[2024] UKUT 427 (AAC)

Before considering the nine grounds of appeal, we set out first our conclusions regarding the evidence we have received.

We found the appellant to be an honest and credible witness. Her ‘story’ has been essentially consistent from her first statement to her employer, through all the written documents and at this hearing. What she says about the reasons why residents’ rooms were locked is not contradicted in any significant respect by the evidence provided by her employer to DBS or the CQC report.

The senior on duty on her shifts was LS. The employer did not provide DBS with a statement from LS, but SP’s account of LS’s outburst when she told her she was suspended provides support for the appellant’s account that doors were locked because violent residents were wandering that night. CQC’s findings were reached without knowledge of the reasons why doors were locked because CQC did not ask the appellant or LS.

We place little weight on the manager’s denial of knowledge of room-locking to CQC. It is evident from the CQC report that the home was very poorly managed in multiple respects. Management would likely have known, even though the appellant at the time did not, that doors should not have been locked without consent without proper capacity assessments and DoLS authorisations in place, which they were not. It was therefore in management’s interests to deny knowledge of why rooms were locked to CQC as that enabled them to present it as the ‘rogue’ action of the appellant and LS. However, it seems to us to be likely that the locking of rooms was something that was at least countenanced by management as otherwise there would not have been the system of signs or locks installed on the outside of doors.

In any event, it is not part of the appellant’s evidence that she personally discussed door-locking with SP or any other manager. Her evidence is that she understood that the senior LS did this, and there is no evidence to contradict her account in that respect.

Further, the appellant’s account that they were that night short-staffed is supported by the employer’s documentation and the CQC report. There is no dispute that, although there should have been five staff on duty according to the employer’s dependency calculations, in fact there were only four staff, only three of whom could provide personal care. The CQC report further indicates that the employer’s dependency calculations may have been inadequate because of the lack of updated care plans and risk assessments so that the employer’s calculation of how many staff were required to meet the needs of residents may have been wrong in any event. As such, the appellant’s account of being overworked and her belief that locking rooms of the most vulnerable was the only way to keep them safe is also plausible and we accept it.

The only aspect of the appellant’s evidence that is contradicted by the CQC report is that one of the two doors that were locked from the outside was evidently the door of one of the extremely vulnerable residents at the end of their lives rather than (as the appellant recalled when answering questions in oral evidence) one of the residents who had asked for their door to be locked. This is because the CQC report mentions that this person’s care plan records that they cannot call out for help. We find that this particular detail is one that the appellant has misremembered given the passage of time and the fact that she understandably cannot remember which resident was behind which door number. This does not lead us to doubt any of the rest of her account.

In the circumstances, we see no reason not to accept all her evidence as we have set it out above in “The Facts” section and we accordingly proceed to consider the individual grounds of appeal on the basis that the factual picture is as set out above.