Case Study: Retrospective Appeal Helps Client Reclaim Nursing Home Fees

Summary

How we helped a client establish that her late mother should have received NHS continuing healthcare funding. Despite the passage of time, the client was able to reclaim nursing home fees of more than £30,000 for the period April 2004 to February 2006.

The situation

Lily contacted Martin Searle Solicitors in 2010 after discovering her late mother may have qualified for NHS continuing healthcare funding while in a nursing home. Lily wanted specialist help with her appeal against the primary care trust (PCT) to show that her mother had a primary health need during the last two years of her life.

Lily’s mother went into a nursing home in 2002 and was assessed as being in the high banding for NHS funded nursing care (then known as RNCC). As a result, she received a small weekly contribution from the NHS towards her nursing home fees.

In the years that followed, Lily’s mother was never assessed for fully funded NHS continuing healthcare. Four years after her mother died in 2006, Lily found out this funding was available for individuals with a primary health need and realised her mother may have been eligible.

Initially, Lily tried dealing with the retrospective appeal process on her own. However, she soon realised how time consuming and incredibly complicated this was and she felt out of her depth. The case was made even more complex by the fact that the appeal period fell before October 2007 – the date the national framework for NHS continuing healthcare came into force. Before this, each local NHS body had applied their own eligibility criteria.

Lily had a meeting with two nurse assessors from the PCT, which she found discouraging and upsetting. She felt the nurse assessors were trying to put her off and that no one believed how unwell her mother had been. She decided she needed expert and specialist advice and contacted Martin Searle Solicitors’ Community Care Law team.

What Martin Searle Solicitors did

Cate Searle, Director and Head of Community Care Law, met with Lily in Shoreham to discuss her late mother’s healthcare needs in detail. Lily had a very good recollection of her mother’s health needs, but the only evidence she possessed was the limited social services assessments from 2004 and 2005.

Cate found that Lily’s own knowledge and the above assessments indicated that Lily’s mother should have been eligible for fully funded care, had she been assessed during the last two years of her life. Cate helped Lily obtain copies of her mother’s care home records to gather more evidence in support of the appeal. Lily also obtained copies of her mother’s GP records. Although the evidence was slim, it was enough to back up Lily’s points.

Cate prepared detailed written representations for Lily to put before the PCT appeal panel to help her claim back nursing home fees. These included the following points about Lily’s mother:

• She displayed impulsive and challenging behaviour resulting from severe fluctuations in her mental state. She was often anxious and distressed and staff had to use skilled interventions to manage her behaviour and her psychological wellbeing
• She suffered from paranoid hallucinations and delusions which caused anxiety and distress on a daily basis; she did not readily respond to reassurance
• The care home notes revealed that she was severely cognitively impaired. She was disorientated in time, place and person and was always confused. She had no ability to assess basic risks
• She was unable to reliably communicate her needs in any way and was totally reliant on staff to anticipate her needs
• She was at high risk of falls and would often try to stand without assistance despite her incapacity

The written representations went before the appeal panel and Lily was invited to address the meeting. Cate compiled a tips and tactics document to help Lily stay focused and concentrate on the main arguments. This was particularly important given the lack of actual evidence in the care home notes.

Lily asked the panel to reconsider its decision on the basis of her written arguments. To her delight, they agreed.

The result

Soon after the meeting, the PCT wrote to Lily informing her that the panel agreed her mother did indeed have a primary health need between 2004 and 2006. As such, she should have been entitled to NHS continuing healthcare. The PCT said it would refund the nursing home fees. As a result, Lily was able to reclaim nursing home fees of more than £30,000.

To find out if you have a case to claim back nursing home fees, contact our specialist Community Care Law Team on 01273 609911, or email info@ms-solicitors.co.uk.