Summary: We will not investigate Mrs X’s complaint about how the Council’s commissioned Care Provider incorrectly used a hoist which caused her daughter, Miss Y, to fall. This is because a further investigation would not lead to a different outcome and we could not add to the previous investigation.

The complaint

1. Mrs X complained the Council’s commissioned Care Provider, incorrectly used a hoist which caused her daughter, Miss Y, to fall. Mrs X said the matter caused her anxiety and distress. She wants the Council to provide an apology for the injustice caused. She also wants the Council to implement service improvements to ensure it does not happen again.

Back to top

The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start or continue an investigation if we decide:

• further investigation would not lead to a different outcome, or
• we could not add to any previous investigation by the organisation.

(Local Government Act 1974, section 24A(6), as amended, section 34(B))

Back to top

How I considered this complaint

3. I considered information provided by Mrs X and the Council.
4. I considered the Ombudsman’s Assessment Code.

Back to top

My assessment

5. The Council’s commissioned domiciliary Care Provider supports Mrs X’s daughter, Miss Y, in her home. Miss Y requires support with her mobility. Care workers use a hoist to help transfer Miss Y from one place to another.
6. In mid-2025, whilst a care worker was using the hoist to transfer Miss Y, Miss Y fell. Mrs X complained to the Care Provider about the incident.
7. The Care Provider investigated Mrs X’s complaint. It spoke with the care worker who was involved in the incident, the servicing company of the hoist and occupational therapists. It also reviewed training records for its care workers who supported Miss Y.
8. In response to Mrs X, the Care Provider said:
• the servicing company of the hoist and occupational therapists had carried out an inspection. It could not identify how the incident had occurred or whether it was caused by the care worker;
• the care workers who support Miss Y have carried out general hoist training. They had also completed bespoke training in relation to Miss Y’s hoist however, it did not have the records to show this;
• the current risk assessment of Miss Y’s hoist lacked detail;
• the care worker involved in the incident had undertaken a sufficient amount of shadowing training before supporting Miss Y with the hoist. They had supported Miss Y previously. It added it was an isolated incident; and
• it had reported the incident to the Care Quality Commission (CQC) as well as to the Council’s safeguarding team. In response, the Council assessed Miss Y’s needs to ensure she was receiving the right support.
9. Although the Care Provider could not say how the incident had occurred, it said it would make changes to its service going forward. These included:
• recording bespoke training care workers had completed;
• updating risk assessments to include specific details of equipment; and
• enhancing direct observations to ensure care workers recognised client-specific equipment and the environmental risks and they were shown a demonstration of appropriate controls.
10. We will not investigate Mrs X's complaint as any additional investigation would unlikely produce a different outcome because the Care Provider does not have sufficient evidence to determine how the incident occurred. The Care Provider also made appropriate service improvements to reduce the risk of a similar incident happening again which was appropriate and there is nothing further we could add. In addition, it reported the matter to the CQC and the Council’s safeguarding team which is what we would expect it to do.

Back to top

Final decision

11. We will not investigate Mrs X’s complaint because a further investigation would not lead to a different outcome and we could not add to the previous investigation.

Back to top

Investigator's decision on behalf of the Ombudsman