Mrs Lisa Jane Thorn

: Social worker

: SW68086

: Final Hearing

Date and Time of hearing:10:00 03/05/2017 End: 17:00 12/05/2017

: Health and Care Professions Tribunal Service (HCPTS), 405 Kennington Road, London, SE11 4PT

: Conduct and Competence Committee
: Struck off

Allegation

You were the manager of Woodlands Care Home in Wakefield between around 1998 and 2009 and:

1. You did not take adequate steps to protect service users from verbal, physical and/or emotional abuse in that:

(a) service users were physically and/or verbally abused

(b) you did not ensure that concerns about Person A’s behaviour were reported and/or investigated

(c) service users were punished for bad behaviour

(d) service users were made to queue up at meal times

(e) service users were subjected to enforced segregation according to their gender

(f) service users were subjected to enforced diets and/or exercise

(g) service users were restricted in their movements around Woodlands

(h) service users were restricted in when they could shower

(i) service users were restricted in when they could change their clothes

(j) service users had set times to get up and go to bed

(k) service users hair was cut and/or shaved without their consent

(l) service users were not always encouraged to maintain contact with their families and/or family members were not encouraged to maintain contact with service users

(m) you did not ensure that service users' accommodation was heated adequately at all times

(n) you did not ensure service users received adequate food and/or drink in that:

i. service users were provided with insufficient amounts of food

ii. service users were given out-of-date food

iii. food and drink was only provided at limited and specific times

iv. service users had limited choice of food and/or drink

2. You did not ensure appropriate management of service users’ money in that service users and/or their families were charged:

(a) service users and/or their families were charged

i. for the cost of service users going on holiday, without appropriate consent and/or authorisation

ii. for the cost of staff travel on holiday, without appropriate consent and/or authorisation

iii. for other residents to go on holiday

iv. for clothes which they did not choose

v. to stay at a caravan owned by Woodlands

vi. for items including a wormery without appropriate consent and/or authorisation

vii. for basic items including a mattress, chairs, wardrobes and/or carpet which should have been provided by Woodlands

viii. for items including a television which they did not use

ix. for services including one-to-one care which they did not always receive

x. for haircuts which were not carried out by professional hairdressers

xi. for items including medication, a mattress and a protective helmet for which funding should have been sought from social services and/or the health service

xii. for homeopathic and/or alternative treatments without appropriate consent and/or authorisation

xiii. excessive amounts for items

(b) you did not ensure that service users received full payment for work undertaken by them

3. You did not ensure that the provision of staff was adequate in that:

(a) you did not ensure that an appropriate number of staff and/or trained staff were on duty at all times

(b) you did not ensure that staff were adequately trained, in that:

i. only around three members of staff were trained in restraint techniques

ii. you delivered in-house training to some staff rather than arrange accredited and/or independent external training

iii. you did not ensure that all staff received adequate training in handling and/or giving medication

iv. you did not ensure that all staff received adequate fire safety training

4. You did not ensure that appropriate consent and/or authorisation was obtained in that:

(a) homeopathic and/or alternative treatment was administered to service users for whom you did not obtain appropriate consent and/or authorisation

(b) you signed consent forms on service users’ behalf

(c) you asked residents who lacked capacity to sign consent forms

5. You sought consent for homeopathic and/or alternative treatments from service users’ families retrospectively after the police enquiry into Woodlands began.

 6. You did not ensure that service users received clinically appropriate treatment, in that:

(a) alternative treatments were used to treat conditions which required medical treatment

(b) medical treatment was not always sought for service users who required it

(c) alternative treatments were used to treat behavioral and/or mental health issues

(d) treatment was administered to service users which was:

i. unnecessarily painful

ii. against their wishes

(e) medication was administered for non-therapeutic reasons in that:

i. medication was given in accordance with staff shift patterns rather than medical advice

ii. a service user was given diazepam without clinical justification

(f) service users’ food intake was restricted without appropriate clinical advice

(g) you did not ensure that service users’ medical clinicians were always consulted and/or made aware of all homeopathic and/or alternative treatment administered to service users

7. Your actions set out in paragraphs 2, 4(b), 4(c) and/or 5 were dishonest

8. The matters set out in paragraphs 1-7 constitute misconduct and/or lack of competence

9. By reason of your misconduct and/or lack of competence, your fitness to practise as a social worker is impaired

Finding

Preliminary Matters

Service

1. Having seen copies of the Notice of Hearing dated 9 February 2017, the Registrant’s Certificate of Registration, and the proof of posting, and receiving the advice of the Legal Assessor, the Panel determined that the Notice of Hearing had been served in accordance with the applicable HCPC (Conduct and Competence Committee) (Procedure) Rules 2003 (the Rules).

Proceeding in absence

2. Ms Chaker applied for the hearing to proceed in the absence of the Registrant under Rule 11 of the Rules. She informed the Panel that following the service of the Notice of Hearing, there had been an email in response dated 13 February 2017 from the Registrant’s legal representatives saying, “We confirm we have spoken to Mrs Thorn who is returning the notice to indicate she will not be attending the hearing and we will not be attending to represent her”. There was a further letter from the Registrant dated 12 April 2017 in which she confirmed that she consented to the HCPC witness Carer G giving her evidence by videolink and/or telephone at this hearing. This was the last communication from the Registrant. Ms Chaker submitted that the Registrant had voluntarily absented herself, and the hearing should proceed in her absence. There was no application for an adjournment. Overall, Ms Chaker submitted that the public interest in proceeding should prevail against the Registrant’s own interests at being present at this hearing.

3. The Panel accepted the Legal Assessor’s advice and took into account all the factors set out in the HCPTS Practice Note “Proceeding in the Absence of the Registrant”. After considering all the circumstances, the Panel concluded that the Registrant had voluntarily waived attendance or representation at the hearing. Therefore, the public interest requirement of proceeding expeditiously with professional disciplinary hearings justified proceeding with the hearing in the absence of the Registrant.

4. All witnesses were anonymised in accordance with an identification key produced by the HCPC.

Background

5. The Registrant was employed as Registered Manager at Woodlands Care Home (Woodlands). Woodlands was a private residence for up to 19 adults with learning disabilities aged 18-65. There is evidence that they or at least some of them were particularly vulnerable. It was owned by Person A and Person B and managed by the Registrant, Lisa Thorn, a registered Social Worker. Woodlands consisted of one large Victorian house which could accommodate 16 people in shared and single occupancy rooms, together with a separate bungalow with 3 more single rooms. Woodlands also had a workshop where service users carried out what was purported to be paid work for a private company.

6. In February 2009, anonymous sources contacted the Commission for Social Care Inspection (CSCI) (later, the Care Quality Commission (CQC)), West Yorkshire Police, and the Wakefield Express newspaper. The whistle-blower(s) made serious allegations of abuse taking place at Woodlands.

7. The CSCI conducted an unannounced inspection of Woodlands on 2 March 2009. This was planned as a random inspection but, due to the seriousness of the findings, it was decided that it should be the first part of a Key Inspection. The second part of the Key Inspection took place on 9 March 2009.

8. GW and KR, together with the Pharmacist, SB, produced the Key Inspection Report dated 9 March 2009. As a result of the findings, the CSCI/CQC reassessed the quality rating of Woodlands to a “zero star poor service” and statutory requirements were issued to urgently raise standards at Woodlands. At a multi-agency meeting held on 28 April 2009, the decision was taken to close Woodlands.

9. Investigations of the Regulator, the Local Authority, and West Yorkshire Police uncovered allegations of physical, psychological, and financial abuse of service users.

10. There is evidence to show that Person A terrified Woodlands’ service users and staff alike. The oppressive regime was very much Person A’s regime. Person B drove the mini-bus, fetched food supplies, and monitored the CCTV. The Registrant managed Woodlands and appeared to be liked by some staff. She was in a position to put a stop to the abusive practices. These would have been obvious to her and were, on occasions, reported to her by staff and family members of service users.

11. The regime in place at Woodlands included:

• Service users being placed on a strict routine in terms of when they got up in the morning, went to bed in the evening, and took their meals during the day;

• On weekdays most service users would go to Woodlands’ workshop, where they would assemble plastic pipes for an external company. No evidence has been found which suggests that the services users were paid for this work;

• Person A would, on occasion, call service users “stupid” and belittle them with other insults;

• Service users were routinely punished for behaviour deemed unacceptable by those in charge. For instance, they would have their personal belongings confiscated or were grounded to their bedrooms. These punishments would not be rescinded until Person A felt that they deserved them back;

• Service users had no choice about what clothes they would wear and purchase;

• Service users had little to no choice about the food they ate and were not provided with sufficient amounts of food; there were no dinner plates at Woodlands, only side plates. Two service users were, for a time, fed out-of-date baby food;

• Service Users were almost all placed on enforced diets as a result of what appeared to be an institutional obsession with weight management;

• Service users were permitted to shower only once per week and only on days specified by management; if they had more than one shower, Person A would require an explanation;

• Service users were only allowed to change their clothes once per week, again only on days specified by management;

• When service users required medical attention, Woodlands routinely turned to alternative therapies rather than evidence-based treatment from medical practitioners. Some of these therapies were painful and without clinical justification of any kind; service users suffering from cataracts had honey smeared along the inside of their eyelids and tea tree powder was used to treat serious fungal infections. Service users were charged large sums of money for these treatments and in almost all cases they were applied without the appropriate consent;

• During the cold months, the heating would be switched off for lengthy periods of time. The rooms became so cold, staff closed all of the curtains during the day to keep in what heat they had and keep all service users together in one room. One carer remarked that it was so cold in the bedrooms the bedsheets felt damp all of the time. One service user, Service User F, complained she was cold as she did not have a proper bed cover, only a light blanket. Person A dictated she was not to have a new bed cover; instead staff were instructed to put her in a coat, hat, and gloves to keep her warm.

12. In June 2012, the Registrant was charged jointly with Persons A and B with eight counts of wilful-neglect/ill-treatment under section 44 of the Mental Capacity Act 2005. In January 2014, the Registrant was due to stand trial for these offences at Leeds Crown Court. However, on the first day of the trial the Crown made an application for a lengthy adjournment in order to obtain expert evidence as to the capacity of the eight service users who were said to be the victims of the counts on the indictment. Without that evidence, the Crown could not prove the offences. The application was refused and the Crown offered no evidence on the indictment; formal verdicts of not guilty were entered by the Judge in respect of each defendant on each count.

13. Person A and B are now believed to be living in the USA. As a registered Social Worker, the Registrant was reported to the HCPC.

Decision on Facts

14. The allegation was read out. The Panel bore in mind the burden and standard of proof, namely the ‘balance of probabilities’ and considered each particular separately.

15. The Panel first considered the witnesses who had given evidence. The HCPC called four live witnesses: GW, KR, Witness 6 (a relative of Service User E) and Carer G. The HCPC also provided written statements from Carer I and the Pharmacy Inspector, SB. The Panel also had the benefit of a large amount of witness statements from Police interviews and CQC interviews with several carers, service users, and service users’ relatives, and other paper exhibits put before it. Some of the exhibits provided included elements of hearsay evidence. It was for the Panel to determine the amount of weight that it should allow to such evidence.

16. The Panel considered the Police interviews with the Registrant in 2009 and 2011. On these occasions she was being interviewed for possible criminal charges and was in the presence of a solicitor. The interviews were a verbatim record of the matters being put to her throughout. She appeared to have a full understanding of her responsibilities as the Registered Manager at Woodlands. This was the only evidence that the Panel had from the Registrant. The Panel noted that both the Registrant and her representatives had remained in contact with the HCPC prior to this hearing, most recently with a letter dated 12 April 2017 in which she confirmed some case management matters. The Panel accorded these communications the appropriate weight in considering the allegation made against the Registrant by the HCPC.

17. The Panel heard live evidence from four HCPC witnesses.

18. At the time of the allegation, GW worked for the CQC as a Compliance Inspector. The Panel found her evidence helpful and it provided some scene-setting for what would be expected from the Registrant as the Registered Manager. However, the Panel considered that the time elapsed and the number of subsequent inspections that she had conducted in her role as Compliance Inspector had detracted from the overall quality of her evidence and its reliability. The Panel felt that this witness was inconsistent in her assessment of some aspects of the Registrant’s character.

19. KR also worked for the CQC, at that time as the Lead Enforcement Inspector. She was professional, credible and her incisive analysis was appreciated by the Panel. She made a very strong impression on the Panel and demonstrated this with the thoroughness and depth of her insight. She clearly articulated her expectations of the Registrant’s role and her responsibilities as Registered Manager, particularly in respect of leadership, control and influence on the culture at Woodlands. She was able to provide categorical clarity regarding the initial registration process and her expectations of the Registrant’s responsibilities as the Registered Manager at Woodlands. She also fostered excellent relationships with staff at Woodlands, despite the nature of the inspection.

20. Witness 6 was a regular visitor to Woodlands, where his relative, Service User E, was a resident. He was wholly credible in his evidence and was clearly a caring individual who took his responsibilities seriously and demonstrated that he had been prepared to challenge the Registrant and Person A at Woodlands regarding his concerns.

21. Carer G worked at Woodlands from 2000, first as a cleaner and then later as a carer. She was articulate and honest in her live evidence. The Panel considered that her evidence succinctly described the pervading atmosphere in Woodlands, which was supported by many personal examples. She was particularly helpful in describing the regime and the night-staffing arrangements.

22. The Panel noted and accepted the written HCPC statement of SB, who was a Pharmacist Inspector. His statement was comprehensive, balanced and detailed, and stated that staff were also observed in their administration of medicines for the service users. The Panel also had regard to the written HCPC statement of Carer I.

23. The Panel then considered the individual particulars. It was assisted by an evidential matrix provided by Ms Chaker in her closing submissions. The Panel also carefully perused all of the statements and exhibits. Because of the large amount of material, the Panel considered that it would assist if it were to identify in detail the evidence it had relied upon to come to its decisions.

Particular 1(a) – Proved

1. You did not take adequate steps to protect service users from verbal, physical and/or emotional abuse in that:

a) service users were physically and/or verbally abused

24. The Panel found this particular proved. In making this decision it relied upon the evidence given, in particular the evidence of the witnesses of the HCPC.

• GW gave evidence of Service User A being grabbed by Person A “by the back of the neck to remove her from the dining table and more or less run Service User A down the corridor to her room”.

• Carer F, in her Police witness statement, gave evidence that she was present when Person A was screaming and shouting at a young Service User on respite, Service User T. Service User T was described as hysterical and that consequently, she didn’t want her dinner. She also stated that she had seen Carer D take Service User A’s shoe and hit Service User A with it. Carer F also stated she had seen Person A get hold of the back of Service User A’s neck and frog-march her down to her room, getting another member of staff to hold the door.

• Carer J’s Police witness statement described how a Service User, who required constant care, would be sat on a chair with a belt tied around her so that she did not fall off, and that Person A’s attitude was, “I’m not paying someone to sit with that [service user]”. Carer J continued, “One incident that sticks in my mind … I could hear Person A shouting at Service User D downstairs … within minutes Service User D came upstairs crying and I noticed a red mark on her face. I asked what had happened and she said Person A had hit her”.

• In her Police witness statement and her oral evidence, Carer G said, “Service User D purchased a clock and was asking the plumbers to set it for her … Person A went ballistic … the next thing I saw was Person A marching Service User D out … she had hold of her by the scruff of the neck and jumper and she marched her into the pink room and all I heard was a thud as if she was throwing her on the sofa”.

• In the Registrant’s Police interviews, she specifically stated that she had seen Person A shouting a couple of times at service users.

Particular 1(b) – Proved

b) you did not ensure that concerns about Person A’s behaviour were reported and/or investigated

25. The Panel found this particular proved.

• Carer E’s evidence in her Police witness statement said that the Registrant did not like standing up to Person A, in that “[the Registrant] won’t ever say anything wrong about Person A. She will always back her up 100%”.

• The Police witness statement of Carer I stated, “We have reported things to [the Registrant] when we’ve not been happy about, you know, the food, the clothes, the way Person A treats the [service users], but nothing ever gets changed – nothing ever gets done.”

• Carer G, in her Police witness statement and her oral evidence, stated that “[The staff] disagreed with how things were run. They thought it was wrong and many reported things to [the Registrant] … as I did, but nothing ever got done. You’d report things to [the Registrant] and a lot of the time she’d shrug her shoulders”.

Particular 1(c) – Proved

(c) service users were punished for bad behaviour

26. The Panel found this particular proved.

• In her Police witness statement, Carer E stated that “[Service users] get grounded which is where they get sent to their bedrooms with nothing to eat or drink, or they don’t get to go out or see their family.” She cited the example of Service User G, “who didn’t want to go outside. He wanted to stay in and read his book but Person A took his glasses and book off him and made him go outside. He got his glasses and book back after he behaved and had been in the garden”.

• Carer E also stated that “Person A used to make [service users] stand there and march because she said they had been naughty … naughty would be something like they had been late because the bus had been late. She would make them march down to their rooms and they would stay there and wouldn’t be allowed to have tea. They would miss meals”.

• Carer F’s Police witness statement said that, “Service User D gets grounded for a week so she’s not allowed to go to the shop. Service User D was probably grounded as she might have said something as she talks to people she’s not allowed to. Service User D gets grounded quite a lot. Service User M was grounded and that included that he couldn’t go to church. He wasn’t allowed to go on the ‘outings’”.

• In her Police witness statement, Carer I stated that “Service User M was kept in the small sitting room for a week during the day with no TV, radio, or social interaction with anyone. He couldn’t talk to anyone or come out of that room. He had to sit and stare at the wall. He couldn’t have the TV on. That was his punishment … from 9 in the morning until 6 or 7 at night. I think his crime was that he pushed in front of someone in the queue for the toilet … he was desperate to go to the toilet and he edged someone out of the way. Because of that Person A made him sit there for a week.”

• Carer C stated in her Police witness statement that, “Person A would punish [service users] for doing wrong in different ways. One [service user], Service User G had his music and karaoke TV taken out of his bedroom … this was last August, when I left [January 2009] he still had not got it back. Others would be made to sit in the bottom sitting room or the yellow room by themselves, not allowed to go out on [service users]’ outings, not allowed to go into Wakefield, or leave the house … these punishments were handed out for arguing with each other, not coming down for meals at the right time, or they had lied about something”.

• GW, in her Police witness statement, stated that evidence from case notes showed examples of staff punishing Service User A by isolating her in her bedroom. She stated that this was usually as a result of Service User A displaying “challenging behaviour” which staff should have been trained to deal with.

• KR, in her Police witness statement, said that she had “found evidence of inappropriate staff approaches and attitudes towards Service User C which created a picture of him being bullied and threatened. Also, regular evidence of staff chastising him for behaviour that may have been caused by his illness, possible clashes of medication, or by the staff’s apparent inability to understand and manage him”.

• Witness 6 gave evidence about his relative, Service User E. He described how she had not been allowed to attend a party at Woodlands, which she had eagerly been looking forward to, but had instead been put in her room with the curtains drawn.

Particular 1(d) – Proved

(d) service users were made to queue up at meal times

27. The Panel found this particular proved.

• Carer E and Carer F gave evidence in their Police witness statements of service users queuing up for their meals and medication, with Carer E stating that “[the service users] queue up outside the door, the men go first and the women go second”.

• In KR’s notes of her inspection visits, she had recorded that “At 12.30pm I was in the main hallway when the service users began to queue in a line outside the entrance to the main kitchen. They each held a tray”. In her oral evidence she told the Panel, “some things you never forget. This was these people’s home.”

Particular 1(e) – Proved

(e) service users were subjected to enforced segregation according to their gender

28. The Panel found this particular proved.

• Carer E’s Police witness statement said that, “Each [service user] has a set room where they can go and sit. Some [service users] can go in the pink room and the others have to go in the yellow room. The men go into the men’s lounge. They can’t swap and change and they can’t decide to change rooms to talk to so and so. They are segregated all the time.”

• The Panel also noted the oral evidence of Carer G, who gave detailed evidence about the segregation in place at Woodlands.

Particular 1(f) – Proved

(f) service users were subjected to enforced diets and/or exercise

29. The Panel found this particular proved.

• In her Police witness statement, Carer F stated that “six of them went to America. They had only been back in [Woodlands] half an hour and she made them get on the scales to get weighed to see how much weight they’d put on. Person A said they had to go on a diet.” She further stated that “when Service User A comes back from her mum’s she only gets flax oil and yoghurt. She doesn’t get anything else for a couple of days. Flax oil is to make you go to the toilet … Service User A could be on that for 1 or 2 days … it depends how long she went home for”.

• Carer G also gave evidence in her Police witness statement that “Person A always told Service User I that she had fat legs and staff would be told to measure her legs, ankles, knees, thighs, and put Service User I on diets. She was told she had to go on the exercise bike … Person A was in America and we got a phone call one evening to say that every time staff left Service User I she stopped peddling and we had to make sure she was peddling.”

• The Panel also heard succinct oral evidence from Witness 6 about the weight loss he had observed in his relative, Service User E, whom he was visiting regularly.

Particular 1(g) – Proved

(g) service users were restricted in their movements around Woodlands

30. The Panel found this particular proved.

• In her Police witness statement, Carer E told the Police that service users were not allowed to go to their bedroom in the afternoon, and that “each [service user] has a set room where they could sit”. She also stated that Service User S and Service User I “can’t go back to [the] bungalow until night time.”

• Carer G gave live evidence that this restriction in movement was part of the punishment regime at Woodlands. This was further supported by the evidence of Witness 6.

Particular 1(h) – Proved

(h) service users were restricted in when they could shower

31. The Panel found this particular proved.

• Carer E’s Police witness statement included evidence that service users “only get bathed once per week.” She stated that “men get showered on a Monday and the women get showered on a Tuesday … Person A says it saves on the water bills and gas bills and stuff … they have their shower whenever within the day but Person A likes them to shower after tea around 6pm.”

• In both her live evidence and her HCPC witness statement, Carer G confirmed the restrictions that were put in place as to when service users could or could not take a shower.

Particular 1(i) – Proved

(i) service users were restricted in when they could change their clothes

32. The Panel found this particular proved.

• Carer E, in her Police witness statement, said that “[service users] have to wear bibs [at meal time] because they can’t change their clothes”. She further added that “if their clothes are dirty they have to wear dirty clothes … they cannot get changed … on a Saturday they change their clothes and again on a Wednesday.”

• Carer G gave evidence of a service user’s purchase of a coat from British Home Stores and its subsequent enforced disposal by Person A.

Particular 1(j) – Proved

(j) service users had set times to get up and go to bed

33. The Panel found this particular proved.

• In their Police witness statements, Carer E told the Police that “[service users] had to be up by 8am [and] go to bed between [9-9.30pm] … they are not allowed to stay up longer” and Carer C stated that “[Service users are] made to go to bed at the same time every night and get up at the same time in the morning”.

• Carer G confirmed in both her live evidence and her HCPC witness statement that service users were not allowed to lie-in in bed.

Particular 1(k) – Proved

(k) service users hair was cut and/or shaved without their consent

34. The Panel found this particular proved.

• Carer F’s Police witness statement said that “Person A is always cutting the [service users]’ hair, whether it needs cutting or not. Person A shaves Service User F’s hair. I don’t know why. Service User F can’t answer as she has dementia … all you get is ‘Yeah’”.

• Carer G confirmed this in her live evidence and described the reaction of one of the relatives, who, on seeing the service user, said she looked like a “Belsen victim”.

Particular 1(l) – Proved

(l) service users were not always encouraged to maintain contact with their families and/or family members were not encouraged to maintain contact with service users

35. The Panel found this particular proved.

• The family of Service User H, in the witness statement they gave to the Police, stated that “Person A told me I couldn’t phone Service User H because it would upset her”.

• In the Police witness statement of the family of Service User E, they stated that “When Service User E originally took up residency at Woodlands I was informed by Person A that I could have access to her or take her out whenever I wanted to but that quickly changed … It became quickly apparent that [Woodlands] didn’t like us taking her out weekly ... so we started ringing up every week.”

• Witness 6, in his live evidence, was very clear about the experiences his relative, Service User E, had undergone in this regard.

• KR gave evidence in her Police witness statement that the family of Service User C had written to Woodlands asking for him to be allowed back home “if it is ok”.

• The Panel also considered that the witness evidence of the families of Service User B and Service User K confirmed this.

Particular 1(m) – Proved

(m) you did not ensure that service users' accommodation was heated adequately at all times

36. The Panel found this particular proved.

• Carer E’s Police witness statement included evidence that “It’s usually cold in there … [the heating] was on for a couple of hours then turned off. The [service users] complained that it was cold and they were told to put a cardigan on. During the winter the heating would be put on for 1 full day then for 2 days it is left off and you have to have all the curtains closed all the time because it keeps the heat in. All the [service users] have to go in one room … they have to stay in one room to keep the heat in.”

• Carer F’s Police witness statement said that “Woodlands is cold. Person A had the curtains shut. They have to have the bedroom curtains shut to keep the heat in. Service User R complained that there was no heat in his room. Service User F does not have a quilt … she has a throw over. It’s the only blanket she has got and it’s not very thick … we try to find blankets for her. The [service users] complain they are cold and nothing happens.”

• Carer G, in her live evidence, said that it was always cold, and that it had got to the point where she was using a thermometer to record the actual temperature because of how cold it was.

Particular 1(n)(i) – Proved

(n) you did not ensure service users received adequate food and/or drink in that:

i. service users were provided with insufficient amounts of food

37. The Panel found this particular proved.

• In her Police witness statement, Carer E stated that for breakfast, service users “would have one scoop of porridge, a scoop being a small ladle. The [service users] can’t have extra breakfast or drinks. They don’t get juice. They don’t have a mid-morning snack, they can have a glass of juice or water. They only have one. They can ask for more but they don’t get it.” She further stated that for dinner “[at 1pm] they would have a sandwich with peanut butter or chocolate spread … They sometimes have soup with the sandwich. They get one of those big tins of soup and that goes between the 18. It’s not a lot really. [The service users] complain that they are hungry all the time but they daren’t ask for anything. Service User A would have a yoghurt for her breakfast lunch and dinner.”

• This was also reflected in the Police witness statement of Carer F, who told Police that the service users “have porridge in the morning. The porridge is measured in a little silver thing … a small cup … five scoops of porridge go into a pan and that has to do for 18 people. Then the ladies have 1 ladle and the men have 2, so they only have a small amount.” She further said that “[Woodlands does not] have dinner plates, they have smaller ones. Like a plate that goes under the soup – a side plate.”

• In Carer I’s Police witness statement, she stated that “[the service users] are all underweight … all undernourished. I wouldn’t have said the meals are adequate. They would never complain but you can tell they are hungry. You watch the [service users] and they’ll look around at other people eating. Food is a big issue to them … there is not enough food. For example I peel more potatoes when I’m making Sunday dinner and there’s 7 in my household … [the Registrant] does quite a bit of the cooking as well … you are panicking when you are sharing out the food because you are thinking this is not going to stretch around everybody.”

• KR, in her live evidence, also confirmed the restricted nature of the food provided.

• Carer G gave evidence regarding a list in the kitchen of the number of slices of bread permitted, which was delineated between male and female service users.

Particular 1(n)(ii) – Proved

ii. service users were given out-of-date food

38. The Panel found this particular proved.

• In her Police witness statement, Carer I told the Police that “A lot of the food the [service users were] getting was out-of-date food and there is not enough food. Two of the [service users], Service User F and Service User A were given out-of-date baby food.”

• KR, in her live evidence, confirmed this with a detailed account of out-of-date food in the Woodlands kitchen. Carer G, in her oral evidence, also described seeing stale corned beef sandwiches and out-of-date baby food being given to service users.

• In one of her Police interviews, the Registrant admitted that out-of-date food had been served, but said that it hadn’t been picked up at the time because the member of staff responsible for the stock rotation of food had been on sick leave and this task had not been reallocated.

Particular 1(n)(iii) – Proved

iii. food and drink was only provided at limited and specific times

39. The Panel found this particular proved. The evidence for this finding was substantively provided by the matters found in particular 1(n)(i).

Particular 1(n)(iv) – Proved

iv. service users had limited choice of food and/or drink

40. The Panel found this particular proved.

• Carer F, in her witness statement to Police, said that the drinks available with service users’ breakfast was either tea or coffee. She stated that “They don’t have a choice at all, it all depends on what they make”. She also added that “the [service users] don’t have a choice in meals … it’s whatever Person A cooks. I know there is a menu up at Woodlands but it’s only for show. What Person A makes, the [service users] have. If the [service users] don’t like it they still get it.”

• Carer I told Police in her Police witness statement that “whilst this inspection has been going on they actually got a choice of menu which is a first. There has never been a choice before it’s always been a sandwich of some sort.” The Registrant acknowledged during one of her Police interviews that they had changed the food provided after the CQC inspection in March 2009.

• In her live evidence, KR also spoke of the lack of individual choice that service users had in regard to their food and/or drink.

Particular 2(a)(i) – Proved

2. You did not ensure appropriate management of service users’ money in that service users and/or their families were charged:

a. service users and/or their families were charged:

i. for the cost of service users going on holiday, without appropriate consent and/or authorisation

41. The Panel found this particular proved.

• Carer F’s Police witness statement evidence that “[the service users] have to go where Person A says [for their holidays] not where they want to go.”

• Carer I stated in her Police witness statement that “Person A has two houses in America as far as I know … As far as I know the [service users] save up for America. They talk about saving up all the time. I think that is all of them. I don’t know much about the money side of things but you hear them say ‘I’m saving to go to America.’ If there are functions going on where they have to pay, the [service users] will say ‘Oh, I can’t do that – I’m saving to go to America!’”.

• In their Police witness statement, the family of Service User H stated, “At no point did I sign any consent forms regarding anyone from Woodlands to oversee Service User H’s finances. I know that someone at Woodlands has opened a bank account for Service User H but I don’t know who … Having looked at the account book I can see there has been a big amount taken out, that was when Service User H went on holiday to America … I know the holidays to America were paid out of Service User H’s savings account. I don’t know how much they cost … that’s something I never found out, but l know it was over £1000 … the first time Service User H went to America with Woodlands I received a post card from Service User H which read ‘I’m in America!’. I couldn’t believe it, I was disgusted! I couldn’t believe that they had taken my daughter on holiday and I didn’t know anything about it.”

• In her Police witness statement, Carer G gave evidence that holidays were booked before service users had been asked whether they wanted to go.

• The Panel also noted the evidence of a witness statement from the family of Service User E saying that £400 had been taken out of her account and they had no information or knowledge of what the money had been spent on.

Particular 2(a)(ii) – Not Proved

ii. for the cost of staff travel on holiday, without appropriate consent and/or authorisation

42. The Panel found this particular not proved. There was some evidence provided relating to the hiring of a car, but it was very limited and the Panel considered that the burden of proof had not been met.

Particular 2(a)(iii) – Not Proved

iii. for other residents to go on holiday

43. The Panel found this particular not proved. The evidence provided in relation to this matter was very limited and the Panel considered that the burden of proof had not been met.

Particular 2(a)(iv) – Proved

iv. for clothes which they did not choose

44. The Panel found this particular proved.

• Carer E’s Police witness statement said that “Person A brings trunks of clothes from America. They are from charity shops. It’s a case of try it and if it fits, have that. They don’t get the choice to go into town and buy their own clothes with their own money. If they don’t want to wear the clothes they are made to wear them.”

• Carer G also gave oral evidence about this, and the Panel noted her statement regarding the purchase of clothes for service users at car boot sales by Person A.

Particular 2(a)(v) – Not Proved

v. to stay at a caravan owned by Woodlands

45. The Panel found this particular not proved. The evidence provided in relation to this matter was very limited and the Panel considered that the burden of proof had not been met.

Particular 2(a)(vi) – Proved

vi. for items including a wormery without appropriate consent and/or authorisation

46. The Panel found this particular proved.

• In her Police witness statement, Carer G told Police that “Service User K and Service User C were made to buy a wormery because Person A said she needed compost [for her allotment]. In one staff meeting one morning, Person A asked [the Registrant] to have a look and see which [service users] had money to buy it.”

• The Panel also noted the Police witness statements from the families of Service User K and Service User B, in particular the statement that “mum always had to buy birthday and Christmas presents for [the Registrant’s] children … This would leave her with no money to buy presents for her own grandchildren.”

Particular 2(a)(vii) – Proved

vii. for basic items including a mattress, chairs, wardrobes and/or carpet which should have been provided by Woodlands

47. The Panel found this particular proved.

• In the Police report of the investigation into Woodlands, reference was made to the family of Service User A paying for and refurnishing her own room, when these items should have been paid for by Woodlands.

• KR also gave detailed evidence regarding the purchase of items in her Police witness statement, and the Registrant confirmed this in one of her Police interviews.

Particular 2(a)(viii) – Proved

viii. for items including a television which they did not use

48. The Panel found this particular proved.

• Carer G gave evidence in her Police witness statement regarding the purchase of a television bought for Service User F, who “hardly ever watched it and already had a TV”. She also gave evidence of a log cabin bought for Service User P, who was “stopped from going into it.” She stated that “[he] only went into it on a couple of occasions … the other [service users] would use it to do jigsaws and then when this investigation started the secretary moved in with her stuff”. The Panel also noted her evidence regarding the purchase of jewellery, which service users were pressured to buy.

• KR corroborated the cost of the purchase of the log cabin in her Police witness statement, stating that Service User P was charged £1942.47. She stated that there were no records or evidence showing that he was ever reimbursed, or how the issue had been resolved.

Particular 2(a)(ix) – Not Proved

ix. for services including one-to-one care which they did not always receive

49. The Panel found this particular not proved. The evidence provided in relation to this matter was very limited and the Panel considered that the burden of proof had not been met.

Particular 2(a)(x) – Proved

x. for haircuts which were not carried out by professional hairdressers

50. The Panel found this particular proved.

• Carer J, in her Police witness statement, told the Police that “the [service users] were charged for hair cutting … two of the carers would cut [service users]’ hair and they would be charged £5.00. Some would be charged even if they hadn’t had a haircut.”

• Carer G said in her Police witness statement that she “found [it] strange that when [service users] had hair cuts one member of staff, [Carer H], was able to cut hair and [service users] were charged for it and it was taken out of their allowance … when [Carer H] found out she refused to cut hair anymore … we approached [the Registrant] and told her it wasn’t right.” Carer G confirmed this in her oral evidence to the Panel.

Particular 2(a)(xi) – Proved

xi. for items including medication, a mattress and a protective helmet for which funding should have been sought from social services and/or the health service

51. The Panel found this particular proved.

• The Panel took particular note of the oral evidence of GW, who confirmed that service users were charged for these items. This was also confirmed by the Registrant in her Police interviews.

Particular 2(a)(xii) – Proved

xii. for homeopathic and/or alternative treatments without appropriate consent and/or authorisation

52. The Panel found this particular proved.

• Witness 6 gave evidence in his Police witness statement that Service User E “was never asked to provide my consent for this treatment and if my consent had been sought I wouldn’t have given it because I don’t think they should have been paying for private treatment like that.” This was corroborated by Service User E’s care records, by the Police witness statement of GW, and by Carer G’s oral evidence and her HCPC witness statement.

Particular 2(a)(xiii) – Proved

xiii. excessive amounts for items

53. The Panel found this particular proved.

• The Panel found that, along with his Police witness statement, Witness 6 gave compelling oral evidence about this matter. This was corroborated by the oral evidence and HCPC witness statement of Carer G that Person A would sell jewellery to service users that she had purchased from shopping channels. The Panel heard evidence that this jewellery was sold to the service users at a profit, and false receipts were subsequently sourced during a trip to Blackpool.

• Carer G’s Police witness statement also stated that “Service User C was also sold a tapestry for £100. Service User C wouldn’t know what he’d bought but it was put on his bedroom wall. Other [service users] were sold things … Service User F was sold a CD stacking system … this used to be Person A’s … in her own house … I know this because I used to clean at her house once a week but it was sold to [Service User F] for a few hundred pounds and put in the pink sitting room. Service User F would not have chosen to buy this.”

Particular 2(b) – Proved

b. you did not ensure that service users received full payment for work undertaken by them

54. The Panel found this particular proved.

• In their witness statement to Police, the family of Service User H stated that “Service User H used to work in the kitchen at Woodlands … she would get paid £10 a week. She would set the table at meal times and do the washing up. I know she’s done other jobs … hoovering upstairs bedrooms, dusting, as well as washing and ironing. She also did some washing in the cellar at Woodlands. I didn’t think £10 a week was enough really”.

• In the Police Report, having interviewed Service User I, the Police summarised that Service User I “was made to clean and work … [she] describes in detail the work [she did] for Polypipes, the fact that she did not want to do it, didn’t enjoy it, but was made [to] by Person A and they were never paid … Service User I [was] also made to work on an allotment … she did not like doing the work and she did not get paid … Service User I also describes being a security guard in the shop at Woodlands … again no payment was received.”

• For this particular, the Panel also relied upon the oral evidence of Carer G and Witness 6, which corroborated the Police witness statements and Police Report.

Particular 3(a) – Proved

3. You did not ensure that the provision of staff was adequate in that: a. you did not ensure that an appropriate number of staff and/or trained staff were on duty at all times

55. The Panel found this particular proved.

• Carer F stated in her Police witness statement that “I was the only carer there. It was just me and 15 [service users] … I’m there on my own with 15 [service users]. There are no staff in there with them … you’ve got one that has epileptic fits, who could have a fit at any time and she usually does during the day.”

• KR stated in her Police witness statement that, as a result of an application for extra funding, Woodlands was receiving £935.14 per week for Service User P to have one to one support; however, she had found evidence within Service User P’s case file that Woodlands failed to provide him with this one to one support and supervision.

• KR also addressed this in her summary of the CQC’s findings at Woodlands, stating “It was identified that this home never has waking night staff … we clearly identified service users with physical and mental dependencies and significant health and care needs who are clearly at risk in the absence of waking staff.”

Particular 3(b)(i) – Proved

b. you did not ensure that staff were adequately trained, in that: i. only around three members of staff were trained in restraint techniques

56. The Panel found this particular proved.

• In her oral evidence, KR described to the Panel the deployment of restraining techniques, with particular reference to a service user who would be sat on a chair with a belt tied around her so that she did not fall off (an incident also referenced in the Police witness statement of Carer J).

• The Registrant also made it clear in her Police interviews that she had never been trained in the use of restraint techniques.

Particular 3(b)(ii) – Proved

ii. you delivered in-house training to some staff rather than arrange accredited and/or independent external training

57. The Panel found this particular proved.

• The Police witness statement of Carer C stated that “my training for Woodland[s] consisted of watching DVD’s [sic] and filling in questionnaires … these were marked by [the Registrant] … I only really had one training exercise and that was for moving and handling. The training lasted about half an hour and that was with [the Registrant].”

• This was reflected in the Pharmacist Report of SB, and the oral evidence from Carer G about the level of training which she had received.

Particular 3(b)(iii) – Proved

iii. you did not ensure that all staff received adequate training in handling and/or giving medication

58. The Panel found this particular proved.

• SB recorded in his Pharmacist Report that “The training records of four staff were examined. All had received in-house training on safe medication handling by watching a commercial video followed by a Q&A test marked by [the Registrant] (the answers for all staff were very similar)”.

• In her Police witness statement, Carer F stated “I thought someone would come in and show you the medication like they did before but it wasn’t, it was on tape, on video. You sat there and watched it and then answered some questions”.

• Both Carer E and Carer F, in their Police witness statements, described the mistakes which were often made when dispensing medication at Woodlands.

Particular 3(b)(iv) – Proved

iv. you did not ensure that all staff received adequate fire safety training

59. The Panel found this particular proved.

• Carer C, in her Police witness statement, stated that “I was also given training as to what to do in the event of a fire but this training was again very basic … I was told that if the fire alarm sounded the [service users] would line up in the porch area of the house and we would then lead them out of the grounds and assemble at the main gates. In all my time at Woodlands I think we only had one fire drill, but I can’t be sure”.

Particular 4(a) – Proved

4. You did not ensure that appropriate consent and/or authorisation was obtained in that:

a. homeopathic and/or alternative treatment was administered to service users for whom you did not obtain appropriate consent and/or authorisation

60. The Panel found this particular proved.

• In her Police interviews, the Registrant made several responses which made it clear that she had not sought the appropriate consent. This was corroborated by the Pharmacist Report of SB, which recorded that “We found no evidence that people’s personal preferences about non-prescribed supplements or complementary remedies are sought or upheld.”

Particular 4(b) – Proved

b. you signed consent forms on service users’ behalf

61. The Panel found this particular proved.

• The Panel paid particular consideration to a ‘Consent to Medication’ form which stated that “Service User B is not able to give consent”. Service User B’s care records demonstrated that he was administered homeopathic remedies on a regular basis and that these had been signed off by the Registrant.

• The Panel also noted an email sent on 3 March 2009 by the Registrant to obtain retrospective consent from Service User B and Service User K’s relatives.

Particular 4(c) – Proved

c. you asked residents who lacked capacity to sign consent forms

62. The Panel found this particular proved.

• The Police witness statement of GW demonstrated two instances where she considered that service users who did not have capacity to sign had signed consent forms for homeopathic medication and treatments.

Particular 5 – Proved

5. You sought consent for homeopathic and/or alternative treatments from service users’ families retrospectively after the police enquiry into Woodlands began

63. The Panel found this particular proved.

• The Panel paid particular attention to the Registrant’s Police interviews, in which she gave evidence about retrospectively approaching the families of service users to obtain consent.

• The Panel also noted the Registrant’s email to the relatives of Service User B and Service User K on 3 March 2009, asking them to provide retrospective consent for homeopathic treatments.

Particular 6(a) – Proved

6. You did not ensure that service users received clinically appropriate treatment, in that: a. alternative treatments were used to treat conditions which required medical treatment

64. The Panel found this particular proved.

• The Panel accepted the detailed evidence given in the Police witness statements of Carer E, Carer I, Carer G and KR, which gave several examples of homeopathic treatments being used, including the application of honey to service users’ eyes or wounds and tea tree powder being applied to skin infections. Other examples included alternative treatments for hernia pain, inflamed ears and inflamed legs, lavender baths for period pains, and cranberry juice for cystitis.

Particular 6(b) – Proved

b. medical treatment was not always sought for service users who required it

65. The Panel found this particular proved.

• In assessing this particular, the Panel considered the Police witness statement of Carer I and Carer J and the oral evidence given at the hearing by KR and GW.

Particular 6(c) – Proved

c. alternative treatments were used to treat behavioural and/or mental health issues

66. The Panel found this particular proved.

• In assessing this particular, the Panel noted the Police witness statements of Carer I and KR.

Particular 6(d)(i) – Proved

d. treatment was administered to service users which was:

i. unnecessarily painful

67. The Panel found this particular proved.

• The Panel noted in particular the evidence regarding the application of honey to service users’ eyes, as described in the Police witness statement of KR and her oral evidence. It also considered the oral evidence of Witness 6 regarding Service User E’s treatment.

Particular 6(d)(ii) – Proved

ii. against their wishes

68. The Panel found this particular proved.

• The Panel paid particular note to the Police witness statements of Carer G and KR.

Particular 6(e)(i) – Not Proved

e. medication was administered for non-therapeutic reasons in that:

i. medication was given in accordance with staff shift patterns rather than medical advice

69. The Panel found this particular not proved. The evidence provided in relation to this matter was limited and the Panel considered that the burden of proof had not been met.

Particular 6(e)(ii) – Proved

ii. a service user was given diazepam without clinical justification

70. The Panel found this particular proved.

• The Panel noted the Police witness statement of KR, including the timespan involved between 12 September 2008 and 5 March 2009.

Particular 6(f) – Proved

f. service users’ food intake was restricted without appropriate clinical advice

71. The Panel found this particular proved.

• The Panel noted the Police witness statements of KR and GW. It also considered the oral evidence and witness statement of Witness 6.

Particular 6(g) – Proved

g. you did not ensure that service users’ medical clinicians were always consulted and/or made aware of all homeopathic and/or alternative treatment administered to service users

72. The Panel found this particular proved.

• In assessing this particular, the Panel took note of the Police witness statements of Carer I and KR and the Pharmacist Report of SB, which stated “We found no evidence that the continuous use [of alternative remedies] have been regularly reviewed by a healthcare professional”. The Registrant had also confirmed this in her Police interview.

Particular 7 – Proved

7. Your actions set out in particulars 2, 4(b), 4(c) and/or 5 were dishonest.

73. The Panel found all of the actions alleged in particulars 2 (except 2(a)(ii), 2(a)(iii), 2(a)(v), 2(a)(ix)), and 4(b), 4(c) and 5 proved.

74. The behaviour by the Registrant related to the misuse of service users’ finances and to actions which would, for example, have meant acquiring their or their relatives’ consent or retrospective consent for medical or homeopathic treatments.

75. In reaching its decision with regards to whether or not the Registrant’s actions at particulars 2, 4(b), 4(c) and 5 were dishonest, the Panel considered the representations made by Ms Chaker, together with the advice of the Legal Assessor. It applied the two-stage test for dishonesty.

76. Firstly the Panel considered whether, on the balance of probabilities, the Registrant’s actions were dishonest, according to the ordinary standards of reasonable and honest people.

77. The Panel considered the duration and scale of the Registrant’s actions and also the demonstrable impact on the service users, who were in her care, and their families. When seen by a reasonable and honest person, the Panel was in no doubt that the Registrant’s actions would be seen to be dishonest.

78. Secondly the Panel considered whether, on the balance of probabilities, the Registrant herself must have known that what she was doing was dishonest by those standards. The Panel considered the comprehensive evidence, especially that relating to service users in the Registrant’s care who did not have the mental capacity to manage their financial affairs. This was particularly pertinent when viewed in terms of the evidence put before the Panel relating to the financial affairs of the service users. Considerable evidence was also considered regarding the purchase of items such as jewellery, a tapestry, a wormery, a log cabin and a television that service users were charged for and for which such purchases would have been viewed with suspicion.

79. In reaching its conclusions on this aspect, the Panel considered the element of awareness on behalf of the Registrant that she would have been transgressing the ordinary standards of behaviour. It was also mindful of the evidence it had heard regarding the nature of the Registrant’s relationship with the owners of Woodlands (Person A and Person B) through her marriage to their son. In addition, she faced difficulties due to her holding dual roles both as the Registered Manager of Woodlands and its Co-Director, which created a conflict of interest.

80. The Panel also considered the General Social Care Council (GSCC) Codes of Practice for Social Care Workers in place at the time and also the National Minimum Standards for Care Homes for Adults (aged 18-65 years) (Care Standards Act 2000). The Registrant would have been well acquainted with both, given her considerable experience in the field of residential care.

81. The Panel was therefore left in no doubt that the Registrant’s actions in particulars 2, 4(b), 4(c) and 5 were dishonest.

Decision on Grounds

82. Having found the majority of the facts proved, the Panel went on to consider whether they amounted to misconduct and/or lack of competence. It bore in mind the submissions made by Ms Chaker and the advice of the Legal Assessor. It bore in mind the legal authorities to which it had been referred, in particular the cases of Roylance v GMC ([2000] 1 AC 311), Calhaem v GMC [2007] EWHC 2606 (Admin) and R (Remedy UK Ltd) v GMC [2010] EWHC 1245 (Admin).

83. The Panel first considered whether the facts found proved amounted to misconduct. The Panel bore in mind that the misconduct needs to be serious or behaviour that is dishonourable or disgraceful, such that fellow practitioners would have regarded it as deplorable.

84. The Registrant was a highly experienced Social Worker. She had been the Registered Manager of Woodlands for 14 years when she was first interviewed by the Police in 2009. The service users at Woodlands were being mistreated whilst under the Registrant’s care. This went on for a long period of time. The Registrant had a fundamental and clear responsibility for the wellbeing and care of the service users. She failed in that responsibility, particularly in that she acted dishonestly towards the service users and failed to show any respect to them as individuals. Her behaviour showed a blatant disregard for the underpinning social work values of respect for the individual, honesty, integrity, and commitment to person-centred care, in which every service user is seen as an individual. The evidence clearly demonstrated the immediate and beneficial improvement in the service users’ quality of life on leaving Woodlands. They were tracked upon leaving, where they were seen to flourish and there were clear improvements in their health and wellbeing.

85. Her behaviour also demonstrated non-adherence to the GSCC Codes Of Practice For Social Care Workers, the standards in place at the time of the Registrant’s behaviour, in particular Codes 2 (2.1, 2.6, 2.7), 3 (3.4, 3.5, 3.7), 4 (4.3), 5 (5.1, 5.2, 5.3, 5.6, 5.7, 5.8) and the entirety of 6.

86. All of the matters found proved showed a blatant disregard to the needs of service users and the Registrant’s duties as a registered Social Worker. She acted dishonestly. In the view of the Panel, her behaviour towards the service users at Woodlands was deplorable and the Panel has no doubt that other members of the profession and the public would have regarded it as deplorable. The Panel considered that this amounted to misconduct.

87. Having considered the persistent, sustained and serious nature of these matters and the timescale over which they took place, together with the extensive evidence of the Registrant’s role and her work, her professional performance was unacceptably low. Nevertheless, the Panel noted the fifth principle put forward by Mr Justice Jackson in the case of Calhaem that “it is neither necessary nor appropriate to extend the interpretation of ‘deficient professional performance’ in order to encompass matters which constitute ‘misconduct’”. In this case, the Panel considers that misconduct is the most serious and relevant ground, and therefore did not find it necessary to make a finding of lack of competence.

Decision on Impairment

88. Having determined that the matters found proved amounted to misconduct, the Panel went on to consider whether the Registrant’s fitness to practise is currently impaired. It bore in mind the submissions made by Ms Chaker, the advice of the Legal Assessor and the HCPTS Practice Note “Finding that Fitness to Practise is ‘Impaired’”.

89. The Panel considered the two component parts relating to impairment, the ‘personal’ component and the ‘public’ component. It first considered the ‘personal’ component: whether the conduct is remediable, whether it has been remedied and whether it is likely to be repeated.

90. The misconduct identified in this case took place over a long period of time. It was conduct that went to the heart of the Registrant’s professional responsibilities. She had a duty to look after the vulnerable service users who were in her care. She failed in that duty. No evidence has been put before the Panel that any part of the Registrant’s misconduct has been remedied or that it is unlikely to be repeated.

91. No evidence has been put before the Panel that the Registrant has maintained or kept up her Continuing Professional Development, nor did it find any evidence of her being provided with any external social work supervision. This would have served to aid her in fulfilling the need for reflective practice, a key cornerstone of the social work profession. She showed little evidence of professional curiosity in responding to concerns raised by service users, their families, or carers. The Panel does not consider that any parts of the ‘personal’ component of impairment have been met. The Panel therefore finds that the Registrant’s fitness to practise is impaired on the basis of the ‘personal’ component.

92. The Panel is aware that it must also look to the ‘public’ component of impairment. It notes the passage in the HCPTS Practice Note “Finding that Fitness to Practise is ‘Impaired’” that it is important for panels to recognise the need to address the “critically important public policy issues” as identified in Cohen v GMC [2008] EWCH 581 (Admin). These are: to protect service users; declare and uphold proper standards of behaviour; and maintain public confidence in the profession. This means that fitness to practise is not impaired simply on the basis that, since the allegation arose, a registrant has corrected matters or “learned his or her lesson”.

93. Because of the serious nature of the misconduct found, the Panel finds that the public element also applies in this case. The matters found proved involved vulnerable service users being neglected or mistreated. The Registrant had a responsibility for their care, welfare, and quality of life. She neglected that duty. The public, knowing the facts and findings in this case, would be caused great concern and their confidence in the profession would be undermined if a finding that the Registrant’s fitness to practise was impaired was not made.

94. The Panel therefore also finds that the Registrant’s fitness to practise is impaired on the basis of the ‘public' component.

Decision on Sanction

95. Having found that the Registrant’s fitness to practise is currently impaired, the Panel went on to consider the question of sanction. Before reaching its decision the Panel considered the HCPC Indicative Sanctions Policy and accepted the advice of the Legal Assessor.

96. The Panel considered the gravity of the matters found proved and then the aggravating and mitigating factors. The mitigating factors are the length of time since the allegation, the fact that the Registrant was not the prime instigator and the fact that the oppressive regime at Woodlands was imposed by Person A. The Registrant gave a number of admissions in her Police interviews, and the regulatory procedure for Care Homes has changed considerably since the time of this allegation in order to prevent a recurrence of similar matters in the future. The dual role held by the Registrant at the time is now expressly prohibited.

97. The aggravating features are the seriousness, duration and gravity of the allegations. This is compounded by the degree of harm, distress and financial upset caused to vulnerable service users and their families, and the pervasive nature of the harm caused by the Registrant’s behaviour. The incidents were not isolated. After the Key Inspection, the Registrant took active steps to cover her tracks.

98. In deciding what sanction, if any, to impose, the Panel has reminded itself that the purpose of any sanction is not to be punitive but to protect service users, although a sanction may have a punitive effect. It is also necessary to satisfy the public interest in this case. It has also considered the deterrent effect to other registrants, the reputation of the profession concerned, and public confidence in the regulatory process. The Panel has taken into account the principle of proportionality, balancing the interests of the public with those of the Registrant.

99. The Panel has concluded that, in the light of the seriousness of the allegation and the wide-ranging nature of the misconduct, a sanction is required. Further, the Panel does not consider that a Caution Order or mediation is a proportionate response to the misconduct in this case.

100. The Panel has concluded that a Conditions of Practice Order is not workable, practicable, nor proportionate in this case.

101. The Panel then went on to consider whether to impose a period of suspension. It carefully considered all of the evidence and its findings of fact. The Registrant has not attended this hearing and the only evidence from her was contained in the Police interviews. Other than dealing with administrative matters, the Registrant has not communicated with the HCPC. There is nothing to indicate she has shown insight, nor is it apparent that she has made any efforts of remediation over the lengthy period of time since the matter was first reported. She has never apologised, either to the HCPC or to any of the service users, for her behaviour.

102. In these circumstances, because of the serious nature of the misconduct and the Registrant’s apparent refusal to recognise her shortcomings, there remains a high risk of repetition and a real risk of significant harm to the public.

103. The Panel paid attention to paragraph 41 of the Indicative Sanctions Policy:

“Striking off should be used where there is no other way to protect the public, for example, where there is a lack of insight, continuing problems or denial. A registrant’s inability or unwillingness to resolve matters will suggest that a lower sanction may not be appropriate.”

104. For all of the above, the Panel has determined to impose a Striking Off Order.

Order

That the Registrar is directed to strike the name of Mrs Lisa Jane Thorn from the Register on the date this order comes into effect.

Notes

The order imposed today will apply from 8 June 2017 (the Operative date).

Hearing history

History of Hearings for Mrs Lisa Jane Thorn

Date Panel Hearing type Outcomes / Status
03/05/2017 Conduct and Competence Committee Final Hearing Struck off