CHC assessment help

[JaceLancs]

DF had stroke 8 weeks ago was in hospital for 6+ weeks and is now in nursing home on discharge to assess pathway
Only offered choice of 3 homes with vacancies in our area who are part of DTA
One we refused due to appalling CQC report
One refused him as said couldn’t meet his needs
One he is in have now said whatever outcome of CHC is they can’t meet his needs as ‘too complex’
DF didn’t meet CHC criteria at first stage which I disagreed with so they have now agreed to do full stage MDT assessment
I downloaded assessment tool and think he nearly qualifies 1 severe and lots of high needs
How can I best argue his case
Is it worth making a written submission stating why and how I think he does
If so would you let them have it in advance? On the day? Or wait for him to fail and use it to appeal?

Also how on earth do I find somewhere that can meet his needs?
In my limited experience the good homes refuse him as they can’t meet his needs and don’t want to fail him
The less than satisfactory ones say they can meet his needs but then don’t!!!

I think the fact that 2 nursing homes have said they cannot meet his needs will definitely help. The bar for chc is very high though.

Have a look at caretobedifferent.co.uk I found it incredibly helpful.

I sat down and broke down my persons daily routine / behaviour etc in detail. I then downloaded the dst form and basically looked at where she would fall in the headings. I found quite a few things crossed multiple domains.

I was told repeatedly we wouldn't get it, everyone minimised needs eg "x needs supervision to change incontinence pads" when the reality is that even with supervision / prompting she can't do it and it needs to be done for her. This isn't only relevant to the continence section but links to her cognition and skin integrity as without intervention and someone mobilising her to change her pads and clean and cream her, she would be at an increased risk of iris and skin breakdown.

I made sure I was fully prepared and knew exactly what grading I was going to argue for, with examples and found it really helped.

The ccg will ask you to fill in a form - it is laughable as they give you barely any space so I prepared my own. They ask for the form in advance but I didn't want them pre-armed so handed it to them on the day. Everything I said was on the form.

Good luck it is such a stressful process.

*uti's not iris

Have his current home said why they can't meet his needs, what complex needs do they say he has that they cannot manage. I would fill out the assessment form, back it up with any evidence you have for each domain, are you going to the MDT meeting.

I will be attending MDT
DB and I are both filling in forms saying where we think he fits into each category
Main reason home cannot meet his needs is he struggles with swallowing so needs 60-90 minute one to one carer to feed him 3 times a day plus encourage self feeding where possible
He is prone to choking or aspirating

Have the home or hospital referred him to speech therapy for his swallowing difficulty, they need to decide if it's safe and appropriate for him to feed himself and also what foods and drinks consistency are safe. Is it a nursing home with registered nurses, spending time with someone who needs full supervision is pretty common, is it because they don't have enough staff or lack of training. You can ask to see his care plan for evidence of his needs. It's so difficult, there always seem to be obstacles put in the way.

In my experience, you can provide all the evidence and still find yourself in a computer says no situation. Really, it depends on the local funding and politics, if the demographics suggest that there's a high elderly population in your area you're unlikely to get anything. We were in Surrey and provided all the evidence that demonstrated she should be on it, and still got refused, it's not exactly like they have to fork out anything if they don't want.

That said, one time we were offered NHS Cont Care by the hospital without even asking, after one care home nearly killed Mum and put her in said hospital. Isn't that nice? They gave her three months to live, a wonderfully ambiguous way of putting it, I now see. I'd like to be convinced that the reason I had to go to the care home every day over the next few years to give my mother drink wasn't because Surrey get their dodgy care homes to put residents in her condition on a variation of the notorious Liverpool Care Pathway (murdered by dehdyration), but you may struggle to convince me. So be careful what you wish for.

That said, if you mean this is a 'Pathway' for your parent as in, this looks like the end, you may indeed get NHS Cont Care. The thing is, they don't want to pay out for someone for any length of time, so for some this will be a sort of 'golden handshake', a 'golden goodbye'.

No it’s not that kind of pathway
Just reason given for Dad being assessed for CHC in community rather than in hospital
I’m sorry to hear about all your bad experiences - a few years ago another more distant elderly relative had malnutrition cited as secondary cause of death on certificate (he was blind and deaf and starved in hospital as no one fed him or made sure he knew where they had left his meals or drinks)

Re feeding whilst in hospital he was getting help from SALT and nutrition team daily to build up swallowing ability however that stopped on discharge to nursing home who were given inadequate handover information
They are very caring but do not have enough staff to spend time to allow him to self feed safely
He has NSG tube but tries to pull it out - they did consider peg feed in hospital but decided with lots of input he may get to position in future to be able to eat stage 2 purées which with thickened build up drinks may be enough

Community therapy team are going out to assess him soon and will then offer support
But I’ve been told there is approx 3 month waiting list and the support may only be weekly or fortnightly and the care home staff would be expected to continue work as suggested by therapists
I’m just not convinced even the most fab nursing home would have enough staff to consistently do this and it’s going to be a struggle to get one to take him with such an intense care plan

first things first you need to make sure that the home he is currently in is recording everything that may meet the CHC criteria.

if he is needing 60 - 90 mins to be fed every single meal time it needs to be written down every single meal time

If he is pulling tubes out it needs to be written down every time.

Most successful CHC assessments have huge amounts of written evidence backing up the decision.

Secondly - I mean this nicely and in order to prepare you, but your role in the CHC meeting will be as observer/supporter/advocate. You will be asked your opinion and your opinion may be noted but ultimately your 'vote' wont count in the decision making, you may even be asked to leave the room whilst the decision is being made.

Its worth familiarising yourself with the paperwork to make sure that everything important that needs to be discussed is discussed in the meeting, as often care home staff don't always remember to bring everything up that might be important.

Its also not quite as simple as saying he has X amount of 'Severes' and X amount of 'Highs'. CHC is determined on how the needs impact on care and how the interact with each other. This is known as the 'four key indicators' which are are the 'nature' of the needs and are they suitably 'unpredictable, complex and intense' to qualify for CHC funding.

Scores of high and severe in many of the domains may indicate that needs are complex, but if they are not also intense or unpredictable then it may be felt that they can be dealt with under normal nursing structures.

Its also common for families for over score when using the CHC paperwork themselves (not saying you have done this OP his nutrition needs will be fairly high from your description).

What often happens though is family see their relative in the context of how they are now in comparison to how they used to be, whereas the health professionals see people with extremely complex needs every day and have a better idea of where on the 'complexity' scale your relatives needs will be for care homes to manage.

Regards to your concerns about homes in the area not accepting him because of his high needs - CHC funding usually is utilised by care homes to fund additional members of staff to meet those kind of needs, thats kind of the point of CHC funding is that it provides for the needs that are 'over and above' what care homes/nursing homes can usually offer.

Good luck!

Different strokes for different NHS CCGs perhaps, but never at any point were we invited into Surrey's decision meeting for NHS Cont Care, so we were never asked to leave! It wasn't like that recent drama, Care.

The peg feed may or may not be significant. Our NHS were very heavy on our Mum getting that, very pushy, we had to fight it all the way, and it may have been connnected to a tickbox criteria re granting NHS Cont Care. Because I never got any sense the consultant gave a damn about her or her lack of fluid on the ward. (There may be a more sinister reason for the PEG being inserted.) Eventually, our mother did get a PEG - we went private - but that was around three years after when her swallow packed up for good.
One bittersweet thing was when I spoon fed my mother liquid honey from a squeegee bottle while she was on a PEG and she really took to it, she loved it, despite her impaired swallow! Sadly that was just the one time, as the care home then had us barred from giving her suction, and she died a few weeks later - the care home was then able to charge the price they had demanded for that now vacant room.
(The care industry is run and managed by cunts.)

Back on subject, a PEG might not work for your dad if he is pulling tubes out.

And NHS Cont Care might work for him, esp if you are in a position to offer top up fees as well. So a care home might demand '24-hr care' which is rubbish really, it's not like it literally means someone will be with them 24 hours a day, but it is really just a way of ratcheting things up if they have 'complex' needs. If so, you could be forking out around £1,500 a week with extra care topped up by the NHS Cont Care, it's not exactly like that, but that's generally it, so it's not like you get the whole thing for free.

To be honest, this sounds like a situation you are going to have to keep your eye on it, so stay off the coffee as hopefully you will be in it for the long haul. Any rehabilitation your parent undergoes, it will all be done by you if my experience is anything to go by. Pace yourself and try to play him nice stuff off your iPod.

The swallowing problem may be a biggie as I think care homes can go nuts on the whole aspiration thing, legally a death by that way can be a minefield for them, whereas of course dehydration really isn't, as no one gets blamed. That may be a reason why some prefer the PEG.

PEG and NG feeding is something registered nurses can deal with, there are bridles which can be used to stop nasal tubes being pulled out but PEG is better long term. Our relative had the salt assessment and careplan sent with them from the hospital, they were on a food and fluid chart and had risk assessments and a careplan around safe eating and drinking. The staff referred back to the g.p. and the salt and comm unity dietician if there were any problems or weight loss. He saw the community physio twice a week, was assessed for rehab potential which he didn't have so that stopped. We were invited to all the meetings and monthly careplan reviews, we didn't have p.o.a. but they were happy to listen to our views. He was self funding, didn't get chc although was totally dependent on staff for everything, we got end contribution for the nursing care.

Update
CHC full assessment was yesterday Dad scored severe in one area, high in many others and moderate in some others
Been turned down for funding as told that many of his needs can be met by trained carers rather than actual nurses
Trying to decide whether to appeal or not
Current nursing home say he has to leave as they can’t meet his needs
We have been given a list of homes to look at but there are only 2 that have vacancies that Mum can afford the top ups and one of those turned him down a few weeks ago on hospital discharge as also assessed him and said they couldn’t meet his needs
We are left with a choice of one - who may well decide the same! What happens then?
It’s also a long journey for visiting - mum has dementia and likes to go every day
How do we ensure that wherever he goes there is a proper care plan in place that actually ensures he gets the help he needs especially for rehab
Community therapy team seem to think he has rehab potential but he will need a lot of input

Does he have a social worker allocated? They should be supporting you to find a home that can meet his needs.

Vacancies change on a day to day basis so if you find somewhere you like that may be able to meet his needs it's worth asking if they will assess and put him on a waiting list.

Until then he will most likely stay where he is.

In my experience he is unlikely to get any meaningful rehab provided by the state in an ordinary residential care/nursing home setting because they aren't funded to provide it and the community rehab teams often don't have the resources to provide it. He could pay privately or push to see if he may be eligable for a residential rehab unit.

I don't know if this will help you make your mind up about appealing but my understanding is you can't appeal the decision you can only appeal if you feel the process wasn't followed correctly.

What was his severe in out of interest? I'm surprised that if it's so difficult to find placements for because of complex needs that he didn't score higher?

Severe was in cognition

Update on situation - have been posting on main thread
DF now readmitted to hospital on Xmas day with internal bleeding and now at risk of pneumonia
Does anyone know how this affects the CHC assessment and discharge to assess?
Any idea how long the nursing home will keep his room for? I’m guessing it depends on funding
When he is hopefully medically fit for discharge does discharge to assess start all over again with another 28 days funding
I think they may agree his needs have changed
Rang SW this morning who just said stop looking at nursing homes until we know when he may be fit to move, mentioned may be possible to do CHC assessment whilst on ward but depends on timing and bed situation - but was rather vague about it all

Yes after 72 hrs in hospital it's likely the whole process will be restarted. There's no guarantee he will go down a discharge to assess pathway again and given the D2A home he was in had already said they couldn't meet his needs it's unlikely they will take him back.

A severe in cognition only wouldnt usually indicate a CHC eligibility I'm afraid unless it was significantly impacting on some of the other domains (e.g mobility/ drugs therapies because lack of understanding makes them a high falls risk or means they have to be administered medicine covertly)

Sorry - I don't keep up with the main thread because I don't want to stick my nose in to what is (in my view) a peer support thread (but I'm always happy for people to @ me if there are any adult social care specific questions I might be able to help with)

Thank you @hatgirl
Looks like DF will be in till at least Monday as they are only going to try and reconnect his NSG feed today
We are still waiting SALT to assess swallow before we can try and get him on oral trials again
Will definitely go over 72 hour admittance if that’s a rule
I mentioned to consultant that SW had said about reassessing him in hospital and they weren’t too happy as obviously it’s a bad time of year for pressure on beds
I suspect not much will happen till Monday now
From what I’ve gathered he still won’t be eligible for CHC funding so it’s more about finding somewhere that can meet his needs
I asked SW about drawing up care plan etc and said I thought part of his role was to to assess DF need and help me find somewhere that met them
He basically said he would just give me a list - it was up to me to choose and that when DF got there the home would draw up a suitable care plan
It’s a bit late if they then say oh no we can’t do X Y n Z
Does this sound right to you?

Its absolutely the responsibility of the home to draw up a care plan as they are the ones that will be caring for him.

The care home will come and assess in hospital and agree if they can meet needs or not. They won't take him if they can't.

If they do take him and if he is being discharged via social services they should be provided with a social work assessment and a proposed support plan of his assessed needs. You might find however that in a pressured hospital environment the support plan created by the social worker will simply state that his assessed needs will be met by 24 hour care (which I don't deny is a bit rubbish).

The social worker won't be allowed to make recommendations about homes so you do need to have a look yourself to see which seems most appropriate.

The list you were given even a week ago isn't likely to still be accurate. Most local authorities (and some hospitals) offer a service where they will do the ringing round on your behalf to find out where the daily vacancies are (after all its in their interests to keep things moving and the care homes don't have the staff to deal with hundreds of individual enquiries). Its worth checking again on Monday what the up to date vacancy list is.

Meanwhile - the longer he is in hospital the better his chances of seeing SALT this side of Summer 2019 so its not all bad news...