Care Home Fees Refund Case Study

Author:
Lucy Alvey
Care Homes Legal Executive
Date:
03/04/2019

See Latest Case Study - £150,000 in Care Home Fees Refunded.

Client Situation

Our client, Miss A, contacted our Care Home Fees Solicitors for assistance in September 2013 after her father had been assessed and turned down for NHS Continuing Healthcare Funding (CHC Funding).

She wished to claim back the care home fees the family had paid for the previous year and obtain funding for future care costs.

Miss A’s father had suffered a stroke and following this, he was unable to communicate, doubly incontinent and at risk of choking. He suffered with significant weight loss and pressure sores due to the fact that he was immobile and bed bound.

Our Care Home Fees Solicitors wrote to the Clinical Commissioning Group (CCG) to request a review of their decision and a new assessment of Mr A’s needs. The CCG confirmed that due to a large number of requests for review there would be some delay.

Unfortunately Miss A’s father passed away in 2014, before the review was complete. He was assessed in hospital and awarded fast track NHS Continuing Healthcare Funding a month before he passed away.

How We Helped

Our Solicitors were instructed to pursue the claim for a refund of care fees paid from October 2012 to June 2014, when fast track funding had been awarded. By February 2015, there had been very little progress and so we made a formal complaint to the Clinical Commissioning Group.

The CCG apologised for the delay, stating that there was a large backlog of cases to review and a lack of resource. When the draft Needs Portrayal Document was completed in March 2017, it became clear that not all of the relevant records had been reviewed.

As a result of this, the full extent of Mr A’s needs was not evidenced. Our Solicitors returned to the CCG to confirm this and they agreed to obtain the missing records and amend their review.

The amended Need Portrayal Document was sent out in June 2017 and the family and our Solicitors were invited to submit comments and suggested scores for the levels of need across the 12 care domains in the Decision Support Tool (DST). The DST is used to assess a patient’s needs in areas such as Cognition, Mobility, Skincare, Nutrition and Breathing.

The review and comments from our Care Home Fees Solicitors were then considered by a Multi-Disciplinary panel made up of a social worker and a panel nurse.

The Outcome

The panel found that Mr A wasn’t eligible for funding because the nature of his needs didn’t amount to a Primary Health Need and there was insufficient evidence of intensity, complexity and unpredictability in his care.

Our Care Home Fees Solicitors appealed this decision in February 2018. A full written submission was produced which explained why Mr A’s health needs had been underestimated and used evidence from his care home and GP records to demonstrate why the care he required was both intense and complex.

The CCG offered a telephone meeting to discuss the appeal in April 2018 and our Solicitors took part in this meeting, along with our client Miss A. On appeal, Mr A was found to be eligible for a refund of care home fees.

The case returned to a Review Panel in May 2018 and the panel found that Mr A met the eligibility criteria for NHS continuing care and was therefore entitled to a refund of fees paid between October 2012 and June 2014.

A statement of account from the care home and copy bank statements were provided to the CCG to evidence the exact fees paid and a refund was made for the full amount, plus interest at RPI.

As the above case study demonstrates, the process of requesting a review of NHS Continuing Healthcare Funding (CHC Funding) eligibility can be complicated and extremely time consuming.

Since 2013, our Care Home Fees Solicitors have recovered in excess of £12 million in care fees for our clients. If you would like to discuss how we may be able to help you, please contact us.

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