Summary: We will not investigate this complaint about an alleged failure by a care provider to apply for NHS funded care for one of its service users. This is because the alleged injustice is speculative and contingent on eligibility being confirmed by the NHS. In any event, we are not the appropriate body to consider eligibility for NHS funded care as this is undertaken by integrated care boards which have their own appeals process.

The complaint

1. The complainant (Mr D) complains on behalf of the executer of his wife’s estate (Mrs D) who died following a period in a residential care home managed by Barchester Care Homes Limited (Care Provider). Mr D says the Care Provider failed to apply for NHS funded nursing care (FNC) and continuing health care (CHC) which he says Mrs D was eligible for.
2. In summary, Mr D says the alleged fault has meant Mrs D paid the Care Provider approximately £36,500 which would have been met through FNC and CHC had the application been made. Mr D wants the Care Provider to reimburse Mrs D’s estate for this amount.

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The Ombudsman’s role and powers

3. We investigate complaints about adult social care providers. We provide a free service, but must use public money carefully. We do not start or continue an investigation if we decide:
• the action has not caused injustice to the person complaining; or
• the injustice is not significant enough to justify our involvement; or
• we cannot achieve the outcome someone wants; or
• there is another body better placed to consider the complaint.

(Local Government Act 1974, sections 34B(8) and (9)).

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How I considered this complaint

4. I considered information provided by the complainant and the Care Provider. I also considered the Ombudsman’s Assessment Code.

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My assessment

5. The Care Provider has applied to the local NHS integrated care board (ICB) to carry out a retrospective review into Mrs D’s eligibility for funded care. The relevant ICB has not yet provided a response to the review. Therefore, the alleged injustice and desired outcome claimed by Mr D is contingent on the outcome of the ICB’s review. Where the ICB decides Mrs D was eligible for NHS funded care then this will provide the outcome being sought. On the other hand, if the ICB decides against eligibility, then Mr D, or the executor of Mrs D’s estate, will be able pursue the matter through the ICB’s appeals process. These matters are therefore outside our remit. We cannot provide a remedy for a speculative injustice based on Mrs D’s eligibility which is yet to be confirmed. Further, we are not the appropriate body to assess that eligibility.
6. I have considered the alleged thee month delay by the Care Provider, though I do not consider this in itself has caused serious loss, harm or distress. There is insufficient evidence of a serious enough injustice to warrant our involvement.

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Final decision

7. We will not investigate this complaint because the alleged injustice is speculative. In any event, we are not the appropriate body to consider eligibility for NHS funded care which has its own appeals process.

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Investigator's decision on behalf of the Ombudsman