Supporting and advising clients about healthcare funding can be a confusing process with lots of variables and parties involved in the health and social care maze. Whilst the law governing eligibility for continuing healthcare funding hasn’t changed, actually getting the funding seems harder than ever.
A key part of overcoming this perceived difficulty is acknowledging the importance of care records—a catch-all term for the written information recorded by professionals who deliver support either in an individual’s home or a care home setting. These provide a picture of an individual’s care needs at a particular time, and the quality of those records can affect whether someone is found eligible or not for Continuing Healthcare (CHC). This can often mean the difference of tens of thousands of pounds per year in care fees.
Three main elements to care records include: a Care Plan, which is usually reviewed and updated by care staff on a monthly basis; Daily Records, providing a record of how the care plan is implemented on a day-to-day basis and the level of support patients need; and a MARS sheet, which is a record of a patient’s medication needs, including whether or not patient accepts it. Good quality, accurate care records fulfil a range of purposes, including helping to ensure service users are safe, and that service providers are meeting their legal requirements by meeting and documenting individual’s care needs.
It is vital that family members attending the CHC assessment familiarise themselves with their relative’s care needs. This can be done by attending regular Care Plan 
review meetings and reading through care records. Other professionals, such as speech and language therapists and mental health teams, may attend these meetings to provide support and advice that is then incorporated into the Care Plan. Their involvement will be recorded in correspondence and a record of professional visits.
If someone has very specific needs, for example in relation to challenging behaviours or continence, it is vital that comprehensive information is recorded by care staff about the level of support they need to provide. Someone is only eligible for Continuing Healthcare funding if they have a ‘primary health need’, which is above and beyond what the local authority can be reasonably expected to provide. If the detail care staff give in Daily Records is vague, such as “had their usual day”, this is not enough evidence to qualify for CHC funding.
For those who receive paid care, it is worth spending some time familiarising yourself with your care records. Many people are unaware of the information a care provider must record about them or their loved one until they participate in a NHS Continuing Healthcare Assessment and the question of care funding is raised.
If you receive a care service, either at home or in a care home, you will be involved in your care planning and access to your records should be quite straightforward as part of your ongoing reviews. Accessing health or social services records requires a more formal approach. Each health provider or local authority will have details available about how they handle requests for personal information. Your request will need to be in writing and the organisation concerned may ask you to complete their own Subject Access Request form. There may be a fee payable between £10 to £50 to process the request, depending on the type of records requested and whether they are stored electronically or in paper form. There are a number of factors that must be considered for personal information requests, including risk of harm to the individual from disclosure and a person’s mental capacity.
QualitySolicitors Moore & Tibbits’ Health and Community Care Team have a wealth of up-to-date knowledge and experience in the law relating to care, including care records. We provide advice and guidance to individuals, families and care providers on record keeping, monitoring and reviews.
