[2025] UKUT 302 (AAC)

In this section, we summarise PEO’s evidence about the incidents in question, and their context.

PEO joined the staff of the assisted living home in 2019 and worked with residents on the first floor (who generally had more severe needs than those on the ground level).

The organisation that employed PEO at the time of the incidents, had taken over management of the assisted living home earlier that year (in 2023). Following this change in management, PEO was told there were counting errors in his administration of medication; he was therefore suspended from administering medication; he was told his competency would be reviewed. The suspension occurred about four months before the incidents in question.

Just before the incidents in question, VA, one of PEO’s regular patients on the first floor, had returned from hospital, and was not well enough to return upstairs, so was staying on the ground floor. PEO was moved to the ground floor to supervise VA; an agency worker went on the first floor.

PEO was told the agency worker would administer medication (as PEO was suspended from doing so). But PEO was asked to show the agency worker where the keys for the medication cupboard were, and to support the agency worker. PEO watched the agency worker administer medication, and advised him to count it. PEO did not himself administer medication.

PEO did not challenge DBS’s fact finding at [8a ii.] above. PEO’s account is that the handover notes from the previous shift stated that all the residents were settled; PEO simply repeated this in his notes (without going in to JS’s, or any other resident’s, room, to check) because he did not want to disturb them sleeping. PEO said this failure to go into the sleeping residents’ rooms and check on them was a mistake on his part; he said he overestimated the independence of the residents on the ground floor. He says information on the electronic note system was not available to him.

PEO accepted DBS’s fact finding at [8a iii.] above as regards getting JS ready for his day out and provide him with a packed lunch; PEO said that he did not know this had to be done; it was not stated on any handover notes.

PEO had worked with VA for four years but never gave her ‘personal care’, as this was done by female members of staff. PEO’s account of the day in question was that VA came out of her room at 7 am and asked for a cup of tea; PEO did this and sat with her on the sofa; his shift ended at 8 am; PEO gave his handover to the day staff; VA was not soiled; the norm was that VA in fact changed herself and, if necessary, PEO would clean her bedding and provide a fresh pad and clothes.