An independent provider in the City of Plymouth area

4. Ms G complains on behalf of her mother, Mrs G, about the service they received from the Service Provider. She complains that the Service Provider:

• does not carry out podiatry home visits for musculoskeletal (MSK) consultations

• did not provide an occupational health assessment requested in October 2023 until August 2024

• delayed a routine podiatry assessment requested in December 2019, then discharged Mrs G in October 2023 without seeing her

• took an excessive amount of time to respond to complaints between December 2023 and September 2025, then took no action to improve its written communication, format, structure, services, or complaints handling

5. Ms G says that these events have caused her a great deal of frustration and left her feeling that her mother’s health was not a priority to the Service Provider. She says the delays left her mother effectively confined to half of the house because she could not get upstairs, which has significantly impacted her quality of life.

6. Ms G says the events have increased her own anxiety and depression. Chasing the Trust for services and answers has taken up much of her free time, which she says has impacted her financially and impacted on the progress of her education.

7. By making the complaint, Ms G hopes to see the Service Provider implement improvements to its services, communication, and complaint handling. She also believes that any identified failings should be formally acknowledged through appropriate financial redress.

8. Mrs G is in her 80’s and has limited mobility, linked to foot and ankle pain. She had some help from carers and her daughter, but required some significant home adaptations, such as a stairlift, as she had to sleep downstairs and use a commode.

9. The Service Provider was tasked to conduct Occupational Therapy (OT), Physiotherapy (PT), podiatry and musculoskeletal (MSK) assessments, along with any onward actions or treatment.

MSK home visits

13. Ms G complains that the Service Provider does not provide home visits. She says it does not account for patients who cannot get to a site for assessment, resulting in a service that is not accessible to many patients, including her mother.

14. The Service Provider explained that MSK manufacture custom insoles on site, which means that a service user can be assessed, receive an exercise plan and custom made supports in the one on site appointment.

15. It said that bed bound patients do not generally experience functional foot pain so, home visits are not provisioned and highlighted the availability of transport services for patients with reduced mobility.

16. Mrs G received an invite to book an MSK appointment in March 2024. The records show that Ms G contacted staff explaining that her mother’s foot and ankle pain meant she could not walk very far. She told staff that Mrs G’s reduced mobility meant she was unable to attend any onsite appointments and requested a home visit.

17. We reviewed the local policy the Service Provider followed to decide that Mrs G did not require an MSK visit at home. Plymouth Community Healthcare Assessment of Patient Eligibility for Domiciliary Care (March 2014) says a home visit can only be offered to a patient who is either:

• permanently confined to a bed • in a nursing home • in a secure establishment • deemed temporarily to be too ill to travel and that not treating their foot problem will cause significant harm.

18. It says that even if a patient meets the criteria, staff must exhaust all options of transfer to the clinic before considering a home visit. Staff must be satisfied that the patient has not left the house for other appointments, including medical and social, such as the hairdressers, going shopping or to the library.

19. We can appreciate that Mrs G had foot and ankle pain that was significantly affecting her mobility, but she did not meet any of the criteria that entitled her to a home visit. We have also seen evidence that Mrs G was using patient transport services at the time the MSK referral was submitted, so we can see she was familiar with utilising this too.

20. We looked at other NHS MSK services around the country. A small number do provide home visits, but the criteria are even stricter, excluding all factors but a profound lack of physical function or recovery from major surgery. The majority of other MSK services across the country take the same approach of providing patient transport for those with reduced mobility.

21. We hope it is reassuring for Ms G to know that the Service provider did work within its policy, and that policy is not an outlier when we compare it to other MSK offerings. We are therefore satisfied that there are no indications of failings regarding this matter.

OT delays

22. Ms G says that her mother needed an OT assessment, so that she could apply for a stairlift and reclaim access to the rest of her house. She complains that despite repeated falls and hospital admissions, it took 10 months for OT to attend and assess Mrs G.

23. She complains that the OT then arrived for the assessment a day early, during a birthday party. Once the assessment was complete, she says the OT did not issue the report for another two months. She says the delays meant that the stairlift procurement process could not begin at local authority until December 2024. She says her mother should not have had to wait two years for this to happen.

24. The Service provider apologised that Mrs G had to wait so long for an assessment.

25. The records document that OT received a routine referral for Mrs G on 12 October 2023. She reached the top of the waiting list on 8 August 2024. After completing the report, the OT sent it to local authority on 10 December. Altogether, Mrs G waited one year and two months from referral to report. We therefore considered how long Mrs G had to wait for assessment, and how long she had to wait for the outcome.

26. We must consider that lengthy waiting lists across all clinical areas in all parts of the country are well publicised. In October 2023, NHS digital reported that almost 7000 patients across the country were waiting for this type of OT assessment.

27. The Local Authority’s Adult Social Care and Activity Report (September 2025), says the local wait time for OT assessment specific to home adaptations stood at 192 days. The report notes that this had come down significantly in recent months, so we can reasonably assume the average waiting time was even longer whilst Mrs G was waiting. When we consider the information at hand, we can conclude that reasonably, Mrs G would not have been seen earlier than May 2024.

28. The records show that Mrs G was a medium risk service user because she could not get upstairs alone and so could not shower daily. This was mitigated by twice weekly carer help, and a commode downstairs in the meantime. She also slept downstairs, which the OT team documented meant she was safe and therefore, not high risk.

29. On 5 March, OT noted that it was allocating patients added in July 2023. With Mrs G added three months after that date, we think she could expect at this point to be allocated around June or early July 2024.

30. On 12 March, the records show that Mrs G’s GP wrote a supporting letter asking that she be moved up the list. They noted Mrs G had increased her use of the commode, which was becoming unmanageable. At the same time Ms G also informed staff about a fall and a recent hospital admission.

31. The OT team moved Mrs G to high risk as a result. It is therefore reasonable to assume that she would be seen earlier than the projected date of July 2024. However, the OT team did not contact Ms G to arrange an appointment until after that date, on 8 August. This indicates that even as a high risk service user, she was still seen about a month later than what we would have expected.

32. We must consider that patients are not the only factor affecting wait times. Staffing can commonly play a role, particularly in the summer months because the pressures of usual staff sickness are compounded by increased rates of annual leave. Both of these factors are reflected in the Trust’s complaint response, so we know this consideration is relevant.

33. Mrs G was on the waiting list for an OT assessment for 10 months. We know this was largely down to a backlog, and we can see through Local Authority reporting, that the Service Provider has already achieved good improvement in the size of OT’s home adaptations queue.

34. Whilst Mrs G did wait a long time for assessment, we do not think this could have been avoided, and we are satisfied that nothing occurred to make that wait longer than it had to be.

35. The records indicate that the OT home assessment took place on 16 August as scheduled, rather than a day early. However, it is of no consequence to our investigation which of the two days this occurred, and the records show the assessment did begin, in place of staff being turned away. The OT records do document that this assessment had to be terminated over safeguarding concerns, because Mrs G was arguing with her daughters.

36. The records reflect staff’s concern about attending alone due to the events in the last visit. The OT and a PT, who was also treating Mrs G, opted to attend together to help manage a calm environment. With annual leave, other service user commitments, and staffing pressures across both PT and OT documented in the records, a joint visit was arranged for 29 October.

37. This was around two and a half months later, so we can appreciate the wait was lengthy. We cannot be critical of staff for forming a plan to effectively deliver care when there is a risk of conflict and escalation. Nor can we hold staff responsible for the need to rebook.

38. The OT sent the completed assessment and report to Local Authority on 10 December, after discussing Mrs G’s needs with provisioning staff. Given its size, detail, and discussions with Local Authority staff first, we think the paperwork was completed in a reasonable timeframe.

39. If the assessment in August had been completed in full, then it seems that the report would have arrived with Local Authority around two months earlier. We cannot attribute the delay in completing the home assessment to the OT, and we cannot see any indication that OT staff should have taken more action, sooner than they did.

Podiatry

40. Ms G says that as an elderly diabetic, her mother was on the podiatry waiting list for foot monitoring because it was important that early intervention could prevent any serious problems. She complains that Mrs G waited for four years, before podiatry discharged her, having never been seen.

41. The Service Provider explained that when Mrs G was placed on a routine referral in December 2019, podiatry’s wait time was 46 weeks. However, the pandemic halted all routine appointments for a long time.

42. It said that it validated Mrs G’s place on the list with her in September 2022 but then changed its policy in October 2023, moving all diabetic patients over to that service instead.

43. The records show a nurse submitted a routine referral to podiatry in December 2019, following an annual routine diabetic foot check. 46 weeks from December 2019, took Mrs G’s wait time to November 2020.

44. The government postponed all routine NHS appointments and elective procedures between March and June 2020, with a national lockdown in place until July, effectively adding a four month delay to that time.

45. In October 2020, the Service provider received a second diabetic referral from her GP, specific to nail care. However, in November the UK entered the second national lockdown. This did not end until March 2021.

46. The pauses in service calculated on their own, would have moved the expected appointment date to around August 2021. However, this would only be the case, if no other patients were added to the list in those months, and if no staff contracted covid themselves, reducing appointment availability. In other words, we can recognise the multifaceted effects the pandemic had on podiatry’s routine waiting list, long after the pauses in services ended.

47. The records reflect podiatry’s September 2022 letter and Mrs G’s confirmation that she would like to remain waiting. Ms G’s frustration in waiting is evident in the notes, but we can see nothing to suggest Mrs G’s need had increased.

48. The Service Provider’s Diabetic Foot: Access and Care Frequency Grid (March 2023) says that routine podiatry referrals for skin and nail care, result in self-care advice and patients maintain their annual foot check at their GP practice. Notwithstanding the practice’s own pandemic restrictions, we know Mrs G was receiving these reviews because the referrals originated here.

49. On 26 October 2023, the records document that the Service Provider discharged routine diabetic patients that had been waiting longer than a year, under its service improvement project. It discharged Mrs G to the diabetic team for further assessment.

50. Under the diabetic foot policy, Mrs G was entitled to self-care advice. She had to wait a very long time to get it, only to be passed on to another service instead. We appreciate how frustrating both the wait, and then the service change was.

51. Podiatry’s existing waitlist was significantly increased by the pandemic, which was true for all services across the country. Ultimately this means that the Service Provider did not provide a good service because of those significant delays. However, we cannot see that the poor service could have been avoided if the Service Provider had done anything differently. The problems that caused the wait were unprecedented, never experienced by the NHS before and completely out of the Service Provider’s control.

52. The Service Provider discharged diabetic patients from podiatry to try and get queues moving again. It provided an onward referral to diabetic services, so we are satisfied that whilst frustrating, the Service Provider did not abandon Mrs G’s care, rather, moved it to another appropriate service.

When we consider what happened, we can see indications of significant delays that were out of the Service Provider’s control. Whilst we recognise how frustrating this wait was, we cannot see how the Service Provider could have changed the situation and therefore, we are not taking any further action.

Complaint handling

53. Mrs G complains that it took the Service Provider five months to issue its first complaint response, then a further 10 months to provide a final response. She says although the Service Provider accepted some of what went wrong, it took no action to ensure similar mistakes would not happen in the future.

54. She also complains that the Service Provider did not make her aware of her complaint rights, regarding escalation to us and the associated timescales.

55. The Service Provider acknowledged that its second response was very late and apologised. It said the customer service team was reviewing what happened to ensure a reduction of delays in this area.

56. Ms G complained on 28 December 2023 and received a response exactly two months later. We think that two months is appropriate to conduct a thorough investigation and so, we can see no problems with how long that first response took.

57. NHS Complaint Standards (December 2022) say that people should be kept updated as to the progress of their investigation.

58. Ms G complained again in April 2024, with the response arriving in September. The records show the Trust did contact Ms G in July, to advise there would be a delay, so we are satisfied it appropriately managed her expectations, in line with the standards.

59. Ms G complained again on 21 November 2024. She chased this by email in May 2025, eventually receiving a response in September, 10 months later. The Service Provider noted staff had made a mistake when triaging the new complaint, so it was overlooked until she chased it in May.

60. We looked at the content of Ms G’s November 2024 complaint to assess the injustice caused by the mistake. She expresses her disagreement with much of the previous complaint response and highlighted points that she felt had not been addressed. These aspects relate to a separate complaint about her own care, and about admin based matters, such as accessible telephone numbers and response times.

61. Once it identified Ms G’s follow up complaint in May, it responded four months later. If the Service Provider had got things right in November, the response times indicate that Ms G would have received a final response six months earlier.

62. Without that gap between November 2024 and May 2025, the complaints investigation would have totalled six months. We think that would have been reasonable as it is in line with what we typically see.

63. To consider poor complaints handling through a second stage detailed investigation, we would need to see strong evidence that the indicated failings led to a distinct and significant injustice to the person affected. We will not consider complaint handling where the impact is limited to frustration.

64. A mistake meant that what happened was not what should have happened. We can therefore recognise completely how frustrated Ms G was, and why. We cannot see that what happened extended beyond that. There is no evidence to indicate that a lengthy complaints process led to any impact on Mrs G’s care.

65. We are also satisfied that the Service Provider did appropriately signpost Ms G to us. Its responses in February and September 2024 provides our telephone number, and live links to our website and enquiries inbox.

66. It is without doubt that Mrs G had to do a lot of waiting, which could not be avoided. Ms G then had to wait again for complete answers to her complaint, but the delay did not lead to any impact outside of frustration. Whilst this does not take away from that experience, it does mean that the mistakes in complaints handling on this occasion do not meet the threshold for a second stage investigation.

67. We will therefore take no further action.

1. We have carefully considered Ms G’s complaint about the Service Provider.

2. We can recognise completely the frustration both Mrs G and Ms G experienced whilst Mrs G was waiting for assessment and care from the Service Provider, but we do not think these waiting times could have been avoided.

3. We also acknowledge that a mistake in complaints handling led to a six month delay between complaint responses, but because that impact was limited to frustration, it does not meet the threshold for us to take further action.