identified and also worked with the NHS to help them bring their procedures in line with national guidance.
Patients with ongoing care needs who may qualify for continuing healthcare have a right to be assessed before they are discharged from NHS or Local Authority services and start their long-term care placement. If it is thought that you may be entitled to continuing healthcare, a hospital trust cannot begin ‘delayed discharge’ procedures until you have been assessed and the trust has established that you are not eligible for continuing healthcare.
Assessments for continuing healthcare which take place whilst you are in an ‘acute’ hospital setting can be inaccurate because you may not have reached your rehabilitation potential. This means that you may have the potential to continue your recovery in the near future with further treatment or rehabilitation, and this could impact upon your ongoing care needs.
Long stays in acute hospital settings can be detrimental to your recovery because they are not designed for long-term care. Even where basic care is good, we find that patients are often unable to receive the dedicated daily rehabilitation that would be available in a more appropriate long-term care placement whilst they are in an acute setting.
For this reason some NHS trusts operate a policy whereby continuing healthcare assessments only take place once the individual has been moved out of the acute setting and into intermediate care in a community hospital, their own home or a care home.
Continuing healthcare assessments should normally be completed within 28 days although this timescale is often not met. If you have been deemed fit for discharge from hospital but you are awaiting a continuing healthcare decision and no interim care services have been arranged, it is usually advisable to move into your long-term care setting rather than insist upon waiting in hospital until the assessment process has been completed. This avoids the further potential for the type of health issues that can occur during long periods in acute settings and if you are found to be eligible for continuing healthcare, the start date for funding can be backdated.
The Care Quality Commission’s national standards for care homes in England require the records kept by care homes to be accurate. If a care home implements a policy preventing the recording of certain types of care needs, it is not meeting the national standards and such policies should be challenged. Registered Nurses also subscribe to a set of professional standards that require them to keep clear and accurate records, which places a greater responsibility on care homes with nursing to keep good records.
A set of care records should contain care plans that describe how each particular area of need affects your wellbeing and details the necessary steps required to meet that particular need. There are many ways in which one particular care need could interact with another and it is important that records reflect how each need impacts upon the person and carefully describes how their needs should be met. If records do not capture the complexity, intensity and frequency of meeting a need then that complexity or intensity will not be reflected in the continuing healthcare assessment, and since intensity and complexity are key indicators of a primary health need, poor record-keeping could be the difference between you being assessed as eligible or not.
If the 28 day timescale has been exceeded we would recommend that you contact your coordinating assessor or local CCG and ask them to specify clear timescales for a decision regarding eligibility, reminding them of their obligation to complete assessments within 28 days of the Checklist referral. If you are unhappy with the final decision regarding eligibility for continuing healthcare and decide to appeal, you can raise the issue of lengthy timescales with the Independent Review Panel as a procedural complaint.
Be aware that some CCGs outsource continuing healthcare assessments to other organisations to complete, often referred to as ‘Commissioning Support Units’. However, it is important to note that regardless of which organisation completes the assessment and writes the decision letter, the CCG still remains legally responsible for eligibility decisions. (NHS England is responsible for making eligibility decisions and commissioning services for prisoners and military personnel).
Whilst the CCG does have certain responsibilities regarding the MDT, such as appointing a coordinating assessor to oversee the MDT and provide guidance as to how to apply criteria, they do not have the remit to pick and choose who is selected from the MDT to take part in the recommendation. The CCG also do not have the power to instruct the MDT to change their recommendation, even if they disagree.