Summary: Miss C complains there was inadequate planning and communication about a change of equipment used to move and transfer her mother. Miss C says this led to the domiciliary care provider giving notice and her mother suffered avoidable distress. We have found fault by the Council but consider the agreed action of an apology, payment and review of internal communication provides a suitable remedy.

The complaint

1. The complainant, whom I shall refer to as Miss C, complains about the standard of Council arranged domiciliary care provided to her mother. In particular, Miss C complains there was inadequate planning and communication about a change of equipment used to move her mother and professionals did not properly consider her views or alternative strategies.
2. Miss C says this led to a breakdown in the relationship with the domiciliary care provider which resulted in them giving notice. Miss C also says both she and her mother suffered avoidable distress and her mother was left soiled and not properly handled.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
5. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

6. I read the papers provided by Miss C and discussed the complaint with her. I have considered some information from the Council and provided a copy of the Council’s response to Miss C after removing third party details.
7. I have explained my draft decision to Miss C and the Council and considered the comments received before reaching my final decision.

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What I found

Key events

8. Miss C’s mother was receiving domiciliary care arranged by the Council. Miss C and care workers were using a stand aid when transferring Miss C’s mother from her chair to her bed or to use her commode.
9. Care workers had concerns about moving and handling issues and sought advice from an occupational therapist (OT) in mid-November 2019. The OT recommended an urgent review. Miss C was unhappy the care workers had contacted an OT without discussing this with her first or arranging a review meeting. Miss C says one of the care workers acknowledged this and apologised.
10. The OT completed an assessment on 19 November and observed Miss C using the existing stand aid with a chest belt. It was noted that the belt appeared to be dragging under Miss C’s mother’s arms and she was agitated and hitting out. The OT recommended a further assessment using a thorax seated support sling. The OT ordered the new sling and arranged a reassessment.
11. The OT made a further visit on 25 November to assess using the stand aid with the different sling. The OT noted that when using the thorax sling and stand aid hoist, Miss C’s mother was not assisting in the transfer and had minimal weight bearing though her legs. Miss C explained she preferred to use the original chest sling with the stand aid and demonstrated this again. The OT noted the belt rubbed under the arms and Miss C’s mother cried out. Miss C disputes this. The OT explained a full mobile hoist and sling would be the safest option and recommended an assessment with these items. Miss C raised her concern that this would result in her mother’s standing ability to deteriorate further and would also have a detrimental impact on continence. The OT confirmed a commode could still be used as a toileting sling could also be provided. The OT explained Miss C’s mother did not have capacity to make decisions about what equipment she preferred and so they needed to work together to come up with the safest and most appropriate solution.
12. The OT completed two visits on 29 November. During the first visit the OT completed a further assessment using the thorax seated support sling and stand aid hoist at Miss C’s request. It remained the OT’s professional opinion that this method was still unsafe and placed Miss C’s mother at high risk of injury as she was hanging from the sling as she was not weight bearing through her legs. The OT also assessed Miss C’s mother using a comfort recline sling which was fitted using a log roll method on the bed. It was noted that during the log roll technique Miss C’s mother presented as agitated but during the hoist transfer itself was calm using the comfort recline sling. At the second visit the OT assessed the use of a quick fit deluxe sling which could be fitted in a seated position. The OT provided this sling to Miss C at this visit. Miss C was concerned the bed transfer would impact on her mother’s balance issues and was not appropriate as she had scoliosis (curvature of the spine). Miss C was also concerned the method took much more time than using the stand aid.
13. 
    The care provider contacted the Council in early December with concerns about being able to use the commode as they had to transfer to the bed first to remove clothing. The care provider noted this method was increasing the call time but before they asked for a reassessment for a longer care call wanted to know if an accessible sling could be used which would avoid using the bed. Miss C also remained unhappy with the outcome of the assessments after the provision of the full passive hoist and was concerned about the detrimental impact on her mother.
14. The Council reallocated the case to a senior OT and a further visit was made on 11 December. Miss C sought a further assessment with the stand aid hoist as she was unhappy with the full hoist as she felt this was impacting on her mother’s continence and taking away her independence. The Council re-ordered a stand aid hoist and thorax sling with seated support for delivery to do so.
15. Following the above equipment being provided, the Council made a further OT visit on 17 December with the moving and handling coordinator to reassess using the stand aid hoist and thorax sling with seated supported. This assessment confirmed the stand aid hoist was unsafe for use as Miss C’s mother was fully dependent on the stand aid hoist, resulting in a drag lift which appeared to cause her pain. Both the OT and moving and handling coordinator recommended the use of a full hoist and slings and completed a demonstration of fitting the slings in a seated position on the bed. They also demonstrated how to use the hoist in a hammock style to prevent legs splaying to increase dignity and that consideration of alternative clothing for Miss C’s mother would make accessing the commode easier. The use of a stand aid hoist was not advocated by the OT or moving and handling coordinator but it was agreed to leave the stand aid in place to allow a trial period with the knowledge that the stand aid hoist was in place if she was unable to manage with the full hoist and slings until a further review.
16. The domiciliary care provider gave notice in early January 2020. A new care provider provided domiciliary care for a short period before Miss C made her own arrangements.
17. Miss C contacted both the continence and OT teams to arrange a joint visit. The Council completed a joint assessment with the OT service and the continence service on 14 January. At this visit the continence team discussed the use of an alternative continence product which could help support hoist transfers to the commode.
18. The OT visited on 22 January to assess Miss C using the equipment and provided further advice. Miss C was able to transfer her mother directly to the commode using the new continence products and felt things were much easier. However, she expressed her concern about how long it had taken to resolve the issue and the impact on her mother.
19. Miss C made a formal complaint to the Council towards the end of January. The Council provided a detailed response to Miss C in early March. Miss C made a further complaint to the Council at the end of March. The Council provided a detailed response in August and apologised for the delay which had been due to services being redirected as a result of the impact of COVID-19. Although the Council did not fully uphold Miss C’s complaint, it acknowledged it had fallen short in its commitment to ensure Miss C felt listened to as a carer for her mother and apologised.

My consideration

20. It is appreciated that Miss C would have preferred the care provider to have had a formal discussion with her about any movement and handling concerns before contacting the OT. However, I do not consider further investigation on this issue would achieve a better outcome for Miss C. I have considered the apology the care worker provided at the time, the eventual outcome of the care worker’s contact with the OT and the subsequent change in care provider in reaching this view.
21. Based on the evidence provided, I am satisfied the Council properly assessed Miss C and care workers using the existing stand aid and tried alternative slings to see if this method could be safely continued before concluding a full hoist was required. However, it is also clear that both Miss C and care workers raised concerns at the time about the impact on her mother’s continence and the increased time taken due to the need for an intermediate bed transfer.
22. The Council says before the joint visit with the continence service in January 2020, Miss C’s mother was able to access the commode using the full hoist and quick fit deluxe sling via transfer to the bed to attend to her continence pad and clothing. The Council also says that adjusting clothing and pads on the bed reduced the risk of moving in the sling while in use and tearing/shearing of skin and is considered best practice. The Council further says it is also best practice for hoist transfers to transfer from one place to another as quickly as possible without leaving the individual suspended in the air whilst attending to clothing or continence products. However, in this instance because of the distress caused to Miss C’s mother by the additional transfer on/off the bed to adjust clothing it was agreed that use of the alternative continence product and adjusting clothing while in the sling was in her mother’s best interests.
23. The Council accepts the alternative continence product was not known to the OT service at the time of its assessment in November 2019. The Council did not involve the continence service until January 2020 when the use of an alternative continence product was highlighted as a potential way to avoid the intermediate bed transfer. I consider there was a failure to involve the continence service at an earlier stage and some avoidable delay which constitutes fault. This resulted in a missed opportunity to trial earlier the use of the alternative continence product and avoid the intermediate bed transfer. Although the Council has confirmed it has ensured this knowledge has now been shared via training and learning to support any future recommendations of a similar nature, I consider both Miss C and her mother were caused avoidable distress during this period that requires a further remedy.
24. The care provider’s contact with the Council in early December 2019 suggested it may need to seek a reassessment of the call time needed if the new hoist and method requiring an intermediate bed transfer was to be continued. This did not suggest the care provider was considering giving notice. However, the care provider did give notice to the Council shortly afterwards in early January 2020. The Council’s complaint correspondence with Miss C says the notice was given primarily due to a lack of available capacity to provide the additional time required for her mother’s care. On balance, I consider the fault identified above would at least have been a factor in the care provider’s decision. Although another care provider was arranged for a short period before Miss C made her own arrangements so her mother was not left without care it is acknowledged this change will also have had an impact on both Miss C and her mother.

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Agreed action

25. The Council has agreed to:
1. write to Miss C to apologise for the failure to involve the continence service at an earlier stage and the avoidable delay within one month of my final decision;
2. pay Miss C £500 in recognition of the avoidable distress both she and her mother suffered within one month of my final decision; and
3. review the way the OT and continence services work to ensure improved communication and liaison in future within three months of my final decision.

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Final decision

26. I have completed my investigation as I have found fault by the Council but consider the agreed actions above provide a suitable remedy.

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Investigator's decision on behalf of the Ombudsman