The contemporaneous documentary evidence in this case
The contemporaneous documentary evidence in this case
Thecontemporaneous documentary evidence relating to the particular incident in this case on 4 August 2021 is somewhat limited.
The care home’s referral to the DBS, made just over a month later on 8 September 2021, was framed in the following terms:
The nature of the allegation is that during the Night shift on the 04.08.2021 a night spot check was carried out. During this inspection. Staff were found to be asleep in a Service Users apartment. Staff had knowingly restricted the Service Users access by placing a chair under the door handle knowingly locking him into his bedroom while they both slept. The allegation was made by the operations manager and new Registered Manager in post during the night spot checking during the spot check on the 04.08.2021.
Mr B, the care home’s registered manager, prepared a short ‘investigation report’ on 9 August 2021, running to just 2½ sides. In terms of methodology, Mr B explained that he had interviewed Mr O (the shift leader) and Mr K (a support worker) and reviewed their (one-page) handwritten statements. He did not speak to the Appellant or Mrs A because they had both resigned by that time. He had also had a Teams call with Ms S, the regional / operations manager (although there was no separate record or transcript of this call). The sum total of his substantive review of the evidence was as follows (the syntax has been left as in the original text and uncorrected):
I undertook a teams call with the Operations Manager Who provided a factual concise account of events from the time of arrival, waiting for the new manager to arrive, there was a delay of the new manager arriving. Operations manager states that she observed from the outside of [the care home] that the office lights were off. Mr O Stated in his investigation meeting that the lights were off because of his eyes itching due to hay fever. Mr K admitted to having cushions on the floor this was due to a sore back. Mr O confirmed That the operations manager asked him to do a walk around with her, it was confirmed that they went into the courtyard and into the first flat. On entry to the flat there was a member of staff on the sofa, and another member of staff in the chair with a coat over her face, this was confirmed in carer 1 [the Appellant’s] statement by her own omission. The Service User was restricted to his bedroom only with a chair wedged under the outside of the bedroom door handle depriving the Service user of a liberty. Mr O states that he checked the team every 30 minutes and had identified no concerns at all.
It will be evident that this brief consideration of the evidence is as much concerned with the conduct of Mr O and Mr K as that of the Appellant and her co-worker Mrs A. The penultimate two sections of the report (before the recommendation that the matter be referred to the DBS) then read as follows (again, without any textual corrections):
Summary of finding statements
Having looked at the statements provided I believe that it is beyond doubt that the staff had knowingly deprived a Service User of their liberty, this has also been found in one of the carer 1 statement. Leading to an infringement of the Service Users Human Rights
Conclusion
Appendices 1 and 1A openly admit to restricting access and depriving a Service user of their liberty. (Carer 1) in her statement openly admits to sitting in the chair with a coat over her face. Therefore, the investigation and statements provided evident that it is highly likely that the staff were asleep on shift when they were aware of their duty being an awake night.
Carer 2 denies being asleep, however in the statement acknowledges that they were laying on the sofa resting. Both staff have robust training regarding safeguarding, Mental capacity act and deprivation of liberty safeguarding. Therefore, they knowingly deprived a Service of their liberty, and infringed upon their human rights this was to ensure that they were able to have an easy shift with no interruptions enabling them to sleep.
Appendices 1 and 1A were listed as the written statements by the Appellant and Mrs A respectively. However, they were not included with the documentation referred to DBS. The Respondent appears to have taken no steps, as part of its decision-making process, to obtain copies of these statements. The Appellant, on the other hand, has made both a Subject Access Request and secured a third party disclosure order from the Upper Tribunal, but her former employers have been unable to produce the document in question. Thus, the Appellant made an application against the care home under rule 16(1)(b) of the Tribunal Procedure (Upper Tribunal) Rules 2008 for specific disclosure of documents referred to in the investigation report, namely the contemporaneous written statements from the Appellant and Mrs A on the night in question. The application was granted by the Upper Tribunal, and a final answer to that request was provided by the care home on 14 December 2023, namely that Mr B had been unable to locate the documents and a further search for the documents by the care home was also unsuccessful.
The care home did however include two other handwritten statements with its referral to the DBS.
The first was from Mr K, one of the support workers. It was signed and dated at 02:15 on 4 August 2021 and so was genuinely contemporaneous. It referred to various other aspects of the spot check carried out by the regional manager, but just made a single passing reference to the Appellant: “Thereafter Ms S took myself and Mr O into the court-yard and she opened Mr N’s flat and found the support workers on the sofa”. There was no reference to a chair having been wedged so as to restrict Mr N’s freedom of movement. There was no suggestion that the Appellant or Mrs A were asleep.
The second handwritten statement was from Mr O, the shift leader, and was dated 4 August 2021. Again, this referred mostly to other aspects of the spot check. There was a single statement relevant for our purposes: “we proceeded next to Mr N’s flat where she also noted that the light was off in Mr N’s flat and also met one of the staff laying on the sofa with blanket. She also noticed that the door was barricaded with chair in which she expressed her anger and frustration”.
The care home also disclosed typed notes of investigation meetings with Mr O and Mr K respectively as held on 8 August 2021 (presumably when interviewed by Mr B). The relevant part of the note of the meeting with Mr O read as follows (the text has been italicised by us to reflect what we understand as our best guess to have been the investigator speaking):
OK so then what happened?
Ms S asked me to complete a walk round with her, we went into the courtyard and into the first Apartment. When we enter the apartment there was on member of staff on the sofa. I do not think that she was asleep.
The other member of staff was on the chair with a coat over her face, there was a chair wedged under the door handle. Who was the carer it was DAK.
So, you were shift leading?
Yes
How frequently were you checking on the staff?
Every 30 minutes
Did you notice anything strange on your checking?
No, I had checked 30 minutes earlier and there were no problems.
The typed notes of the meeting with Mr K include nothing directly relevant by way of evidence about what the Appellant was doing or was not doing, beyond the general observation that “I knew that Ms S was not happy about finding people asleep on shift and rightly so”.
The Appellant was suspended on 4 August 2021, i.e. on the day of the incident, the reason being given in the letter of suspension that she had failed in her duty of care towards the service user and “it is alleged that you have been restricting the movements of a service user … You put a chair outside Mr N’s flat, holding the door handle and blocking the door, not allowing the service user to leave his flat. This is a form of abuse”. The Appellant resigned by e-mail on 6 August 2021, although shortly afterwards on 9 August 2021 she wrote seeking to withdraw her resignation and stating that she was available to take part in the disciplinary investigation.
There is no other relevant contemporaneous documentation. In particular, we note that there is no statement from Ms S, the regional manager. The most that we have is some hearsay account mediated through the investigation report and notes of meetings conducted by Mr B.
- Heading
- The decision of the Upper Tribunal is to allow the appeal. The First-tier Tribunal made mistakes in the findings of fact on which its decision was based. Pursuant to Section 4(6)(a) of the Safeguardin
- Introduction
- The two Upper Tribunal oral hearings
- The statutory framework
- The case law authorities
- The people involved in this case
- The factual background
- The DBS decision under appeal
- The Appellant’s grounds of appeal
- The contemporaneous documentary evidence in this case
- The oral evidence in this case
- The Appellant’s oral evidence
- Mr O’s oral evidence
- The Upper Tribunal’s findings of fact
- Conclusions
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