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Understanding a fair CHC assessment
A fair assessment starts with an accurate account of the person’s needs.
Practical questions for families, carers and other significant people, with an anonymised example from our family’s experience of NHS Continuing Healthcare (CHC).
Scrutiny matters. Read the completed assessment as carefully as the decision letter. Where an error, omission or unexplained contradiction could affect the outcome, raise it clearly in writing and support it with the relevant evidence.
Information only: this page, its case examples and any quizzes are educational. They are not legal, medical or financial advice, cannot determine CHC eligibility and do not replace advice about your circumstances. See the disclaimer and sources of further help.
CHC terms in plain English
| Term | Meaning |
|---|---|
| CHC – NHS Continuing Healthcare | An NHS-funded package meeting assessed health and associated social care needs when someone has a primary health need. |
| Primary health need | The test for full CHC eligibility. In broad terms, it asks whether the total needs go beyond the care a local authority can legally provide as part of social care. It is not decided by a diagnosis or the percentage of tasks labelled “medical”. [1] |
| Checklist | The initial screening tool normally used to identify whether full assessment is needed. A positive result does not award funding. |
| DST – Decision Support Tool | The national tool bringing assessment evidence together across 12 care domains to support an eligibility recommendation. |
| Domain | An area of need, such as breathing, nutrition, cognition or mobility. Each has descriptions used to identify the appropriate level. |
| MDT – Multidisciplinary Team | The professionals who consider assessment evidence and make a CHC recommendation, usually involving health and social care. |
| ICB – Integrated Care Board | The NHS organisation normally responsible locally for coordinating CHC assessment, deciding eligibility and arranging funded care. |
| IRP – Independent Review Panel | A panel arranged by NHS England to independently review a disputed CHC eligibility decision through the review process. |
| FNC – NHS-funded Nursing Care | An NHS payment towards registered nursing care in a nursing home for eligible people who do not qualify for CHC. It does not fund the full care package. CHC should be considered before FNC eligibility is decided. [7] |
| Fast Track | A separate, urgent CHC route for the specified rapid-deterioration and possible-terminal-phase criteria, completed by an appropriate clinician. |
How the CHC pathway starts
You do not have to wait for someone else to mention CHC. If you believe a person may have needs that warrant consideration, ask their health or social care practitioner, care provider or local Integrated Care Board (ICB) CHC team about screening. A family member can raise concerns and help the person request consideration. Being a relative does not automatically authorise access to confidential records or decision-making on their behalf.
The National Framework’s Practice Guidance 14 explains that people can ask a practitioner to complete a Checklist, contact the ICB CHC team, or ask their care provider to contact it. The formal Checklist is completed by a suitable practitioner; a family-completed form is not itself a formal referral. In most circumstances, the guidance considers completion within 14 calendar days of a request appropriate. This is not an unconditional guarantee that every request must produce a Checklist. [1, Practice Guidance 14]
What may prompt consideration?
Significant ongoing support needs, a change in care requirements, a care review or planning a longer-term placement can prompt consideration. It is not confined to a particular diagnosis. Screening should occur when ongoing needs can be understood; a temporary acute illness may require treatment and recovery first. Explain the actual needs that concern you, rather than relying only on the diagnosis. [1, Practice Guidance 17]; [4]
| Stage | What happens |
|---|---|
| 1. Raise the possibility | A practitioner identifies possible CHC needs, or the person or someone supporting them asks for consideration. Explain the concerns and ask who will respond. |
| 2. Screening | A suitable health or social care practitioner usually completes the Checklist. It is a screening tool, distinct from the DST. Some cases proceed directly to full assessment; Fast Track follows a separate route. [4] |
| 3. Checklist outcome | A positive outcome leads to full assessment, not an award of funding. A negative outcome means no full assessment is required on that screening; the person can ask the ICB to reconsider if they disagree. [6] |
| 4. Full assessment and DST | The multidisciplinary team (MDT) evaluates needs, uses the evidence to complete the DST and recommends whether a primary health need exists. The person’s and representative’s views should be considered. [6] |
| 5. ICB decision | The ICB makes the eligibility decision and provides the reasons and completed DST. The decision is normally expected within 28 calendar days of a positive Checklist or other notification of potential eligibility; exceptions can occur. The clock is not ordinarily restarted simply because the DST meeting is booked later. [2, paragraphs 41–43] |
| 6. Care planning or challenge | If eligible, agree a package to meet assessed needs. If not eligible, discuss other appropriate support and the route for challenging the decision. A refusal of CHC does not remove the need for a safe care plan. [6] |
Fast Track: a different route when time matters
Fast Track is for a primary health need arising from a rapidly deteriorating condition and the condition may be entering a terminal phase
. An appropriate clinician—an eligible registered nurse or medical practitioner responsible for the person’s diagnosis, treatment or care—completes the tool. A properly completed tool establishes eligibility without a Checklist or DST. The ICB should arrange funding and care promptly. [5, paragraphs 3–10]
Family members can bring deterioration to the clinician’s attention and ask for urgent consideration. The clinician determines whether the criteria are met. Guidance rejects a fixed remaining-life threshold and does not limit Fast Track to imminent death. Standard CHC eligibility does not require a terminal condition. [5, paragraph 13]; [6]
A practical way to request consideration
I am concerned that [person] has significant ongoing care needs, particularly [brief examples of support, monitoring or risks]. Please consider whether CHC screening is appropriate, confirm who will arrange it and the expected timescale, and explain the reasons in writing if a Checklist is considered unnecessary. If the person’s deterioration may warrant Fast Track, please ask the appropriate clinician to consider this urgently.
This is a suggested request, not a completed referral. Keep a copy, note whom you contacted and follow up if you do not receive a response.
Common CHC myths
| The myth | The explanation |
|---|---|
| “CHC is only for people at the end of life.” | Standard CHC is based on a primary health need. Fast Track is the route addressing rapid deterioration and a possible terminal phase; it is not the only route to CHC. [6]; [5] |
| “Families cannot start the conversation or request screening.” | Families can raise concerns and support a request to a practitioner or ICB CHC team. They cannot independently establish eligibility or make the formal referral by completing the Checklist themselves. [1, Practice Guidance 14] |
| “Only a doctor can complete a Checklist.” | Suitably trained health or social care practitioners can complete it. Checklist guidance gives examples including nurses, doctors, other healthcare professionals and social workers. [4, paragraph 9] |
| “A positive Checklist means funding has been approved.” | It means a full eligibility assessment is required. Screening and deciding eligibility are different stages. [4, paragraph 3] |
| “Having savings or a house makes someone ineligible.” | CHC eligibility is not means-tested. It concerns assessed needs; the financial rules for local authority social care are different. [3] |
| “Fast Track requires a prediction of only days or weeks left.” | The criteria must be met, but guidance does not allow a rigid remaining-life cut-off or require death to be imminent. [5, paragraph 13] |
When a broad statement appears to close the door to consideration, ask which current guidance supports it and how it applies to the person’s actual circumstances. Seek specialist advice if the explanation remains unclear.
Before the assessment: a practical checklist
Preparation can make the person’s daily needs easier to understand. Use relevant existing records; you do not need to create an exhaustive dossier before asking for consideration.
- Confirm the meeting: ask whether it is Checklist screening, a full assessment, a care review or another process, and identify the coordinator.
- Arrange participation: confirm how the person and their chosen representative can take part, including communication or accessibility support.
- Prepare a typical-day account: record actual care, observations, duration and assistance, with dated examples of relevant variation.
- Identify supporting records: current care plans, care logs, risk assessments, medication records and relevant specialist assessments or reports.
- Flag gaps: list documents that appear missing, outdated or inconsistent. Ask who will obtain or verify them.
- Explain interactions: describe how one need affects another, rather than submitting only a list of diagnoses.
- Record different accounts fairly: distinguish your observations, staff reports and professional conclusions, and retain their dates.
- List your questions: include unclear terminology, disputed facts and concerns you want the team to address.
- Plan the follow-up: ask how to receive the completed documents, check the recorded views and raise any disagreement.
This is an editorial preparation aid, not an additional eligibility requirement. Formal evidence and participation arrangements should follow the national guidance. [2]
What a fair assessment considers
CHC eligibility turns on whether the person has a primary health need. The assessment considers their overall needs and the legal boundary between NHS and local authority responsibilities. A diagnosis alone does not decide eligibility. The four characteristics are [1]:
- Nature: the type of needs and care required.
- Intensity: how much care is needed, how severe the needs are and how sustained the support must be.
- Complexity: how interacting needs increase the skill needed to manage care.
- Unpredictability: fluctuations, difficulty anticipating needs and risks if timely care is unavailable.
One characteristic, or a combination, may demonstrate a primary health need. Consider the person’s needs together. [1]
Make the daily care visible
Build a short, dated account of a typical day and relevant variations. For each intervention, note the reason, staff involved, duration, observations and response. Include difficult episodes as well as settled periods. Avoid presenting a single exceptional incident as an everyday occurrence.
Well-managed needs still matter
Successful care does not erase an ongoing need. Describe the support maintaining that stability. A genuine lasting reduction in need and active management can affect eligibility; scoring should not invent an untreated worst-case scenario. [1]
A worked example: seeing the four characteristics together
Fictional teaching example: a person has swallowing difficulties, becomes breathless during meals and cannot reliably describe symptoms. Their agreed care plan requires supported feeding and observation. Some meals need repeated pauses and take longer than others. This example is not a clinical feeding protocol or a finding about our family member’s eligibility.
| Characteristic | What the episode could show | Evidence to examine |
|---|---|---|
| Nature – what care is needed? | Swallowing and breathing problems affect the kind of support needed during eating. Difficulty communicating can make symptom recognition harder. | The assessed swallowing needs, agreed meal plan and documented observation and response requirements. |
| Intensity – how much care? | Repeated assistance and pauses may require sustained support. Describe how often this happens and for how long. | Dated meal records, intervention frequency, duration and assistance. Avoid turning one prolonged meal into an assumed everyday pattern. |
| Complexity – how do needs interact? | Breathlessness, swallowing difficulty and impaired communication together can increase the skill required to interpret symptoms and adapt care. | Records of the judgements and adjustments actually required, who made them and what happened. |
| Unpredictability – what changes? | If tolerance changes unexpectedly, staff may need to recognise and respond promptly. A variable condition is not automatically unpredictable. | Frequency, pattern, warning signs, response times and documented risks if a needed response is delayed. |
How to use it: build the explanation from recorded facts, identify gaps and connect the needs. The four characteristics are lenses for considering the overall picture; a single episode can provide evidence relevant to several. It does not automatically establish a particular domain level or CHC eligibility. [1, Primary Health Need section]
An illustrative observation: “The meal record describes repeated pauses and sustained support. Because the person could not explain their symptoms, staff had to interpret changes in presentation. Please explain how these recorded needs and their interaction were considered in the overall recommendation.”
Place of care and family support
Eligibility is not determined by the setting, provider or identity of the carer. Living in a nursing home, or receiving support from family, does not itself establish or rule out a primary health need. [1]
When reviewing an assessment, look for the evidence behind phrases such as “routine care” or “needs met in this setting”. Ask what work makes the care appear routine: observation, anticipation, adaptation, repeated interventions or escalation. Describe those tasks accurately, including which require clinical judgement and which involve personal care.
The availability of a committed family member can make substantial work less visible. Record what they actually do and the support they need to sustain it. The burden on the family is important, but its size alone does not settle the eligibility question.
Eligibility and the eventual care arrangement are separate questions. Once eligible, the ICB should work with the person on an appropriate package and consider their views. Different settings may be suitable; cost and value for money can also be considered. CHC does not guarantee any chosen placement. [3]
Check the completed assessment
The Decision Support Tool (DST) brings together assessment evidence; it is not the needs assessment itself. Domain levels inform the overall decision. [2] This practical checklist helps you trace the reasoning from the records to the recommendation.
| Check | What to look for |
|---|---|
| Facts and dates | Wrong personal details, future dates, old incidents presented as recent, incorrect units, copied text or inconsistent measurements. Identify the original source and ask for verification. |
| Evidence trail | Can you identify each record, its date and version? Check whether care plans, risk assessments, medication records, specialist reports and family evidence actually reached the assessors. |
| Missing information | Ask whether an unavailable record was later retrieved. A missing record leaves a gap; it does not establish that the event did or did not happen. |
| Care described | Compare the written description with care logs. Are frequency, duration, staffing, monitoring and responses clear? Does “occasional” or “minimal” match the dated evidence? |
| Domain reasoning | Compare each selected level with its actual descriptor. Explain the specific mismatch you identify. A serious diagnosis or high risk score does not automatically establish a particular domain level. |
| Summary and totals | Do the selected levels match the summary table? Do totals add up? Check the “other significant care needs” entry before treating a count as an error. |
| Combined needs | Does the concluding explanation connect related needs? For example, difficulty communicating may affect recognition of pain, breathlessness or swallowing problems. |
| Professional views | Are attendees’ roles clear? Can you distinguish formal MDT members from contributors? Are differing views and reasons recorded accurately? |
| Document control | Do you have the final version, attachments, recommendation and decision reasons? If a further meeting is mentioned, request its date, attendees and record. |
| Changes and review | Does the record address relevant changes and any anticipated deterioration? Ask who will review the person and when if concerns remain. |
Accuracy works both ways. Correct overstatements as well as omissions. Separate what you observed, what a professional recorded and what you believe needs further investigation.
Professional disagreement
If relevant evidence has been considered and the MDT still cannot decide or agree between domain levels, the DST guidance says to select the higher level under consideration and record the evidence and significant differences of opinion. [2, paragraph 25]
This concerns a disputed domain level; it does not automatically settle overall eligibility. Ask for each professional’s reasoning and the final recommendation. A headcount of favourable opinions cannot replace a reasoned assessment.
People attending a meeting can have different roles. A treating nurse’s clinical opinion is relevant evidence, but whether they were a formal MDT member should be established from the meeting record. If the written account of their view is disputed, seek a written clarification from them.
Our family’s experience: what the records prompted us to question
Our family reviewed a September 2026 DST and raised a written quality and process challenge in October 2026. The comparison below removes names and identifying numbers. It distinguishes entries visible in the DST from concerns raised in the family’s challenge. It does not present those concerns as independently upheld findings or a final determination of eligibility.
| Record or concern | What needs scrutiny | A clearer account would show |
|---|---|---|
| Summary totals — visible in DST, page 44 | Several professionals’ rows total 13 domain entries. The coordinator’s row totals 11. The summary also records differing professional markings. | A reconciliation with every domain, including any “other significant care needs”, and an explanation of the final selected levels. |
| Recommendation wording — visible in DST, page 54 | The document contains an “agreed MDT recommendation” date, while the family’s challenge describes later accounts of disagreement. | Whose recommendation the text represents, which members agreed or disagreed, and how the final recommendation was reached. |
| Family evidence — visible in DST, page 45 | The DST identifies a family self-assessment as an attachment. The family asked for confirmation of the version considered and its availability in the supplied record. | The actual attachment or accessible copy, its date/version, and a response to any material evidence it contains. |
| Professional opinion — concern raised in family challenge | A social worker’s recollection, a nursing account and descriptions of a nurse’s role required reconciliation. | A distinction between clinical evidence, a contributor’s opinion and a formal MDT recommendation, supported by the professional’s own clarification. |
| Further discussion — concern raised in family challenge | A later record reportedly referred to a reconvened discussion; some contributors said they were unaware of a further meeting. | The meeting date, invitations, attendees and discussion record. Lack of awareness alone does not prove a meeting did not take place. |
| Daily care and monitoring — concern raised in family challenge | The family questioned whether the concluding reasoning fully reflected the feeding support, transfers, pressure care and observation described elsewhere. | A traceable explanation of those interventions and their combined significance, including any evidence supporting a different interpretation. |
| Dates and measurements — concern raised in family challenge | The challenge identified dates and weight-related entries that appeared inconsistent. | Verification against original records, corrected entries where appropriate, and an explanation of whether corrections change the reasoning. |
The lesson: an error can matter without proving eligibility. The next question is whether correcting it changes the evidence, domain assessment, overall reasoning or decision. Equally, a decision should not be defended using information known to be inaccurate.
Raise a clear, evidence-based challenge
You should receive decision documents and clear reasons. [3] Work from the actual final documents rather than memory alone.
- Keep the record: preserve the original documents, emails, attachments and dates received. Make notes on copies.
- Identify the entry: give the document name, version, page and disputed wording.
- Provide the evidence: identify the dated care note, assessment or professional account that supports your concern.
- Explain the significance: state what the discrepancy changes or why it requires clarification. Avoid assuming a clerical mistake necessarily changes eligibility.
- Ask for a specific response: a correction, missing document, explanation or review of the recommendation or decision.
- Protect the challenge route: check the decision letter’s procedure and deadline. A correction request or complaint may not itself register an eligibility challenge. State explicitly if you are challenging eligibility and ask for written acknowledgement.
A useful format for one disputed entry
In [document/version], page [number], the assessment states [entry]. The record dated [date], at [page/entry], shows [evidence]. Please verify this discrepancy, correct the record if appropriate, and explain whether it affects the domain level, recommendation or eligibility decision. Please provide the updated document and a written response to this point.
Keep factual corrections, concerns about the process and disagreement with eligibility clearly identified, even if they appear in the same letter. Request the relevant local resolution procedure and, where applicable, information about independent review. Do not allow an unanswered request for documents to make you miss a challenge deadline.
If needs change while a challenge is ongoing, seek a current assessment or review as well. The older decision and today’s care needs may require separate consideration.
A scrutiny sheet for your own assessment
Use one row for each concern. Keep it factual and identify the document version and page. The columns separate the evidence from the interpretation and the action requested.
| Assessment entry | Supporting evidence | Discrepancy and significance | Requested correction or explanation | Response and next step |
|---|---|---|---|---|
| Document, version, page and exact entry | Record, date, page and relevant facts | What differs or is missing? Why might it matter? | What specific action are you asking for? | Date, written response and any follow-up |
A private working sheet can contain case details. Keep it secure and share it only with appropriate people. Keep your original records unchanged; date any notes or corrections you add to copies.
Questions about the care setting
Alongside scrutiny of eligibility, families may need to consider whether the proposed setting can meet the person’s needs safely and sustainably.
- How will staffing and relevant skills meet the person’s assessed needs throughout the day and night?
- Who will observe changes, respond to symptoms and seek clinical help?
- What responsibilities would fall to family or other significant people, and what happens when they are unavailable?
- How will continuity, communication and the person’s preferences be supported?
- If a move is proposed, what evidence addresses the likely effects on the person, and how will those risks be managed?
Record the answers separately from the eligibility argument so that both the funding decision and the practical care plan receive proper attention.
When assessment tools do not tell the whole story
A reassuring score or outcome needs context. Ask what the tool measures, whether its inputs and dates are correct, and what care maintains the result. A score does not automatically determine a DST level or eligibility.
| Evidence | What to check |
|---|---|
| MUST | Check weight, height, dates and weight-loss inputs. Compare the malnutrition screen with swallowing assessment, feeding duration, assistance and hydration needs. A low score does not describe every feeding need. |
| Waterlow, Braden or Norton | Check risk factors and preventive care: repositioning, observation and equipment. High pressure-ulcer risk does not automatically establish High Skin; intact skin does not remove the need for prevention. |
| Falls or mobility records | Examine transfers, staffing, supervision and prevention, not only the number of falls. High risk in another tool is not automatically a High DST level. |
| Pain or cognitive scores | Check whether the method fits the person’s ability to communicate and participate. Review observed distress, function and support; a score alone does not provide a complete care account. |
| Behaviour, intake or medication charts | Check what assistance or treatment produces an apparently reassuring outcome. Verify records rather than assuming unrecorded events occurred. Examine omissions and overstatements fairly. |
Ask: “Please verify the score and underlying information, explain its purpose, and show how the care records and specialist assessments were considered alongside it.”
See BAPEN’s MUST guidance, NICE pressure-ulcer guidance, recommendation 1.1.3, and DST guidance paragraphs 25–32 and 38–40. These are review prompts, not proof of deliberate misuse.
Work through a case: domains, characteristics and eligibility
Fictional learning case: this exercise describes a fictional adult with advanced dementia, severe respiratory illness and swallowing difficulties. It is not our relative’s DST, a reconstruction of an IRP finding or an assessment of a real person. All measurements, clinical findings and care arrangements below belong to this invented case.
The evidence has been written to support an eligible recommendation. Learn how that conclusion follows from the evidence; do not alter a real person’s needs to reproduce it. If evidence changes, the interpretation can change.
First review all twelve domains. Then examine the four characteristics and make an eligibility recommendation. Select an answer before opening its explanation, and use the next-stage link to move through the case. Your choices are practice only: they are not submitted or stored by this exercise, and there is no eligibility calculator.
Each stage offers four selected choices, not every level available in every domain. Use the linked official tool for the full descriptors. The answer assumes the scenario’s clinical findings have been verified; missing or disputed evidence in a real case requires clarification.
Stage 1: Breathing
The clinical assessment confirms severe breathing difficulty even at rest despite maximum medical therapy. During washing and feeding, carers repeatedly stop, reposition and reassess. There is no tracheostomy or invasive ventilation. The current treatment plan is documented by the respiratory team.
Hint
Distinguish symptoms during activity from symptoms that persist at rest.
Show answer, explanation and guidance
Suggested answer: C — Severe.
Severe difficulty at rest persists despite maximum therapy. Do not infer maximum therapy from absence of treatment: it is explicitly established in this scenario. Priority is not supported by the stated facts.
Guidance to apply: Breathing descriptors, printed page 6. This explanation is an educational application; read the complete official wording when reviewing a real assessment.
- A — Low: This is not the best-supported choice. Do not infer maximum therapy from absence of treatment: it is explicitly established in this scenario. Priority is not supported by the stated facts.
- B — Moderate: This is not the best-supported choice. Do not infer maximum therapy from absence of treatment: it is explicitly established in this scenario. Priority is not supported by the stated facts.
- C — Severe: This is the best-supported choice for the stated facts. Severe difficulty at rest persists despite maximum therapy.
- D — Priority: This is not the best-supported choice. Do not infer maximum therapy from absence of treatment: it is explicitly established in this scenario. Priority is not supported by the stated facts.
Stage 2: Nutrition — food and drink
A swallowing specialist confirms dysphagia. The person eats by mouth but requires a prescribed texture, careful positioning, teaspoon feeding, observation and intervention by staff trained in the swallowing plan. Meals take 50 minutes. The nutrition team records stable weight and a MUST score of 0.
Hint
Ask what the swallowing assessment establishes beyond the duration of a meal.
Show answer, explanation and guidance
Suggested answer: C — High.
Dysphagia requires skilled airway and nutritional support. The MUST result is not a complete feeding assessment. Eating by mouth with these needs does not establish the Severe descriptor; prolonged feeding alone would also be insufficient to justify High.
Guidance to apply: Nutrition descriptors, printed page 8. This explanation is an educational application; read the complete official wording when reviewing a real assessment.
- A — Low: This is not the best-supported choice. The MUST result is not a complete feeding assessment. Eating by mouth with these needs does not establish the Severe descriptor; prolonged feeding alone would also be insufficient to justify High.
- B — Moderate: This is not the best-supported choice. The MUST result is not a complete feeding assessment. Eating by mouth with these needs does not establish the Severe descriptor; prolonged feeding alone would also be insufficient to justify High.
- C — High: This is the best-supported choice for the stated facts. Dysphagia requires skilled airway and nutritional support.
- D — Severe: This is not the best-supported choice. The MUST result is not a complete feeding assessment. Eating by mouth with these needs does not establish the Severe descriptor; prolonged feeding alone would also be insufficient to justify High.
Stage 3: Continence
The person is doubly incontinent. Staff provide planned changes and skin care, monitor bowel records and give prescribed regular laxatives. Constipation is currently controlled. There is no catheter, impaction, manual evacuation or other evidence of problematic care beyond this routine monitoring.
Hint
Distinguish regular monitoring from problematic care requiring additional skilled intervention.
Show answer, explanation and guidance
Suggested answer: C — Moderate.
Routine continence care includes risk monitoring. High is not justified simply by frequent pad changes or complete dependency. Explain actual complications and intervention if arguing for a different level.
Guidance to apply: Continence descriptors, printed page 10. This explanation is an educational application; read the complete official wording when reviewing a real assessment.
- A — No needs: This is not the best-supported choice. High is not justified simply by frequent pad changes or complete dependency. Explain actual complications and intervention if arguing for a different level.
- B — Low: This is not the best-supported choice. High is not justified simply by frequent pad changes or complete dependency. Explain actual complications and intervention if arguing for a different level.
- C — Moderate: This is the best-supported choice for the stated facts. Routine continence care includes risk monitoring.
- D — High: This is not the best-supported choice. High is not justified simply by frequent pad changes or complete dependency. Explain actual complications and intervention if arguing for a different level.
Stage 4: Skin and tissue viability
The person cannot reposition independently. Staff provide pressure relief every two hours, inspect fragile skin and use pressure-relieving equipment. Skin is intact and there are no wounds or specialist dressings. A checked Waterlow assessment records very high risk.
Hint
Consider the frequency of prevention and the presence or absence of treatment for wounds.
Show answer, explanation and guidance
Suggested answer: C — Moderate.
Repeated daily prevention matches Moderate. Neither intact skin nor a very high Waterlow score decides this domain alone. The scenario establishes preventive workload but does not establish a High wound or dressing criterion.
Guidance to apply: Skin descriptors, printed page 12. This explanation is an educational application; read the complete official wording when reviewing a real assessment.
- A — No needs: This is not the best-supported choice. Neither intact skin nor a very high Waterlow score decides this domain alone. The scenario establishes preventive workload but does not establish a High wound or dressing criterion.
- B — Low: This is not the best-supported choice. Neither intact skin nor a very high Waterlow score decides this domain alone. The scenario establishes preventive workload but does not establish a High wound or dressing criterion.
- C — Moderate: This is the best-supported choice for the stated facts. Repeated daily prevention matches Moderate.
- D — High: This is not the best-supported choice. Neither intact skin nor a very high Waterlow score decides this domain alone. The scenario establishes preventive workload but does not establish a High wound or dressing criterion.
Stage 5: Mobility
The person cannot bear weight and cannot assist or cooperate with transfers or repositioning. A current moving-and-handling assessment specifies two carers and a full-body hoist. No condition making positioning critically hazardous is identified in the supplied evidence.
Hint
Read the capacity to participate, rather than counting pieces of equipment.
Show answer, explanation and guidance
Suggested answer: C — High.
Cannot bear weight or assist with movement. Equipment alone is not the test. The stated inability to assist is central; the scenario does not establish the additional circumstances for Severe.
Guidance to apply: Mobility descriptors, printed page 14. This explanation is an educational application; read the complete official wording when reviewing a real assessment.
- A — Low: This is not the best-supported choice. Equipment alone is not the test. The stated inability to assist is central; the scenario does not establish the additional circumstances for Severe.
- B — Moderate: This is not the best-supported choice. Equipment alone is not the test. The stated inability to assist is central; the scenario does not establish the additional circumstances for Severe.
- C — High: This is the best-supported choice for the stated facts. Cannot bear weight or assist with movement.
- D — Severe: This is not the best-supported choice. Equipment alone is not the test. The stated inability to assist is central; the scenario does not establish the additional circumstances for Severe.
Stage 6: Communication
The person cannot reliably express needs verbally or non-verbally at any time. Hearing support, pictures and other practicable approaches have been tried. Familiar carers must anticipate thirst, pain, breathlessness and toileting needs through observation.
Hint
Look at reliability after assistance, not whether any sound or movement occurs.
Show answer, explanation and guidance
Suggested answer: D — High.
Needs cannot be communicated reliably despite support. Do not confuse occasional facial movements with reliable communication of a need. Describe how staff recognise changes and what they must anticipate.
Guidance to apply: Communication descriptors, printed page 16. This explanation is an educational application; read the complete official wording when reviewing a real assessment.
- A — No needs: This is not the best-supported choice. Do not confuse occasional facial movements with reliable communication of a need. Describe how staff recognise changes and what they must anticipate.
- B — Low: This is not the best-supported choice. Do not confuse occasional facial movements with reliable communication of a need. Describe how staff recognise changes and what they must anticipate.
- C — Moderate: This is not the best-supported choice. Do not confuse occasional facial movements with reliable communication of a need. Describe how staff recognise changes and what they must anticipate.
- D — High: This is the best-supported choice for the stated facts. Needs cannot be communicated reliably despite support.
Stage 7: Psychological and emotional needs
Observations identify periods of anxiety during unfamiliar care. They affect comfort but promptly settle with familiar reassurance and distraction. There is no evidence of persistent distress despite these approaches or severe impact on wellbeing.
Hint
Examine the effect on wellbeing and the response to support.
Show answer, explanation and guidance
Suggested answer: B — Low.
Distress affects wellbeing but responds to reassurance. Advanced dementia should not prevent examination of emotional needs. Equally, the facts here do not support persistent or severe distress.
Guidance to apply: Psychological and emotional descriptors, printed page 18. This explanation is an educational application; read the complete official wording when reviewing a real assessment.
- A — No needs: This is not the best-supported choice. Advanced dementia should not prevent examination of emotional needs. Equally, the facts here do not support persistent or severe distress.
- B — Low: This is the best-supported choice for the stated facts. Distress affects wellbeing but responds to reassurance.
- C — Moderate: This is not the best-supported choice. Advanced dementia should not prevent examination of emotional needs. Equally, the facts here do not support persistent or severe distress.
- D — High: This is not the best-supported choice. Advanced dementia should not prevent examination of emotional needs. Equally, the facts here do not support persistent or severe distress.
Stage 8: Cognition
The person is severely disorientated and cannot recognise basic danger even with supervision, prompting or assistance. They cannot understand choking risk, recognise respiratory deterioration or safely decide whether to move. Others must anticipate basic needs and protect them from harm.
Hint
Ask whether any awareness of basic risk remains when support is provided.
Show answer, explanation and guidance
Suggested answer: D — Severe.
Cannot assess basic risks even with assistance. The diagnosis is background; functional evidence supports this level. Do not infer absence of all preferences or make a blanket finding about decision-making capacity.
Guidance to apply: Cognition descriptors, printed page 20. This explanation is an educational application; read the complete official wording when reviewing a real assessment.
- A — Low: This is not the best-supported choice. The diagnosis is background; functional evidence supports this level. Do not infer absence of all preferences or make a blanket finding about decision-making capacity.
- B — Moderate: This is not the best-supported choice. The diagnosis is background; functional evidence supports this level. Do not infer absence of all preferences or make a blanket finding about decision-making capacity.
- C — High: This is not the best-supported choice. The diagnosis is background; functional evidence supports this level. Do not infer absence of all preferences or make a blanket finding about decision-making capacity.
- D — Severe: This is the best-supported choice for the stated facts. Cannot assess basic risks even with assistance.
Stage 9: Behaviour
During personal care the person sometimes grabs tubing or pushes carers away. An individual risk assessment records a foreseeable risk to the person and staff. A documented care plan uses a familiar approach and a planned pause. Skilled carers consistently manage the predictable episodes; specialist monitoring is not required and risk is controlled by the plan.
Hint
Distinguish an absence of risk from risk controlled through a consistent plan.
Show answer, explanation and guidance
Suggested answer: C — Moderate.
Predictable risk is managed through a care plan. Compare the actual risks and successful planned response. Do not label the person difficult; do not automatically select a higher level because an incident occurred.
Guidance to apply: Behaviour descriptors, printed page 22. This explanation is an educational application; read the complete official wording when reviewing a real assessment.
- A — No needs: This is not the best-supported choice. Compare the actual risks and successful planned response. Do not label the person difficult; do not automatically select a higher level because an incident occurred.
- B — Low: This is not the best-supported choice. Compare the actual risks and successful planned response. Do not label the person difficult; do not automatically select a higher level because an incident occurred.
- C — Moderate: This is the best-supported choice for the stated facts. Predictable risk is managed through a care plan.
- D — High: This is not the best-supported choice. Compare the actual risks and successful planned response. Do not label the person difficult; do not automatically select a higher level because an incident occurred.
Stage 10: Drug therapies and medication: symptom control
Staff specifically trained for the task administer the prescribed regimen and check for sedation, treatment effectiveness and changes in the medical condition. Clinical records establish meaningful risks if those checks are missed. With that monitoring the regimen is usually non-problematic. There is no rapidly changing treatment regime or unresolved severe pain.
Hint
Notice the difference between needing monitoring and remaining problematic despite monitoring.
Show answer, explanation and guidance
Suggested answer: C — High.
Specific administration and monitoring address clinical risks. Count neither medicines nor prescriptions as points. The evidence concerns what monitoring is necessary and how reliably it controls the risks.
Guidance to apply: Drug therapy descriptors, printed page 24. This explanation is an educational application; read the complete official wording when reviewing a real assessment.
- A — Low: This is not the best-supported choice. Count neither medicines nor prescriptions as points. The evidence concerns what monitoring is necessary and how reliably it controls the risks.
- B — Moderate: This is not the best-supported choice. Count neither medicines nor prescriptions as points. The evidence concerns what monitoring is necessary and how reliably it controls the risks.
- C — High: This is the best-supported choice for the stated facts. Specific administration and monitoring address clinical risks.
- D — Severe: This is not the best-supported choice. Count neither medicines nor prescriptions as points. The evidence concerns what monitoring is necessary and how reliably it controls the risks.
Stage 11: Altered states of consciousness
A review of medical and care records finds no seizures, syncope, coma or other altered-state episodes. The person sometimes dozes during the afternoon, without an identified altered-state event.
Hint
Separate ordinary drowsiness from a documented episode affecting consciousness.
Show answer, explanation and guidance
Suggested answer: A — No needs.
No altered-state episodes are evidenced. Ordinary sleepiness is not automatically an altered state for this domain. If a new event occurs, seek clinical assessment rather than using this exercise to classify it.
Guidance to apply: Altered states guidance and descriptors, printed pages 25–26. This explanation is an educational application; read the complete official wording when reviewing a real assessment.
- A — No needs: This is the best-supported choice for the stated facts. No altered-state episodes are evidenced.
- B — Low: This is not the best-supported choice. Ordinary sleepiness is not automatically an altered state for this domain. If a new event occurs, seek clinical assessment rather than using this exercise to classify it.
- C — Moderate: This is not the best-supported choice. Ordinary sleepiness is not automatically an altered state for this domain. If a new event occurs, seek clinical assessment rather than using this exercise to classify it.
- D — High: This is not the best-supported choice. Ordinary sleepiness is not automatically an altered state for this domain. If a new event occurs, seek clinical assessment rather than using this exercise to classify it.
Stage 12: Other significant care needs
The team has checked the available assessments for relevant needs not adequately captured in the first eleven domains. None is identified. The breathing, swallowing, cognition and other established needs are already recorded in those domains.
Hint
Ask whether a distinct unmet description exists outside the other domains.
Show answer, explanation and guidance
Suggested answer: A — Record that no additional need was identified.
Document the review; no additional need identified. Do not invent another level to increase a total. In this case no additional need is scored in the twelfth domain; this is different from failing to review it.
Guidance to apply: Other significant care needs, printed pages 27–28. This explanation is an educational application; read the complete official wording when reviewing a real assessment.
- A — Record that no additional need was identified: This is the best-supported choice for the stated facts. Document the review; no additional need identified.
- B — Add High because several diagnoses are present: This is not the best-supported choice. Do not invent another level to increase a total. In this case no additional need is scored in the twelfth domain; this is different from failing to review it.
- C — Repeat all existing needs here as Severe: This is not the best-supported choice. Do not invent another level to increase a total. In this case no additional need is scored in the twelfth domain; this is different from failing to review it.
- D — Leave the question unchecked: This is not the best-supported choice. Do not invent another level to increase a total. In this case no additional need is scored in the twelfth domain; this is different from failing to review it.
Bring the domain evidence together
Review the suggested domain profile after completing the twelve stages
| Domain | Suggested level |
|---|---|
| Breathing | Severe |
| Nutrition — food and drink | High |
| Continence | Moderate |
| Skin and tissue viability | Moderate |
| Mobility | High |
| Communication | High |
| Psychological and emotional needs | Low |
| Cognition | Severe |
| Behaviour | Moderate |
| Drug therapies and medication: symptom control | High |
| Altered states of consciousness | No needs |
| Other significant care needs | No additional need identified; no extra level scored |
The first eleven domains contain two Severe, four High, three Moderate, one Low and one No needs entry. The twelfth-domain review found no additional need. These are levels, not numerical points.
Stage 13: Nature
Review the whole case. The person has severe respiratory difficulty at rest, unsafe swallowing without a skilled plan, profound inability to recognise risk and unreliable communication. What is the strongest interpretation?
Hint
Look beyond the name of a task to why and how it must be performed.
Show answer, explanation and guidance
Suggested answer: B — Respiratory and swallowing interventions have health-related qualities requiring examination.
The types of respiratory and swallowing intervention matter. This is an application to the fictional facts, not a conclusion that all help with daily activities is healthcare. Explain the quality of care and then apply the legal boundary.
Guidance to apply: DST guidance paragraphs 34–40; consider the National Framework primary health need test. This explanation is an educational application; read the complete official wording when reviewing a real assessment.
- A — All support is social care because it occurs during daily activities: This is not the best-supported choice. This is an application to the fictional facts, not a conclusion that all help with daily activities is healthcare. Explain the quality of care and then apply the legal boundary.
- B — Respiratory and swallowing interventions have health-related qualities requiring examination: This is the best-supported choice for the stated facts. The types of respiratory and swallowing intervention matter.
- C — Only the diagnosis should be considered: This is not the best-supported choice. This is an application to the fictional facts, not a conclusion that all help with daily activities is healthcare. Explain the quality of care and then apply the legal boundary.
- D — The nursing-home setting establishes eligibility: This is not the best-supported choice. This is an application to the fictional facts, not a conclusion that all help with daily activities is healthcare. Explain the quality of care and then apply the legal boundary.
Stage 14: Intensity
The person needs prolonged supported meals, repeated pauses and observation during respiratory difficulty, two-person movement and regular pressure relief throughout the day and night. What evidence should lead the analysis?
Hint
Build a timed daily account rather than relying on a reassuring outcome.
Show answer, explanation and guidance
Suggested answer: D — The severity, duration and continuity of support across the day and night.
The workload is substantial and sustained in this case. Avoid counting the same minutes twice when tasks overlap. Give actual durations, staffing and observations; do not require emergencies as the only evidence of intensity.
Guidance to apply: DST guidance paragraphs 34–40; consider the National Framework primary health need test. This explanation is an educational application; read the complete official wording when reviewing a real assessment.
- A — Only the number of hospital admissions: This is not the best-supported choice. Avoid counting the same minutes twice when tasks overlap. Give actual durations, staffing and observations; do not require emergencies as the only evidence of intensity.
- B — Only whether equipment is present: This is not the best-supported choice. Avoid counting the same minutes twice when tasks overlap. Give actual durations, staffing and observations; do not require emergencies as the only evidence of intensity.
- C — Only whether the daily schedule is planned: This is not the best-supported choice. Avoid counting the same minutes twice when tasks overlap. Give actual durations, staffing and observations; do not require emergencies as the only evidence of intensity.
- D — The severity, duration and continuity of support across the day and night: This is the best-supported choice for the stated facts. The workload is substantial and sustained in this case.
Stage 15: Complexity
Breathlessness interrupts feeding. Dysphagia requires adjustments to pacing and positioning. Cognitive impairment prevents cooperation and recognition of danger; communication impairment prevents a reliable report of symptoms. What best explains the interaction?
Hint
Ask how managing one need makes another harder to manage.
Show answer, explanation and guidance
Suggested answer: A — The interaction increases the judgement needed to deliver and adapt care safely.
The interaction changes the skill and judgement required. Show what carers actually adapt and observe. A list of conditions without an explanation of their interaction is insufficient.
Guidance to apply: DST guidance paragraphs 34–40; consider the National Framework primary health need test. This explanation is an educational application; read the complete official wording when reviewing a real assessment.
- A — The interaction increases the judgement needed to deliver and adapt care safely: This is the best-supported choice for the stated facts. The interaction changes the skill and judgement required.
- B — Having four diagnoses automatically proves complexity: This is not the best-supported choice. Show what carers actually adapt and observe. A list of conditions without an explanation of their interaction is insufficient.
- C — Each domain should be considered in isolation: This is not the best-supported choice. Show what carers actually adapt and observe. A list of conditions without an explanation of their interaction is insufficient.
- D — Successful care proves that the interaction is irrelevant: This is not the best-supported choice. Show what carers actually adapt and observe. A list of conditions without an explanation of their interaction is insufficient.
Stage 16: Unpredictability
Dated records in this fictional case show respiratory episodes of variable onset and duration. Staff cannot rely on the person to report deterioration. They sometimes have to stop feeding or defer movement, reassess and implement the clinical plan promptly. What is the best-supported interpretation?
Hint
Focus on the effect of fluctuations on everyday management, not surprise alone.
Show answer, explanation and guidance
Suggested answer: B — Fluctuation creates challenges requiring responsive care; examine delay-related risk.
Variable episodes require timely adaptation. Do not assert that every need is unpredictable. Identify the actual fluctuations, response required and consequences of delay, while acknowledging predictable elements.
Guidance to apply: DST guidance paragraphs 34–40; consider the National Framework primary health need test. This explanation is an educational application; read the complete official wording when reviewing a real assessment.
- A — An unexpected event alone proves a primary health need: This is not the best-supported choice. Do not assert that every need is unpredictable. Identify the actual fluctuations, response required and consequences of delay, while acknowledging predictable elements.
- B — Fluctuation creates challenges requiring responsive care; examine delay-related risk: This is the best-supported choice for the stated facts. Variable episodes require timely adaptation.
- C — Unpredictability is absent because a written plan exists: This is not the best-supported choice. Do not assert that every need is unpredictable. Identify the actual fluctuations, response required and consequences of delay, while acknowledging predictable elements.
- D — A nurse must be called to every episode before it counts: This is not the best-supported choice. Do not assert that every need is unpredictable. Identify the actual fluctuations, response required and consequences of delay, while acknowledging predictable elements.
Stage 17: Your eligibility recommendation
Now consider the full evidence, the domain profile, the four characteristics and the legal boundary. Both Severe domain findings are verified and the remaining support is documented. Which recommendation is best supported for this fictional case?
Hint
Consider the expected recommendation for two Severe domains alongside the full evidence.
Show answer, explanation and guidance
Suggested answer: C — Recommend CHC eligibility on the verified evidence and explain the primary health need.
The verified case supports a CHC-eligible recommendation. This is not a decision about the reader or our family member. The ICB makes the real eligibility decision; the exercise demonstrates a reasoned recommendation on stated facts.
Guidance to apply: DST guidance paragraphs 35 and 38–40; National Framework paragraphs 55–67. This explanation is an educational application; read the complete official wording when reviewing a real assessment.
- A — Not eligible because care is successfully delivered: This is not the best-supported choice. This is not a decision about the reader or our family member. The ICB makes the real eligibility decision; the exercise demonstrates a reasoned recommendation on stated facts.
- B — Eligible only if all four characteristics independently establish a primary health need: This is not the best-supported choice. This is not a decision about the reader or our family member. The ICB makes the real eligibility decision; the exercise demonstrates a reasoned recommendation on stated facts.
- C — Recommend CHC eligibility on the verified evidence and explain the primary health need: This is the best-supported choice for the stated facts. The verified case supports a CHC-eligible recommendation.
- D — Make no recommendation because eligibility can never be considered using a DST: This is not the best-supported choice. This is not a decision about the reader or our family member. The ICB makes the real eligibility decision; the exercise demonstrates a reasoned recommendation on stated facts.
Overview: why this fictional case supports eligibility
Suggested recommendation: CHC eligible. The case establishes Severe Breathing and Severe Cognition. Paragraph 35 of the DST guidance identifies two or more Severe domain needs as a profile where an eligible recommendation and decision would be expected. This is an expected outcome under guidance, not a points-based guarantee.
The respiratory finding is established at rest despite maximum therapy; it has not been inferred from a diagnosis. The cognitive finding is evidenced by inability to recognise basic risks even with help. Swallowing and communication needs, sustained assisted care and risk-related medication monitoring add to the picture.
Nature: the care includes clinically significant respiratory and swallowing management. Intensity: interventions and observation are sustained, prolonged and repeated. Complexity: respiratory, swallowing, cognitive and communication needs alter how care must be delivered. Unpredictability: variable respiratory episodes require timely recognition and adjustment. These are explanatory lenses, not four separate pass marks.
The recommendation must address the primary health need test and the limits of what a local authority can lawfully provide. In this invented case, the quality and quantity of the verified health-related support, considered together, support a primary health need. That is the educational interpretation of the scenario, not an independent legal determination.
Successful prevention and treatment must be understood alongside the ongoing support. Avoid treating controlled symptoms as absent needs, but also avoid inventing an untreated worst case. MUST and Waterlow contribute relevant evidence without replacing the domain descriptors. A care setting, family availability, cost pressure or absence of an emergency does not supply the reasoning for this case.
Where evidence is missing, obtain it. If domain disagreement remains after considering relevant evidence, apply paragraph 25. Do not turn an overall recommendation into a vote count or equate one level with a number of lower levels. Record the person’s contribution and explain the conclusion.
If the scenario were different: if maximum respiratory therapy were not established or the symptoms were limited to activity, the Severe Breathing finding would need reconsideration. One Severe plus other needs may still support eligibility, but requires a careful reasoned assessment. Do not carry this case’s outcome over automatically.
Scope: this exercise applies selected guidance relevant to its stated facts. It is not a substitute for the full National Framework, clinical assessment or specialist advice. A rapidly deteriorating condition that may be entering a terminal phase also requires consideration of the Fast Track route; do not delay urgent support to complete this exercise.
Read the full official DST guidance · Read the National Framework
Check your understanding: 10 questions
This optional quiz is for learning, not an eligibility assessment. Consider each question, then open its answer, worked example and guidance. It does not collect your answers or personal information. Examples are fictional unless explicitly identified as drawn from family records; short guidance quotations are explained in context.
1. What does a primary health need decision consider?
Show answer, example and guidance
Answer: C — Their overall assessed needs and the limits of local authority care
Illustrative example: Two people have the same dementia diagnosis but need different amounts and types of care. Their needs must be assessed individually; the diagnosis is not a substitute for that assessment.
Relevant guidance: National Framework: Primary Health Need section uses the wording totality
. Consider needs together and the boundary between NHS and local authority responsibilities. Source details.
2. What is the purpose of the Decision Support Tool (DST)?
Show answer, example and guidance
Answer: A — To bring assessment evidence together and support an eligibility recommendation
Illustrative example: A swallowing assessment, meal records and a medication chart describe different parts of someone’s care. The MDT brings that evidence into the DST before making its recommendation.
Relevant guidance: DST guidance, paragraph 4 uses the wording not an assessment of needs in itself
. Use the DST to organise evidence from the comprehensive assessment. Source details.
3. How should domain levels be selected?
Show answer, example and guidance
Answer: B — By matching evidenced needs to the relevant domain descriptors
Illustrative example: A person needs help during meals. Compare the documented swallowing difficulty, time, support and risks with the nutrition descriptors. Do not choose a level simply because another domain was rated High.
Relevant guidance: DST guidance, paragraph 23 uses the wording most closely relates to them
. Match the evidenced needs to the relevant descriptor; paragraph 38 rules out converting one level into another. Source details.
4. A person cannot reliably communicate symptoms, and breathing difficulties complicate feeding. Which characteristic particularly concerns how these needs interact?
Show answer, example and guidance
Answer: C — Complexity
Illustrative example: During feeding, a person becomes breathless and cannot explain what is wrong. Staff must distinguish fatigue, respiratory distress and swallowing problems, then adapt care and decide whether to escalate. The interaction can increase the skill needed.
Relevant guidance: National Framework: Complexity definition uses the wording present and interact
. Explain how interacting needs affect the skill required to manage care. Source details.
5. A person’s skin remains intact while staff provide regular preventive care. What should the assessment examine?
Show answer, example and guidance
Answer: B — The actual preventive care and current needs against the descriptors
Illustrative example: Skin remains intact while staff reposition the person and use pressure-relieving equipment. Record those actual interventions. Do not conclude that intact skin means no need, or invent an ulcer and score it as though it were present.
Relevant guidance: National Framework, paragraphs 162–166 uses the wording well-managed needs are still needs
. Recognise ongoing management; do not score hypothetical untreated conditions. Source details.
6. A DST summary appears to contain more entries than expected. What is the most useful next step?
Show answer, example and guidance
Answer: D — Reconcile the summary with each domain and request an explanation
Example from our family’s DST: The September 2026 summary records totals adding to 13 entries for several contributors and 11 for the coordinator. Those counts prompted a request to reconcile every domain and its final level. The discrepancy itself does not establish eligibility.
Relevant guidance: DST guidance, paragraph 35 uses the wording clear recommendation
. A reconciled summary helps readers trace the reasoning. Checking arithmetic is a practical scrutiny step, not an eligibility test. Source details.
7. After considering all relevant evidence, the MDT still cannot agree between two domain levels. What does paragraph 25 of the DST guidance say?
Show answer, example and guidance
Answer: A — Select the higher level under consideration and record the evidence and significant disagreement
Illustrative example: Two MDT members disagree between Moderate and High after reviewing the relevant evidence. They should follow the disputed-level guidance and document the reasons, rather than invent a Moderate-to-High level.
Relevant guidance: DST guidance, paragraph 25 uses the wording higher of the levels under consideration
. If disagreement remains after considering relevant evidence, select the higher disputed level and document significant differences. Source details.
8. An earlier Independent Review Panel (IRP) found someone eligible. When scrutinising a later reassessment, what is the strongest approach?
Show answer, example and guidance
Answer: C — Compare assessment periods, evidence, changes in needs and the earlier reasoning
Illustrative comparison informed by our family’s experience: An earlier IRP found a primary health need. A later assessment says needs are now lower. Ask what has changed, which dated records demonstrate it, and whether effective care is being mistaken for reduced need. This is a scrutiny exercise, not a quotation from our IRP findings.
Relevant guidance: National Framework: Primary Health Need section uses the wording needs could change
. Assess the later period on its evidence. Retain the earlier findings as context and examine the basis for any claimed change. Source details.
9. A person receives care in a nursing home. What does that tell you about CHC eligibility?
Show answer, example and guidance
Answer: C — The setting alone does not decide eligibility; their assessed needs must be considered.
Illustrative example: A family is told that care is normal for a nursing home. Ask for reasoning about the person’s actual needs. The building or staffing model does not answer the eligibility question.
Relevant guidance: National Framework: eligibility rationale uses the wording setting of care
. The setting is not a basis for the eligibility decision. Source details.
10. Which evidence most directly helps explain the intensity of a person’s care needs?
Show answer, example and guidance
Answer: A — The quantity and severity of care needed, including how sustained the support must be.
Illustrative example: Care records show repeated interventions through the day and night, with the duration and assistance documented. This helps explain the quantity and continuity of care. No particular number of interventions automatically establishes eligibility.
Relevant guidance: National Framework: Intensity definition uses the wording sustained/ongoing care
. Describe the amount and continuity of support needed. Source details.
Use the explanations to identify which sections to revisit before reviewing an assessment.
Sharing your experience safely
If you post a comment or share a case publicly, describe the issue without identifying the person receiving care, relatives or individual staff members.
- Remove names, dates of birth, addresses, contact details, NHS numbers, case identifiers and signatures.
- Check screenshots and attachments for headers, footers, filenames and other identifying details. Use a properly redacted copy rather than placing a shape over sensitive text.
- Consider whether a combination of a care-home name, location, unusual incident and dates could identify someone even after their name is removed.
- Respect the person’s privacy and the authority you have to share their information. Being a relative does not automatically give permission to publish their confidential records.
Public comments are not the place to submit an unredacted DST, clinical record or appeal bundle. Use the appropriate confidential route when sending evidence to an adviser or assessment team.
Disclaimer and further help
This website provides general information and educational material about NHS Continuing Healthcare in England. Its explanations, checklists, case examples and any quizzes are not legal, medical or financial advice and are not a substitute for advice from an appropriately qualified professional or specialist adviser about your particular circumstances.
The material cannot determine eligibility, predict the outcome of an assessment or challenge, or guarantee funding. Case examples relate to their own evidence and assessment periods. Similar circumstances do not necessarily lead to the same outcome.
Guidance and procedures can change. Check current official information and the deadlines in your decision correspondence, and seek advice promptly if you are unsure about your rights, a decision or how to challenge it. Do not delay taking necessary action while using this website.
Established sources of information and support
- Compass CHC: a commercial provider of specialist CHC advice, advocacy and representation. It advertises a free initial assessment; further services are chargeable. Confirm the scope and fees before instructing it.
- Care to be Different: CHC articles and practical guides covering assessments, evidence, appeals and care funding, with information about professional support. Check any charges for products or services before purchasing.
- Beacon CHC: specialist CHC information and advice, including a free advice service. Check its current arrangements and limits. More extensive casework or representation may carry a fee.
- Age UK: information explaining CHC eligibility, assessment and care funding, with links to further advice.
- Alzheimer’s Society: CHC information for people affected by dementia, including its guide When does the NHS pay for care? and information about challenging decisions.
For legal advice, consider a solicitor with relevant experience in NHS Continuing Healthcare and community care law. Before paying for any service, ask about its scope, qualifications, charges and what it can realistically offer.
These links are provided for information and signposting. Their inclusion does not imply an affiliation, endorsement by those organisations or a guarantee about their services. This website is independent of the NHS and the organisations listed.
Read the full NHS CHC literature review →
Explore the research behind the wider CHC discussion, with
plain-English explanations, tables and figures.
Sources and case status
- Department of Health and Social Care. National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care, July 2022, corrected July 2023. See paragraphs 55–67, 162–166 and Practice Guidance 23.
- Department of Health and Social Care. Decision Support Tool guidance, updated October 2022. See paragraphs 4, 23–26 and 43. The publication includes links to the tool and domain descriptors.
- NHS. NHS Continuing Healthcare: assessment and care planning.
- Department of Health and Social Care. NHS Continuing Healthcare Checklist and guidance, updated October 2022.
- Department of Health and Social Care. Fast-track pathway tool guidance, updated August 2022. See paragraphs 3–14.
- Department of Health and Social Care. Public information leaflet: CHC and NHS-funded nursing care, updated August 2022.
- NHS. NHS-funded nursing care.
Case material: September 2026 DST, including pages 44, 45 and 54; the family’s quality and process challenge dated 5 October 2026, including reproduced professional accounts. These are family-held records. The comparison summarises selected matters and does not publish the underlying confidential documents. Unresolved concerns are described as concerns; the absence of a published response here is not evidence that a concern has been upheld.
This page concerns the CHC system in England. It combines official guidance with practical editorial suggestions and a family case example. It is independent of the NHS.