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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Assessing People for NHS Funding Policy

1. Purpose

The purpose of this policy is to set out how {{org_field_name}} identifies and supports individuals who may require consideration for NHS Continuing Healthcare (CHC) or NHS Funded Nursing Care (FNC), and how the service co-operates with the relevant Local Health Board, local authority and other professionals during assessment, decision-making, care planning and review.

This policy is implemented in accordance with the National Health Service (Wales) Act 2006, the Social Services and Well-being (Wales) Act 2014, including section 47 in relation to nursing care provided by a registered nurse, the Regulation and Inspection of Social Care (Wales) Act 2016, the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, the Welsh Government Continuing NHS Healthcare – National Framework for Implementation in Wales 2021, as amended by any subsequent Welsh Government policy statements or statutory provisions, and the applicable Welsh Government guidance on NHS Funded Nursing Care.

The service will ensure that individuals who may require consideration for NHS funding are identified promptly, that appropriate referrals are made to the relevant NHS or local authority professionals, that the individual is supported to participate in the process, and that relevant care records and evidence are accurate, current and made available lawfully to those responsible for determining eligibility.

Nothing in this policy transfers responsibility for determining eligibility for CHC or FNC from the relevant Local Health Board or other statutory body to {{org_field_name}}.

2. Scope

This policy applies to all residents who may be eligible for NHS Continuing Healthcare or Funded Nursing Care, including those newly admitted, those whose needs change over time, and those undergoing routine care reviews. It applies to all staff involved in the care planning, assessment, and advocacy process, including the Registered Manager, nursing staff, senior care staff, and administrators liaising with health board professionals.

3. Related Policies

This policy should be read in conjunction with the following:
CHW07 – Person-Centred Care Policy
CHW09 – Consent to Care Policy
CHW11 – Safe Care and Treatment Policy
CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy
CHW18 – Risk Management and Assessment Policy
CHW36 – Initial Assessment and Care Planning Policy
CHW42 – Communication and Engagement with Service Users and Families Policy
CHW41 – Managing Service User Finances Policy

4. Policy Statement and Implementation

4.1 Overview of NHS Funding Options

There are two distinct NHS funding arrangements relevant to individuals receiving care in a care home:

• NHS Continuing Healthcare (CHC) is a package of ongoing care arranged and funded by the NHS for an adult aged 18 or over who has been assessed as having a primary health need. Eligibility is determined by consideration of the totality of the individual’s needs, including their nature, intensity, complexity and unpredictability. Eligibility is not determined by a particular diagnosis, condition, care setting or the individual’s financial circumstances.
• NHS Funded Nursing Care (FNC) applies to individuals living in a care home where nursing care is provided and who have been assessed as requiring care from a registered nurse. FNC is distinct from CHC and contributes towards the registered nursing care that the NHS is responsible for providing.

Eligibility for CHC must always be considered before a decision is made about eligibility for FNC. FNC must not be used as an alternative to undertaking an appropriate consideration or assessment for CHC where the individual may have a primary health need.

The relevant Local Health Board is responsible for determining NHS funding eligibility. {{org_field_name}} does not make CHC or FNC eligibility decisions.

The role of {{org_field_name}} is to:

• identify circumstances where CHC or FNC consideration may be required;
• make or support appropriate referrals;
• provide accurate, complete and current evidence concerning the individual’s needs;
• participate in assessments and reviews when requested and appropriate;
• support the individual and their representative to participate in the process;
• notify the relevant statutory body where there is a significant change in the individual’s needs; and
• ensure that the individual continues to receive care and support in accordance with their assessed needs and personal plan.

Funding status must not determine the level or quality of care provided by {{org_field_name}}. Care and support must at all times be based upon the individual’s assessed needs, personal outcomes, provider assessment and personal plan.

4.2 Identification of Potential Eligibility

{{org_field_name}} will remain alert to circumstances in which an individual’s health and care needs indicate that consideration of eligibility for NHS Continuing Healthcare may be required.

Consideration of CHC eligibility may arise:

• during pre-admission or admission assessment;
• during the provider assessment;
• during review of the individual’s personal plan;
• following a significant deterioration or change in physical or mental health;
• following hospital admission or discharge;
• where the frequency, intensity, complexity or unpredictability of the individual’s needs increases;
• where the individual requires increasing levels of skilled health or nursing intervention;
• where there are significant palliative or end-of-life care needs;
• where existing FNC arrangements may no longer adequately reflect the individual’s needs; or
• where the individual, their representative or a relevant professional requests consideration of CHC eligibility.

Staff must record significant changes in the individual’s needs accurately and contemporaneously within the care record and must escalate concerns to the Registered Manager or an appropriately delegated senior member of staff.

Where there are reasonable grounds to consider that an individual may require assessment for CHC, the Registered Manager or appropriately delegated senior member of staff will contact the relevant Local Health Board CHC team, named Care Co-ordinator, GP or other appropriate health or social care professional without avoidable delay so that the appropriate statutory process can be initiated.

Where an individual is rapidly deteriorating, may be entering a terminal phase, has experienced a catastrophic health event, or otherwise appears to have developed an evident primary health need requiring urgent NHS provision, staff must immediately escalate this to an appropriate health professional so that consideration can be given to the CHC Fast Track process.

A Fast Track assessment and recommendation must be undertaken by an appropriate clinician in accordance with the applicable Welsh Government Continuing NHS Healthcare Framework. {{org_field_name}} must not make a Fast Track eligibility decision itself.

Where requested, {{org_field_name}} will provide relevant evidence to support Fast Track consideration, including current assessments, personal plans, nursing records, daily records, clinical observations, medicines records, risk assessments and other information relevant to the individual’s current needs.

Identification of possible CHC eligibility must not result in any reduction, withdrawal or avoidable delay in the care and support required to meet the individual’s current assessed needs.

4.3 Referral and Use of the CHC Checklist

Where there are grounds to consider that an individual may require NHS Continuing Healthcare, {{org_field_name}} will contact the relevant Local Health Board CHC team, named Care Co-ordinator or other appropriate statutory professional so that the appropriate screening or assessment process can be arranged.

The CHC Checklist is a screening tool used to identify whether an individual should proceed to a full assessment of eligibility for CHC. Use of the Checklist is not mandatory in every case and it must not replace professional judgement.

A positive Checklist does not mean that an individual has been found eligible for CHC. It indicates that a full assessment of eligibility is required.

Where a Checklist is used, {{org_field_name}} will support its completion in accordance with the current Welsh Government Continuing NHS Healthcare Framework.

The Checklist must be completed by appropriately trained practitioners in accordance with the requirements of the Welsh Government Framework. This includes the required involvement of local authority representation within the Checklist process.

Care home staff may contribute relevant evidence, professional observations and information about the individual’s day-to-day needs but must not assume responsibility for making the CHC eligibility decision.

Before the CHC assessment process takes place, the individual’s consent must be considered in accordance with the Welsh Government Framework, the Mental Capacity Act 2005 and applicable information governance requirements.

Where the individual has capacity to make the relevant decision, informed consent must address:

• participation in the CHC assessment process;
• obtaining relevant information;
• sharing relevant information between organisations and professionals involved in the process; and
• processing information for the purposes of assessment, decision-making and review.

The individual must be given sufficient information to understand the purpose of the CHC process, what information will be considered and the possible consequences of the assessment.

Where a Checklist is arranged, the individual or their representative should be given reasonable notice and an opportunity to participate. The individual should also be supported to involve an appropriate representative, family member, carer or advocate where they wish to do so or where such involvement is otherwise appropriate.

The individual’s communication and language requirements must be identified and accommodated throughout the process.

{{org_field_name}} will provide accurate, current and relevant care records and other evidence requested for the assessment, subject to applicable confidentiality, consent, information-sharing and data protection requirements.

Where a Checklist is completed, the outcome and rationale must be communicated to the individual or their representative by the responsible statutory body in accordance with the Welsh Government Framework.

Where a positive Checklist outcome is reached, the individual must proceed to a full assessment of eligibility for CHC.

Where the Checklist does not result in referral for a full CHC assessment, {{org_field_name}} will support the individual or their representative to obtain information from the relevant Local Health Board about the outcome and the appropriate route for requesting reconsideration or raising concerns.

4.4 Full Assessment for NHS Continuing Healthcare

Where a full assessment of eligibility for CHC is required, the process will be co-ordinated through the relevant statutory arrangements by the named Care Co-ordinator or other appropriate lead professional.

Responsibility for co-ordinating the CHC assessment does not rest with {{org_field_name}}.

{{org_field_name}} will co-operate fully with the assessment process and will provide relevant, accurate and up-to-date evidence concerning the individual’s needs and the care required to meet those needs.

Evidence may include, where relevant:

• the provider assessment;
• the current personal plan;
• risk assessments;
• nursing records;
• daily care records;
• clinical observations;
• nutritional and hydration records;
• skin integrity records;
• continence records;
• behavioural support records;
• incident and accident records;
• medicines administration records;
• records relating to falls;
• records of professional involvement;
• hospital correspondence;
• records of changes in dependency;
• records of interventions required during the day or night; and
• any other information relevant to the nature, intensity, complexity or unpredictability of the individual’s needs.

Care home nursing staff, senior care staff or other staff with appropriate knowledge of the individual may participate in the multidisciplinary assessment where requested and appropriate.

The multidisciplinary team will use the current Welsh Government Decision Support Tool to support its assessment and recommendation.

The assessment must consider the totality of the individual’s needs and whether those needs demonstrate a primary health need, with particular consideration of:

• nature;
• intensity;
• complexity; and
• unpredictability.

The Decision Support Tool supports professional decision-making and does not replace professional judgement.

{{org_field_name}} must not:

• alter the nationally approved Decision Support Tool;
• represent an individual score or domain as automatically determining eligibility;
• promise that a particular level of need will result in CHC funding; or
• inform an individual that they are eligible or ineligible before a formal decision has been made by the appropriate Local Health Board.

The individual must be placed at the centre of the assessment process and, where appropriate, their representative must be enabled to participate.

The individual’s wishes, views, communication needs, preferred language and level of understanding must be taken into account throughout the assessment.

Where there is disagreement between {{org_field_name}} and other professionals about the description of the individual’s needs, care home staff must ensure that their professional evidence and reasons are accurately recorded and presented through the appropriate assessment process.

The multidisciplinary team makes a recommendation concerning eligibility. The final eligibility decision rests with the relevant Local Health Board.

When a written eligibility decision is received, {{org_field_name}} will ensure that any resulting changes to the individual’s care arrangements, provider assessment, personal plan, risk assessments, commissioning arrangements or service agreement are implemented as appropriate and documented.

Where the individual or their representative disagrees with the eligibility decision, {{org_field_name}} will provide reasonable assistance to enable them to understand how they may obtain further information, request a review or access the relevant dispute, complaints or advocacy arrangements.

4.5 NHS Funded Nursing Care

NHS Funded Nursing Care applies to an individual living in a care home where nursing care is provided who has been assessed as requiring care from a registered nurse.

Eligibility for NHS Continuing Healthcare must always be considered before a decision is made about eligibility for FNC.

Where there is evidence that an individual may have a primary health need, FNC must not be used as a substitute for appropriate consideration or assessment for CHC.

The relevant Local Health Board is responsible for determining eligibility for FNC in accordance with applicable Welsh Government legislation, policy and guidance.

{{org_field_name}} will provide relevant information and evidence concerning the individual’s nursing needs and will participate in the assessment or review process where requested.

Information provided may include:

• nursing assessments;
• provider assessments;
• personal plans;
• dependency information;
• medicines records;
• clinical observations;
• monitoring records;
• evidence of registered nursing interventions;
• records of changes in condition; and
• relevant information from health and allied health professionals.

Where FNC is awarded, the funding arrangements notified by the Local Health Board or relevant commissioner will be accurately reflected within the service’s contractual and financial records.

The individual or their representative will be provided with clear information about the effect of the FNC decision on any charges for which they remain responsible.

An award of FNC does not mean that the entire care home placement is funded by the NHS.

Where an individual receiving FNC subsequently experiences deterioration or another significant change in needs that may indicate a primary health need, {{org_field_name}} will notify the appropriate Local Health Board contact without avoidable delay so that eligibility for CHC can be reconsidered.

4.6 Recording and Communication

{{org_field_name}} will maintain accurate, complete, contemporaneous and current records relating to an individual’s CHC or FNC process insofar as those records are received, created or held by the service.

Relevant records will include, as applicable:

• referrals and requests for consideration of CHC or FNC;
• records of concerns leading to referral;
• consent and information-sharing records held by the service;
• mental capacity assessments or best interests records relevant to the service’s involvement;
• relevant assessments and evidence submitted by the service;
• completed Checklists provided to the service;
• Decision Support Tools provided to the service;
• Fast Track documentation provided to the service;
• correspondence from the Local Health Board, local authority, Care Co-ordinator or other relevant professionals;
• eligibility decisions;
• review decisions;
• records of meetings in which care home staff have participated;
• records of professional discussions;
• changes to commissioned care;
• changes to funding arrangements;
• relevant contractual correspondence; and
• any resulting amendments to the provider assessment, personal plan, risk assessments or service agreement.

Records must be stored securely and handled in accordance with applicable confidentiality, data protection, information governance and record-retention requirements.

Funding status must not be treated as a substitute for assessment of the individual’s care and support needs.

Where an assessment, eligibility decision or funding review identifies a change in the individual’s needs, the provider assessment and personal plan must be reviewed and revised as required.

Where the care home identifies a significant difference between the individual’s documented commissioned care and their actual current needs, this must be recorded and escalated to the relevant commissioner, Local Health Board or other responsible statutory body.

Information communicated directly by {{org_field_name}} to the individual must be provided in an appropriate language, style, presentation and format having regard to the individual’s communication needs, wishes and level of understanding.

Where appropriate, reasonable adjustments and communication aids must be used to support the individual to understand and participate in the process.

4.7 Reviews, Changes in Need and Reassessment

{{org_field_name}} will co-operate with all CHC and FNC care-plan reviews and eligibility reassessments arranged by the relevant Local Health Board or other responsible statutory body.

For an individual whose package of care has commenced following a CHC decision, an initial review of the care plan should take place within three months of services first being provided unless an earlier review is required.

Thereafter, CHC review should take place at least annually or more frequently where the individual’s needs or circumstances indicate that this is necessary.

Individuals receiving FNC must be reviewed at least annually. When FNC is reviewed, potential eligibility for CHC must also be considered and a full CHC assessment undertaken where required.

The statutory CHC or FNC review is not led by {{org_field_name}}.

{{org_field_name}} remains responsible for continuously monitoring the individual’s health, safety, well-being and care needs as part of the service’s responsibilities under the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

The individual’s personal plan must continue to be reviewed at least every three months and sooner where required, regardless of the timetable for CHC or FNC review.

Staff must promptly identify, record and report:

• marked deterioration;
• significant improvement;
• increased dependency;
• reduced dependency;
• changes in cognition or behaviour;
• changes in nursing requirements;
• repeated hospital admission;
• new or worsening clinical risks;
• increased frequency or complexity of interventions;
• changes in end-of-life or palliative care needs; or
• any other significant change which may affect the appropriateness of the current care or funding arrangements.

Such changes must be reported to the Registered Manager or appropriately delegated senior person.

Where the change may affect the appropriateness of the existing care package or funding arrangements, the relevant Care Co-ordinator, Local Health Board, local authority or other funding body must be notified without avoidable delay.

Where there is evidence of a change in needs which may affect CHC eligibility, the Local Health Board is responsible for arranging a reassessment where required.

Where a full reassessment of CHC eligibility is required, this must be undertaken through the appropriate statutory process using a new Decision Support Tool and an appropriately constituted multidisciplinary assessment.

{{org_field_name}} will provide current and accurate evidence to reviews and reassessments, including relevant:

• provider assessments;
• personal plans;
• daily care records;
• nursing records;
• clinical observations;
• medicines records;
• risk assessments;
• incident records;
• monitoring records; and
• information from relevant professionals.

Existing care and support must not be withdrawn or reduced by {{org_field_name}} merely because funding eligibility is being reviewed or reassessed.

Any change to care provided by {{org_field_name}} must be managed safely and in accordance with:

• the individual’s current assessed needs;
• the personal plan;
• applicable commissioning arrangements;
• the service agreement;
• the service’s statement of purpose; and
• applicable statutory requirements.

4.8 Consent, Mental Capacity, Advocacy and Rights

Individuals must be supported to participate meaningfully in decisions concerning CHC and FNC and must be given information in a form they can understand.

Where an individual has capacity to make the relevant decision, their informed consent must be addressed before the CHC assessment process is undertaken.

Consent must include, where relevant:

• participation in the CHC assessment process;
• obtaining relevant information;
• sharing relevant information between organisations and professionals involved in the assessment; and
• processing relevant information for assessment, decision-making and review.

The individual must receive sufficient information to understand:

• the purpose of the assessment;
• what the assessment involves;
• what information may be obtained and shared;
• who may be involved;
• the possible outcomes; and
• how the decision may affect their care and funding arrangements.

An adult who has capacity to make the relevant decision is entitled to refuse participation in the assessment process.

Where an individual with capacity refuses an assessment or refuses relevant information sharing, staff must not override that decision merely because they consider another decision preferable.

Any refusal known to {{org_field_name}}, together with relevant information provided to the individual and any action taken by the service, must be appropriately recorded.

Where there is reason to doubt an individual’s capacity to make a particular decision, capacity must be considered in accordance with the Mental Capacity Act 2005.

Capacity must be assessed in relation to the specific decision at the relevant time.

An individual must not be presumed to lack capacity solely because of:

• age;
• diagnosis;
• disability;
• behaviour;
• appearance;
• communication difficulty; or
• a decision which others consider unwise.

All practicable steps must be taken to support the individual to make the decision before concluding that they are unable to do so.

Where the individual lacks capacity for the relevant decision, staff must establish whether there is a person with lawful authority to make or participate in the decision on the individual’s behalf, including, where applicable:

• an attorney acting under a valid and applicable Lasting Power of Attorney; or
• a deputy appointed by the Court of Protection with relevant authority.

Where no person has applicable lawful authority, decisions must be made in accordance with the Mental Capacity Act 2005 and its best interests requirements.

Any decision made on behalf of an individual who lacks capacity must be decision-specific and must not confer general authority upon relatives or representatives who do not otherwise hold legal authority.

The individual must be informed about available advocacy support and supported to access advocacy where required.

Where statutory criteria for independent professional advocacy apply, appropriate arrangements must be made through the responsible statutory body.

{{org_field_name}} will support the individual’s representative, advocate or other lawfully authorised person to participate in the process in accordance with the individual’s wishes, capacity, legal rights and applicable information-sharing requirements.

Staff must follow CHW09 – Consent to Care Policy and CHW39 – Mental Capacity and DoLS Policy where applicable.

4.9 Staff Competence and Governance

Staff whose roles involve assessment, registered nursing care, care planning, review or senior oversight must have sufficient knowledge relevant to their role to recognise when an individual’s changing health and care needs may require consideration of CHC or FNC.

Relevant staff must understand:

• the distinction between CHC and FNC;
• that CHC eligibility is based upon whether the individual has a primary health need and is not determined solely by diagnosis;
• that an individual’s financial circumstances do not determine CHC eligibility;
• the care home’s responsibility to identify concerns and contact appropriate NHS or local authority professionals;
• the importance of accurate, objective and contemporaneous care records as evidence of an individual’s actual needs;
• the four key characteristics of nature, intensity, complexity and unpredictability;
• the need to escalate rapidly deteriorating or catastrophic changes so that Fast Track consideration can take place where appropriate;
• consent and mental capacity requirements relevant to the assessment process;
• confidentiality, data protection and information-sharing requirements;
• the requirement to notify the appropriate Care Co-ordinator, Local Health Board or funding body of significant changes in an individual’s needs; and
• the limits of the care home’s role in relation to statutory eligibility decisions.

A member of staff must not represent themselves as authorised to determine CHC or FNC eligibility.

A member of staff must not state that they are responsible for completing or authorising a CHC Checklist, Decision Support Tool or Fast Track recommendation unless they are properly participating in the process in accordance with the Welsh Government Framework and the requirements applicable to their professional role.

Staff contributing to assessments must provide objective evidence describing the individual’s actual needs and interventions rather than attempting to influence the assessment by exaggerating or minimising needs.

The Registered Manager will maintain oversight of:

• referrals made or supported by the service;
• requests for information;
• scheduled assessments;
• outstanding decisions;
• review dates known to the service;
• changes in need requiring escalation;
• correspondence requiring action; and
• unresolved delays or concerns.

Where a delay or unresolved issue may adversely affect the individual’s safety, well-being, care arrangements or rights, the Registered Manager will escalate the matter to the relevant statutory organisation without avoidable delay.

Training and competency requirements will be monitored in accordance with CHW27 – Staff Supervision, Training and Development Policy.

4.10 Financial Transparency, NHS Funding and Service Agreements

Where an individual receives CHC or FNC, {{org_field_name}} will ensure that the service agreement, invoices and financial records accurately reflect the funding arrangements formally notified by the relevant Local Health Board, local authority or commissioner.

Where an individual is eligible for CHC and their care is provided in a care home, the NHS is responsible for arranging and funding the assessed CHC package, including accommodation, board, personal care and health care required as part of that commissioned package.

The individual or their representative must not be required by {{org_field_name}} to make an additional payment in order to receive care which forms part of their assessed and NHS-commissioned CHC package.

An individual may separately choose to purchase genuinely additional goods or services which do not form part of their assessed and NHS-funded package, provided that:

• the additional service is genuinely optional;
• refusal to purchase the additional service does not adversely affect the assessed care provided to the individual;
• the additional charge does not duplicate care or services for which the NHS is responsible;
• the individual or their representative is given clear written information about what the additional charge covers;
• the individual or their representative freely agrees to the arrangement;
• the arrangement complies with the relevant commissioning contract; and
• the arrangement complies with applicable consumer protection and contractual requirements.

FNC is different from CHC.

An award of FNC does not mean that the entire cost of the care home placement is funded by the NHS.

Any amounts payable by the individual, local authority, Local Health Board or another commissioner must be clearly identified in the relevant contractual and financial documentation.

Where the funding arrangements change, the individual or their financial representative will receive clear written information explaining:

• the nature of the change;
• when the change takes effect;
• the effect upon any amount for which the individual remains responsible; and
• any consequential contractual changes.

The service agreement and associated financial records must be amended where necessary.

No additional fee or charge may be introduced solely because an individual has become eligible for CHC or FNC.

Staff must not provide financial or legal advice outside the limits of their role.

Where an individual or representative requires clarification about NHS or local authority funding liability, disputes a charge, or requires independent financial or legal advice, they must be directed to the appropriate Local Health Board, local authority, commissioner, advocacy service or suitably qualified independent adviser.

5. Policy Review

This policy will be reviewed at least annually and sooner where required following any change to the Continuing NHS Healthcare National Framework for Implementation in Wales, Welsh Government CHC interim or replacement policy statements, NHS Funded Nursing Care policy or guidance, relevant legislation, the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 as amended, CIW statutory guidance, or relevant commissioning requirements. The Registered Manager is responsible for ensuring that the policy remains current and that any changes affecting staff practice are communicated and implemented.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.