Clinical commissioning group was wrong to say that bigger care home room was lifestyle supplement

Summary 307 |

Mr P complained that the local CCG refused to pay the full cost of his mother, Mrs G's, continuing healthcare care home fees because her room was larger than a standard room. He also complained that the CCG did not reconsider funding when his mother's health deteriorated.


What happened

Mrs G lived in a care home. Although the CCG had agreed she should have fully-funded care, it was only prepared to fund part of her care home fees. This was because it said her room was three square metres bigger than a standard room.

The CCG took legal advice and said the larger room constituted a lifestyle supplement, based on a previous court ruling. Mr P had no choice but to pay the shortfall until Mrs G's death. This amounted to £7,500.

Mr P said that after Mrs G's stroke, the CCG should have reassessed her needs and eligibility for NHS-funded healthcare using a checklist in accordance with national guidance.

What we found

The CCG reasonably explained that it is not its role to consider whether continuing healthcare eligibility should be revisited if a person's health deteriorates.

It unreasonably decided that Mrs G benefited from a lifestyle supplement solely on the basis that she had a larger room. And it unfairly applied the court judgement and failed to consider other options, such as moving Mrs G to a different care home.

Putting it right

The CCG acknowledged its failings, apologised to Mr P and paid him £7,500. It prepared an action plan to show that it had learnt lessons and explained what it will do differently to prevent this mistake from happening again.

Health or Parliamentary
Health
Organisations we investigated

Nene CCG

Location

Northamptonshire

Complainants' concerns ?

Came to an unsound decision

Did not apologise properly or do enough to put things right

Replied with inaccurate or incomplete information

Result

Apology

Compensation for non-financial loss

Recommendation to learn lessons or draw up an action plan