Ms Maureen Kyama Kabaale

: Social worker

: SW75063

Interim Order: Imposed on 28 Jan 2016

: Final Hearing

Date and Time of hearing:10:00 19/07/2017 End: 17:00 26/07/2017

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

: Conduct and Competence Committee
: Conditions of Practice

Allegation

During the course of your employment as a Social Worker at the London Borough of Hounslow, between approximately 19 January 2015 and 11 August 2015, you:

1. did not contact the Service User within 48 hours and / or in a timely manner after the case had been allocated to you in relation to:

a. Service User 1

b. Service User 3

c. Service User 4

d. Service User 10

e. Service User 13

f. Service User 15

g. Service User 21

h. Service User 24

i. Service User 5

j. Service User 27

k. Service User 28

2. did not complete an assessment and / or review in a timely manner and / or did not complete the corresponding paperwork in a timely manner, in relation to:

a. Service User 1

b. Service User 2

c. Service User 3

d. Service User 4

e. Service User 5

f. Service User 8

g. Service User 9

h. Service User 10

i. Service User 11

j. Service User 12

k. Service User 13

l. Service User 16

m. Service User 18

n. Service User 20

o. Service User 21

p. Service User 27

q. Service User 15

3. did not schedule a 6 week review in relation to:

a. Service User 2

b. Service User 7

c. Service User 9

e. Service User 17

f. Service User 20

g. Service User 23

h. Service User 24

4. did not complete an investigation report in relation to Service User 26

5. did not liaise and / or did not record that you had liaised with other professionals in a timely manner in relation to:

a. Service User 2 when concerns arose regarding the service user’s refusal to eat and excessive drinking in April 2015 which should have led you to liaise with their General Practitioner.

b. Service User 13 when concerns arose in relation to the service user’s medication in July 2015 which should have led you to liaise with their General Practitioner.

c. Service User 16 when concerns arose regarding the service user’s refusal to take medication in May and June 2015 which should have led you to liaise with his General Practitioner.

d. Service User 18 when concerns arose in relation to the service user’s refusal to eat and/or take medication in July 2015 which should have led you to liaise with her General Practitioner and/or mental health services.

e. Service User 21 when an update was requested by a Community Matron in April 2015.

6. In relation to Service User 5:

a. During the home visit on 15 June 2015, you did not discuss with Service User 5 and / or you did not record that you had discussed with him, possible solutions to help mitigate the risk of him falling.

b. You did not contact and/or record that you had contacted Service User 5 in a timely manner following a call from the Fire Brigade on 19 June 2015 informing you that Service User 5 would not allow them to arrange an appointment.

7. Having undertaken two home visits to Service User 8 in July 2015, you did not submit a referral to the high risk panel regarding fire risks in a timely manner.

8. In relation to Service User 13, you:

a. Did not complete and /or record that you had completed a quality alert following a missed care visit on 19 June 2015.

b. On or around 17 July 2015, assisted Service User 13’s partner to apply for appointeeship in circumstances where there were concerns regarding the involvement of Service User 13s partner.

9. In relation to Service User 16, you:

a. did not conduct a home visit in a timely manner when concerns regarding cleanliness of Service User 16 and his home environment arose in May and June 2015.

b. did not action a request for a deep clean in a timely manner following the request on 22 June 2015.

10. In relation to Service User 28, following notification on or around 6 July 2015 of failed home visits by a care worker you failed to take the following action and/or record that you had done so:

a. Notify a manager of the concerns.

b. Visit Service User 28.

c. Offer a change of agency to Service User 28.

d. Complete a quality alert.

11. The matters set out in paragraphs 1 10 constitute misconduct and/or lack of competence.

12. By reason of your misconduct and/or lack of competence your fitness to practise is impaired.

Finding

Preliminary matters
Application to discontinue Particulars 5 c) and d)
1. The HCPC applied to discontinue Particulars where the evidence failed to support the charge. The Panel accepted the advice of the Legal Assessor and allowed the application on the basis that the application was based on a realistic assessment of the evidence and that the case was not being under prosecuted.

Application to adjourn proceedings
2. On the first day of the hearing, 30 May 2017, the Panel heard evidence from Ms Kabaale’s Team Manager, and evidence-in-chief from her line manager. The hearing was then adjourned part heard to the next day, 31 May. The hearing could not proceed as planned on that day because Ms Kabaale’s representative, Ms Robertson, was unable to attend due to unforeseen personal circumstances that arose on her journey to the hearing that morning.   It became clear, following various enquiries, that she was unlikely to be able to continue to represent Ms Kabaale during the scheduled timescale for the hearing. 

3. Following telephone discussions with another senior BASW representative, Ms Kabaale applied to adjourn the hearing part heard to another date to be fixed. The HCPC took a neutral stance on the application. The Panel accepted the advice of the Legal Assessor and considered the principles set out in the HCPC Practice Note on Postponements and Adjournments and the case of Picton. The Panel took into account the need for expedition in all proceedings and the fact that a witness was part heard in giving her evidence. However, the Panel concluded that Ms Kabaale had been placed at a sudden and significant disadvantage by an unexpected turn of events, which had led to the loss of her representation through no fault of her own.  This was an important case with potentially serious consequences for her future career.  It was also a factually complex case with a substantial number of Particulars still in issue. The Panel therefore decided to allow the application to adjourn in the interests of justice.

Background
4. Ms Kabaale was employed as a Social Worker at Hounslow Borough Council (the Council). She commenced her employment on 21 September 2009. She was initially based within the Independent Living Team (ILT) then transferred to the Chiswick Locality Team, following a structural reorganisation, from 1 April 2015. The nature of the work was similar in terms of risk assessment and safeguarding issues. Ms Kabaale was responsible for the welfare of vulnerable adults aged over 18 years, including those with physical disabilities, but not those with learning disabilities or mental health problems.  Many were resident in supported accommodation or looked after by carers in their homes.

5. This case concerned alleged failures by Ms Kabaale to undertake or complete basic safeguarding procedures in relation to vulnerable adult service users.  Following concerns about Ms Kabaale’s work a snapshot case file audit of her work was undertaken; this was completed on 9 July 2015 and highlighted further concerns. Following implementation of action plans, a formal investigation was undertaken and a fuller independent audit was completed in August 2015 by a Locum Department Team Manager employed by the Council.

Decision on facts
6. At the start of the hearing Ms Kabaale admitted Particulars 1(a) to (k), 2(a), (b), (d), (f) to (k), (p) and (q), 3(a) to (g), 4, 5(e), 6(b), 7, 8(a), 9(b) 10(d). 

7. During the course of the hearing Ms Kabaale admitted Particulars 2(c), 2(e), 2(l), 2(m), 2(n), 2(o), 5(a), 5(b). However, she also indicated that she no longer admitted Particular 10(d).

8. The Panel heard oral evidence from the following witnesses on behalf of the HCPC:
• EH, Team Manager, Chiswick Locality Team
• JG, Deputy Team Manager, Chiswick Locality Team (at the relevant time)

9. The Panel also heard oral evidence from Ms Kabaale.

10. The Panel also received documentary evidence from the HCPC and   Ms Kabaale.

11. In reaching its decision the Panel considered all the evidence in this case together with the submissions made by Ms Mitchell-Dunn on behalf of the HCPC, and by Ms Robertson, on behalf of Ms Kabaale.

12. The Panel accepted the advice of the Legal Assessor who reminded the Panel that the burden of proof rests on the HCPC. The Legal Assessor also reminded the Panel that the standard of proof is the civil standard, namely the balance of probabilities.

13. The Panel found both HCPC witnesses to be credible and reliable.

14.  In relation to Ms Kabaale’s evidence the Panel found it to be confused at times, and considered that she found it difficult to answer some straightforward questions with clarity. Overall the Panel concluded that she was not deliberately trying to mislead the Panel but it treated her evidence with caution.

15. The Panel has made the following findings of fact:

Particular 1(a) – (k) -found proved.
16. Ms Kabaale has admitted this Particular in full.

17. The Panel has accepted the evidence presented by the HCPC.

18. EH evidence was that the standard required throughout the Council is that a service user is contacted by an allocated Social Worker within 48 hours of a case being allocated. This requirement was not set out in writing however, all members of staff at the Council should be aware of this requirement, because they were advised of it at the beginning of their employment and reminded of it during team meetings, and by email.

19. EH told the Panel that Ms Kabaale attended and passed the standard in-house courses expected of Social Workers.  She was therefore aware of the requirements and timescales when dealing with risk assessment and management under the Safeguarding Adults procedures.  The timescales were intended to protect vulnerable adults from the risk of harm. It is important that service users new to the Council are contacted in a timely manner in order to ascertain their circumstances.  In relation to review cases, JG stated that “the potential impact of a delay is less as the Service User will already have some form of support in place”.

20. EH said that the Council used an electronic record keeping system called Liquid Logic, in which all staff were trained.  Social Workers had daily access to the system to update and monitor records. There were no paper files.  The Council’s policy is that all records should be written up as soon as possible to record the most accurate account of details and events. The records were accessible to staff on the Council intranet.

21. The records show when a case was allocated to Ms Kabaale and record what actions she took in respect of the service user.

a) Service User 1
22. Ms Kabaale was allocated the case of Service User 1 on 8 June 2015. On 15 June 2015, Ms Kabaale contacted the care home where Service User 1 was residing, in order to arrange a visit. On 16 June 2015, Ms Kabaale visited the service user. There was therefore an eight day delay between Ms Kabaale being allocated this case and contact being made with the service user.

b) Service User 3
23. This case was allocated to Ms Kabaale on 13 April 2015 for a six weekly review. Service User 3 had advanced dementia and needed 24 hour support due to her wandering and the high risk of falls. Ms Kabaale did not make contact to arrange a visit with Service User 3 until 30 June 2015, and then only after an email was received from the Council Chief Executive’s PA, following a voicemail left by Service User 3’s son.

24. On the same date a complaint was also received from a Councillor in relation to Service User 3's case. The complaint related to a lack of response from the allocated Social Worker. A ticket detailing the complaint was created by EH, dated 30 June 2015.  When questioned about this case by EH, Ms Kabaale said that she had forgotten about the case. There was a considerable delay between Ms Kabaale being allocated this matter and contact being made with the service user.

c) Service User 4
25. This case was allocated to Ms Kabaale on 12 February 2015 for a reassessment of needs but contact was not made until 23 February 2015. There was therefore a delay of 11 days between this matter being allocated to Ms Kabaale and the service user being contacted. There are no records of any attempts to make contact with the service user before 23 February 2015.

d) Service User 10
26. This case was allocated to Ms Kabaale on 2 March 2015.   There is no record to suggest that the service user was contacted within 48 hours of allocation. A subsequent record on 16 May 2015 suggests that Ms Kabaale had visited the service user, but the date of the visit is not clear as no case notes are recorded.

e) Service User 13
27. This case was allocated to Ms Kabaale on 9 June 2015, as it required urgent re-allocation. Contact was not made with the service user until 29 June 2015. This was 20 days after the service user was allocated to Ms Kabaale.

f) Service User 15
28. This case was allocated to Ms Kabaale on 21 May 2015 for an assessment of needs.  However, no contact was made with the service user until 24 July 2015. There were no case notes on the system showing any follow-up when JG conducted an audit on 9 July 2015. In this case there was a considerable delay between Ms Kabaale being allocated this case and contact being made with the service user.

g) Service User 21
29. This case was allocated to Ms Kabaale on 5 February 2015, in order for her to complete a review of the carer. No contact was made in this case until 13 July 2015.  A note was made on 18 February 2015 stating the carer review was due by 2 March 2015. Subsequently there is a note on 29 April 2015, requesting an update, and notes on 6 May 2015 and 9 July 2015, stating the review is still outstanding. When JG conducted an audit on 9 July 2015, no contact had been made. On 13 July 2015 the service received a phone call from the service user’s daughter requesting a reassessment as her mother’s needs had changed. Following this, Ms Kabaale made contact with the service user’s daughter to schedule a meeting on 16 July 2015. This was almost five months after the case was allocated to Ms Kabaale.

h) Service User 24
30. This case was allocated to Ms Kabaale on 27 January 2015, but no contact was made with the service user until 1 April 2015, when a home visit was conducted. As a result, there was a considerable delay between Ms Kabaale being allocated this matter and contact being made with the service user.

i) Service User 5
31. This case (smoker who was a fire risk because of blackouts) was allocated to Ms Kabaale on 27 April 2015, because there were concerns about neglect and urgent enquiries needed to be made in relation to his needs.  Contact was not made with the service user until 15 June 2015, following prompting by JG during a supervision on 6 May 2015. At the supervision an action plan was agreed. There was a considerable delay between Ms Kabaale being allocated the matter and contact being made with the service user.

j) Service User 27
32. This case was reallocated to Ms Kabaale on 18 February 2015 to complete a carers review. Service User 27 cared for Service User 21, who was already allocated to Ms Kabaale. On 6 May 2015, during supervision with Ms Kabaale, JG noted that there had been no contact with Service User 27. It was agreed during the supervision session that Ms Kabaale should contact Service User 27 by 8 May 2015 to arrange reviews for the following week. This review was still outstanding when Ms Garside conducted a review on 9 July 2015. There had been no contact with the service user since the case was allocated to Ms Kabaale.

k) Service User 28
33. This matter was allocated to Ms Kabaale on 7 May 2015, for a 6 weekly review and to complete the necessary paperwork. No contact was made with the service user until 21 May 2015, which was 14 days after the matter was allocated to Ms Kabaale.

Particular 2(a) - (q) – found proved.
34. The Panel has accepted the evidence presented by the HCPC.

35. Once a new service user has been allocated to a Social Worker they have to undertake an assessment; in the case of an existing service user the Social Worker has to undertake a review.

36. There are two parts to an assessment/review namely the visit and the write-up. An assessment/review is only considered to be complete when both aspects have been completed.

37. EH told the Panel that assessments should be undertaken and written up within two weeks of allocation, although there is no formal policy regarding this.

38. If an assessment is not written up in a timely manner anyone looking at the case record will not know what action has been taken nor what the potential needs or risks to the service user are.

39. A Locum Deputy Team Manager carried out an audit of Ms Kabaale’s case files.

a) Service User 1
40. Ms Kabaale conducted a home visit on 16 June 2015. However, only a case note was recorded in respect of this review, and no report was completed. At the meeting on 9 July 2015, Ms Kabaale was asked to write up the full review. On 16 July 2015, there is a case note by JG indicating that Ms Kabaale had advised her that she had not had the opportunity to follow up on the actions of 9 July 2015. The report had still not been completed by the time of an audit on this case on 27 August 2015.

b) Service User 2
41. This case was audited on 25 August 2015 and noted that Service User 2’s Resident Led Assessment (RLA) had not been completed, despite the fact that JG requested on 9 July 2015 that this should be completed.

c) Service User 3
42. This case was audited on 27 August 2015.  It was noted that the Mental Capacity Act (MCA) assessment report had not been completed. EH stated that an assessment is only considered complete once the assessment and the associated paperwork have been completed.

d) Service User 4
43. Service User 4 was allocated to Ms Kabaale on 12 February 2015. On 25 February 2015, Ms Kabaale conducted a home visit for a reassessment of needs. This visit was recorded on the case notes but the (RLA) paperwork still had to be completed. This paperwork should have been completed within 28 days. On 9 July 2015, there is a note on the service user’s records, made by JG, stating that the RLA still needs to be completed. DG audited this case on 26 August 2015 and noted that an RLA and review had not been completed.

e) Service User 5
44. Service User 5 (an epileptic man who smoked heavily so a high fire risk) was allocated to Ms Kabaale on 27 April 2015. Ms Kabaale made a home visit to the service user on 15 June 2015. On 9 July 2015, JG conducted an audit and noted on the case record that the review was still in the process of being typed up and noted that the risks needed to be addressed and the review completed. The next note on the record shows that on 30 July 2015 the review paperwork was received by JG for review.

f) Service User 8
45. Service User 8 (also a high fire risk) was allocated to Ms Kabaale on 6 July 2015, and she visited the service user on 7 July 2015.  On 9 July 2015, JG made a note in Service User 8's records, noting that feedback was required on the visit undertaken on 6 July 2015 (this should have read 7 July 2015). It was also noted that the reassessment had to be written up following this home visit.  The Locum Deputy Team Manager noted in her audit of 24 August 2015 that, despite completing two home visits, there was no evidence that an RLA report was completed.

g) Service User 9
46. Ms Kabaale was allocated this case for review because a review was pending on 28 April 2015. On 6 May 2015, a note was placed on the record by JG, stating that that Ms Kabaale planned to complete the paperwork. A plan of action was then put in place that the reassessment paperwork and continuing care checklist should be completed by 15 May 2015. On 9 July 2015, there is a further note which states the paperwork from the visit needs to be written up. This matter was re allocated to a different social worker on the 4 August 2015. It was noted during the audit that a reassessment took place on 30 April 2015, but the assessment was not completed by the time of her audit. In addition, she also noted there was no evidence of a six week review despite advice on 9 July 2015 to book one in.

h) Service User 10
47. Ms Kabaale was allocated this matter on 2 March 2015. At the time of her audit on 9 July 2015, JG noted that there was an Outcome Focused Review outstanding from May 2015. It was agreed with Ms Kabaale that the review could be a light touch telephone review as the Service User had no memory concerns, no communication difficulties and Ms Kabaale had previously visited the Service User and knew her needs. Despite the fact that no home visit was required, no review had been undertaken by the 9 July 2015.

i) Service User 11
48. Service User 11 was allocated to Ms Kabaale on 29 April 2015. A home visit review was made on 9 June 2015 by Ms Kabaale to review Service User 11’s needs. When JG completed her audit on 9 July 2015 the review was still in draft form and had not been written up. This case was audited by the Locum Team Manager on 21 August 2015 and it was noted that review was made on 9 June 2015, but the review report was still in draft and not authorised when she audited the case.

j) Service User 12
49. This case was allocated to Ms Kabaale on 29 June 2015. On 9 July 2015, JG noted that a six weekly review was due in this case on 23 July 2015. This case was audited by the Locum Deputy Team Manager on 21 August 2015. The audit highlights that the six weekly review was not scheduled and had not been completed despite the instructions on 9 July 2015.

k) Service User 13
50. This case was allocated to Ms Kabaale on 9 June 2015. It was audited on 26 August 2015 by the Locum Deputy Team Manager. The audit highlighted that no review, risk assessment or analysis was completed.

l) Service User 16
51. This case was allocated to Ms Kabaale on 19 January 2015. When JG audited this case, a review was outstanding. There is a note that the review should be completed by 8 May 2015. The review was not undertaken at this date as planned. There was no MCA assessment completed in this case. A MCA assessment should be completed when the provider flagged concerns regarding the cleanliness of the Service User.  In addition to this, the case was audited by on 24 August 2015, and the audit highlights no review, and poor grasp of risk analysis or management of the case.

m) Service User 18
52. This case was allocated to Ms Kabaale on 29 June 2015. Service User 18 was an elderly lady who suffered from dementia.  A home visit was arranged for the 3 July 2015, to reassess the Service User’s needs.  The Service User was refusing her medication, not eating food, was reluctant to engage and withdrawn. There were issues in relation to her mobility and incontinence. Ms Kabaale did not complete an MCA on this date, as would have been usual. Service User 18 was admitted to hospital only a few days after Ms Kabaale’s visit. Had the MCA assessment have been completed this may have been different.

n) Service User 20
53. Service User 20 had an eating disorder and suffered from depression. This case was audited on 25 August 2015, and the audit highlights that an RLA was not completed until 15 July 2015, despite this case being allocated on 7 May 2015. As set out, the requirement for such assessments is that they are to be completed within 28 days.

o) Service User 21 and p) Service User 27
54. Service User 21 was allocated to Ms Kabaale on 5 February 2015. Service User 27 was the carer for Service User 21. Service User 27 was reallocated to Ms Kabaale on 18 February 2015. The record makes it clear that Service User 27 required a review of Carer Direct payment. A review was also to take place of Service User 21, as she had recently started receiving her direct payment.

55. On 29 April 2015 a Community Matron, requested an update as to the current situation with Service User 21 and her needs. There was no evidence in the notes that Ms Kabaale responded to this request. JG discussed this case with Ms Kabaale during supervision on 6 May 2015 because she had noted that the Outcome Focused Review was outstanding for Service User 21 and the carer review of Service User 27. A plan of action was put in place for Ms Kabaale to speak with both service users by 8 May 2015 to arrange for reviews for the week of 11 May 2015. The follow up paper work was to be completed by 15 May 2015.  When JG completed an audit on 9 July 2015, the reviews remained outstanding.

q) Service User 15
56. This service user was allocated to Ms Kabaale on 21 May 2015 for an assessment of needs. When JG conducted an audit of Ms Kabaale cases on 9 July 2015, no case notes were on the system showing a follow up.

Particular 3(a) – (g) - found proved
57. Ms Kabaale has admitted this Particular in full.

58. The Panel has accepted the evidence presented by the HCPC.

59. If the Council provides a new service to a service user, for example a new package of care, they are required to carry out a review six weeks after implementation of the new service. If a service user only requires a low to medium level of assistance this review can be conducted over the telephone, otherwise it should take place in person.

60. JG told the Panel that when a case is getting close to review it is allocated, by a manager, to a Social Worker. Sometimes allocations will occur after the six week period has elapsed as reviews are not the first priority when a team is busy. Once a Social Worker has been allocated a review they have 48 hours to make contact and generally reviews are arranged within one or two weeks of allocation.

61. EH had asked a Locum Deputy Team Manager to carry out an audit of Ms Kabaale’s case files and in relation to Service Users 2, 7, 9, 17, 20, 23, 24 she could find no evidence of Ms Kabaale undertaking such a review.  In relation to Service Users 9 and 17, there was documentary evidence that she had been reminded to schedule the reviews by other staff, but she had still failed to do so.

62. JG gave evidence in relation to the safeguarding issues. Service User 2 had alcohol issues which required monitoring. Service User 7 had mental health or incapacity issues.  Service User 17 had carer and support issues.  Service User 20 was in sheltered accommodation and had a mental health diagnosis.

Particular 4 – found proved
63. Ms Kabaale has admitted this Particular.

64. The Panel has accepted the evidence presented by the HCPC.

65. Service User 26 was allocated to an unqualified Social Worker. There was a safeguarding concern raised with regard to an allegation of neglect, because Service User 26 had a Grade 3 pressure sore and was losing weight. A tissue viability nurse report had been requested to provide an opinion on the possible causes of the pressure sore and this was to form part of the investigation. A GP report was also needed for a clinical opinion on the weight loss.

66. A strategy meeting was held on 12 May 2015 and on the same day JG had a conversation with the unqualified worker and Ms Kabaale. It was agreed that Ms Kabaale would complete a report by 9 June 2015. The report was not prepared by this date, so an extension was agreed. The report was then required by 5 July 2015.

67. When JG conducted an audit on 9 July 2015 the investigation report and protection plans were still awaited. The delays in completing the report would lead to a delay in the safeguarding process.  There is a requirement to complete the investigation report within 20 days, which is referred to in the PAN London Guidance (safeguarding).

68. This case was audited by the Locum Deputy Team Manager on 28 August 2015. She noted that no case notes had been recorded by Ms Kabaale since the matter had been allocated to her. Neither had she completed an investigation report, despite requests for this to be done since 5 July 2015. The potential impact of not completing the report was that the Council did not know whether the service user was safe or whether there was a need for a further protection plan or further action.

Particular 5(a), 5(b) and 5(e) - found proved
69. The HCPC discontinued Particulars 5 c) and d).

70. The Panel has accepted the evidence presented by the HCPC.

a) Service User 2 
71. The case was allocated to Ms Kabaale on 31 March 2015 for urgent review. Ms Kabaale made contact with the service user’s daughter on 1 April 2015 and arranged a visit to the service user on 9 April 2015. The service user’s records show that she was refusing to eat and was drinking excessively.

72. The Locum Deputy Team Manager audited this case on 25 August 2015, and she concluded that there was no evidence that Ms Kabaale had liaised with the service user’s GP. It is recorded that there is no evidence of multi-agency working in this case.

b) Service User 13
73. Service User 13 was allocated to Ms Kabaale on 9 June 2015. This case was deemed high risk due to safeguarding concerns around Service User 13's partner who was withholding medication. The partner was also reported to be alcohol dependent and multiple concerns were raised by the service user’s neighbours.

74. There was no liaison with Service User 13's GP regarding medication concerns, despite the fact that JG left a note on the case on 10 July 2015 stating: “Duty to follow up as a priority today please (re concerns about relationships with partner and also medication concerns) 1) contact care agency and gain their feedback- does Service User 13 talk to any of the care workers about her relationship with her partner. Do the agency have any concerns about her partner 2) Call GP and advise of medication concerns (re missed calls as case notes from 29/6/15)”

e) Service User 21
75. Service User 21 was allocated to Ms Kabaale on 5 February 2015. On 29 April 2015 there was a request by a community matron for an update as to the current situation in relation to Service User 21 and her needs. There is no evidence within the notes that Ms Kabaale responded to this request.

Particular 6(a) – found not proved
76. Ms Kabaale was allocated Service User 5 on 27 April 2015 because there were issues with self neglect. He was at risk of falling and also presenting concerns in relation to being a fire risk, because he was a smoker and had no fire alarm in place.

77. During a supervision session on 6 May 2015 between Ms Kabaale and JG, a plan of action was identified and Ms Kabaale was asked to arrange a reassessment visit and contact the service user that day. Despite this contact was not made until 15 June 2015. Ms Kabaale visited the service user on 15 June 2015 and noted that the service user suffered from dizzy spells and Myalgic Encelopathy and as a result he had had several falls.

78. In the case notes, on two occasions discussions are recorded regarding the risk of falling although it is not entirely clear when these entries were made. Accordingly, the Panel has concluded that the HCPC has not discharged the burden of proof.

Particular 6(b) – found proved
79. Ms Kabaale has admitted this Particular.

80. Ms Kabaale did not contact and/or record that she had contacted Service User 5 in a timely manner following a call from the London Fire Brigade (LFB) on 19 June 2015, informing her that Service User 5 would not allow them to arrange an appointment. The service user had refused the appointment, because the LFB were not from the Council. Ms Kabaale had recorded that she would contact the service user to discuss allowing the LFB access. However, when JG conducted an audit on this case on 9 July 2015, there was no evidence that any such contact had been made. The follow up with Service User 5 should have been done as a matter of urgency due to the risk of fire.

Particular 7 – found proved
81. Ms Kabaale has admitted this Particular.

82. The Panel has accepted the evidence presented by the HCPC.

83. On 7 July 2015, Ms Kabaale undertook a home visit and noted evidence of burn marks. Service User 8 reported to her that she only smoked to get rid of moths from her nose and that she was willing to stop smoking.

84. During a meeting on 10 July 2015, it was identified that this was a priority case and Ms Kabaale had to follow up to mitigate the fire risks and to contact housing regarding the London LFB and request for fire sprinklers.  Ms Kabaale recorded that she undertook the home visit on 17 July 2015 and that Service User 8 told her she did not smoke. Although Ms Kabaale had the cost of sprinklers considered, Ms Kabaale failed to deal with the immediate risk of Service User 8 smoking. When asked by JG how the immediate risk was going to be addressed, Ms Kabaale simply responded that Service User 8 was going to stop smoking.

85. On 22 July 2015 JG entered a case note in Service User 8's records as follows: 'Advice given to Maureen following her home visit on Friday 17th; As [Service User 8] presented with some confusion and belligerence in terms of her behaviour, coupled with the concerns raised by the LFB, despite her promise to immediately stop smoking the likelihood is she will start again very soon she has smoked for a long time and there is evidence that she has been smoking more than she says. Therefore we cannot rest on her word and assume the risk has vanished and suggest we present her case to the high risk panel along with the fire brigade referral and photos of the cigarette burns. The risk has been diminished whilst she is not smoking but should she start again which there is a high possibility she will she will become a very high risk.'

86. Ms Kabaale recorded that she made the referral to the high risk panel on 7 August 2015, however, she had been advised to refer to the panel on 22 July 2016. The papers were not sent to the high risk panel as the case notes by Ms Kabaale and also the referral in draft, contained information about a different service user altogether.

Particular 8(a) – found proved
87. Ms Kabaale has admitted this Particular.

88. The Panel has accepted the evidence presented by the HCPC.

89. This case was allocated to Ms Kabaale on 9 June 2015 because it required urgent reassessment. This case was high risk due to safeguarding concerns relating to Service User 13's partner who was withholding medication. The partner was also reported to be alcohol dependent and multiple concerns had been raised by neighbours in respect of Service User 13’s safety.

90. Within the records of Service User 13 there was an email from AH, care coordinator, dated 19 June 2015, indicating that a visit had been missed that morning as the care worker had incorrectly read her rota. Ms Kabaale should have completed a quality alert form. This is to monitor any patterns and ensure the care agency is fulfilling its service requirements. There were no notes recording that a quality alert had been completed and no form was uploaded.

Particular 8(b) – found proved
91. In a note within the case records dated 17 July 2015 Ms Kabaale stated that she had applied for appointeeship on Service User 13’s partner’s behalf to manage Service User 13’s money. Ms Kabaale acknowledged that there were concerns relating to Service User 13’s partner as documented by her in an earlier entry.

92.  In her oral evidence Ms Kabaale accepted she had provided assistance.

Particular 9(a) – found proved
93. The Panel has accepted the evidence presented by the HCPC.

94. This case was allocated to Ms Kabaale on 19 January 2015. From 8 May 2015 concerns were raised about Service User 16 refusing personal care and medication. There were also concerns over his cleanliness, health and safety.

95. JG’s audit of 9 July 2015, identified that a visit to Service User 16 was outstanding (Exhibit 1, Appendix 4). Ms Kabaale was asked to attend the home as a matter of urgency because numerous concerns were reported throughout May and June that the service user was not taking his medication, was covered in faeces, urine incontinent and not eating adequately.

96. In her oral evidence Ms Kabaale put forward a number of reasons why she did not visit however despite being asked to conduct a home visit urgently, she did not conduct a home visit until 15 July 2015.

Particular 9(b) – found proved
97. Ms Kabaale has admitted this Particular.

98. The Panel has accepted the evidence presented by the HCPC.

99. At the time of JG’s audit of 9 July 2015, there was no evidence within the case notes that Ms Kabaale had taken any steps to action a deep clean which had been requested on 22 June 2015. This should have been done, given the concerns about faeces on the service user’s clothes and around the service user’s home, which was an obvious hygiene risk. In order to arrange a deep clean, a Social Worker has to obtain quotes and complete the necessary funding paperwork, but this process can be dealt with retrospectively in urgent cases.

Particular 10(a) – (c) - found proved
100. This case was allocated to Ms Kaabale on 7 May 2015.  On 21 May 2015, she raised a safeguarding alert as the care agency had failed to provide two visits. Ms Kaabale dealt with this issue appropriately when she visited the following day.  She offered a change of agency and raised a quality alert. The safeguarding concern was closed at the alert stage. 

101. On 6 July 2015, the Ms Kaabale received another call to say that the care agency had not turned up twice over the course of a weekend. She advised that she was going to speak with the care agency to find out what happened and would call her back.

102. There is no evidence that the Ms Kaabale notified a manager, visited the service user or offered a change of agency on or around this time. She should have undertaken the same action that she had done in respect of the previous concern raised a month earlier. Whenever a safeguarding concern arises, it should be raised with a manager immediately or within 4 hours, but there is no evidence that this was done.

Particular 10(d) - found not proved
103. The records show that a quality alert was completed by Ms Kabaale on 10 July 2015.

Decision on grounds
104. The Panel has determined that the facts do not demonstrate a lack of competence. Prior to the events with which the Panel are concerned Ms Kabaale appeared to have practised without difficulty and there is nothing to suggest that she does not have the necessary knowledge to practise effectively.

105. The Panel then went on to consider misconduct.

106. The facts proved show that on a number of occasions Ms Kabaale failed to undertake basic social work tasks. For example by not contacting service users in a timely manner neither Ms Kabaale nor anyone else at the Council knew what risks service users faced and by not carrying out assessments in a timely manner the severity of any risk was not promptly identified.

107. These were not isolated incidents. The facts found proved were serious and concerned a large number of vulnerable service users over a period of several months, with wide ranging deficiencies in basic social work skills.

108. The Panel considered that the following standards of the HCPC’s Standards of conduct, performance and ethics have been breached:
1.  You must act in the best interests of service users
10 You must keep accurate records

109. The Panel also considered that the following standard of the HCPC’s Standards of proficiency for Social workers in England was breached:
4.  Be able to practice as an autonomous professional, exercising their own professional judgement.

110. The Panel has concluded that Ms Kabaale’s failings fell well below the standard of a Registered Social Worker and amounted to misconduct.

Decision on impairment
111. In reaching a decision the Panel considered the Practice Note “Finding that Fitness to Practise is Impaired” and accepted the advice of the Legal Assessor.

112. The Panel considers that Ms Kabaale’s failings are remediable but it has concluded that they have not yet been remedied. In reaching this decision the Panel has noted that Ms Kabaale has recently been practising under close supervision at Parent and Child Fostering Assessments (PACFA) which is a small private sector social work agency. In a report dated 20 February 2017 her manager at PACFA states “Maureen’s situation is a work in progress…”.

113. The Panel is concerned that at no time in her evidence did Ms Kabaale seem to appreciate that her behaviour put service users at risk of harm. Indeed, the Panel are of the view that Service Users 13 and 16 suffered actual harm as a result of her inaction.

114. Throughout her evidence Ms Kabaale seemed unable or unwilling to accept that any fault lay on her for what went wrong. Instead she sought to blame her workload, computer failings or the inactions of colleagues. Of particular concern was the only semblance of an apology came belatedly through her representative at the end of her closing submission. It has therefore concluded that any insight is limited.

115. The Panel had regard to the words of Kerr J in the case of Kimmance v GMC where he said in relation to insight and remediation;

“I do not much like those jargon words. They do not do much to illuminate the reality, which is that a doctor or other professional who has done wrong has to look at his or her conduct with a self-critical eye, acknowledge fault, say sorry and convince a panel that there is real reason to believe he or she has learned a lesson from the experience.”

116. The Panel has concluded that Ms Kabaale has not achieved what Kerr J hoped for from a practitioner.

117. In all the circumstances, the Panel cannot rule out a repetition of similar behaviour and consequent risk if Ms Kabaale finds herself in a similar working environment to that of the Council.

118. As a result of her inactions in relation to service users, complaints were made to the Council. In view of the serious and repeated nature of the misconduct, public trust and confidence in the profession and regulatory process would be undermined if a finding of impairment was not made.

119. Accordingly, the Panel has concluded that Ms Kabaale’s fitness to practise is impaired by reason of her misconduct.

Decision on sanction
120. In coming to its own, independent, decision as to sanction, the Panel took into account all the evidence including the oral evidence given by Ms Kabaale at this stage. The Panel also took into account the submissions made and it has accepted the advice of the Legal Assessor.

121. In deciding what sanction to impose, if any, the Panel has reminded itself that the purpose of sanctions is not to be punitive but to protect service users and the public interest, although there may be a punitive effect. The Panel has also taken into account the principle of proportionality, balancing the interests of the public with those of Ms Kabaale. It has also taken into account the HCPC’s Indicative Sanctions Policy and considered the sanctions available in ascending order.

122. The Panel has identified the following aggravating factors:
• Limited Insight
• Actual Harm to two service users
• Not an isolated incident
• Large number of service users involved
• Failure to appreciate the impact of her misconduct on service users and other agencies
• Failure to take personal responsibility for her misconduct

The Panel has identified the following mitigating factors:
 
• Previous unblemished record
• Engagement with the HCPC regulatory process
• Family and personal difficulties at the relevant time
• Willingness to engage in remediation

123. In view of the nature of the matters that gave rise to the finding of impairment it would not be appropriate to arrange mediation, to conclude the case without taking any action or impose a Caution Order as these would not adequately protect service users or address the public interest.

124. The Panel then considered a Conditions of Practice Order, the Indicative Sanctions Policy states at paragraph 30:

“Conditions of practice will be most appropriate where a failure or deficiency is capable of being remedied and where the Panel is satisfied that allowing the registrant to remain in practice, albeit subject to conditions, poses no risk of harm or future harm. Panels need to recognise that, beyond the specific restrictions imposed by a Conditions of Practice Order, the registrant concerned is being permitted to remain in practice. Consequently, the Panel’s decision will be regarded as confirmation that, beyond the conditions imposed, the registrant is capable of practising safely and effectively.”.

Paragraph 33 of the Indicative Sanctions Policy states:

“Conditions will rarely be effective unless the registrant is genuinely committed to resolving the issues they seek to address and can be trusted to make a determined effort to do so. Therefore, conditions of practice are unlikely to be suitable in cases:
• where the registrant has failed to engage with the fitness to practise process, lacks insight or denies any wrongdoing;
• where there are serious or persistent overall failings; or
• which involve dishonesty, breach of trust or the abuse of service users.”

125. Whilst the Panel determined that Ms Kabaale had limited insight it was encouraged by the positive report given by her current line manager, and concluded that Ms Kabaale is capable of developing insight and that the misconduct is capable of remediation. The Panel is satisfied that conditions of practice can be formulated that would allow Ms Kabaale the opportunity to remediate and the same time protect service users and address the public interest.

126. In view of the fact that the Panel has decided that Ms Kabaale has limited insight it gave careful consideration as to whether a Conditions of Practice Order is appropriate and decided that it is. The reason being that despite the fact Ms Kabaale has blamed others for her failings the Panel is satisfied that she has demonstrated a strong desire to become a good and effective Social Worker again. This is evidenced by the fact that after leaving the Council and whilst subject to an Interim Conditions of Practice Order she secured work at PACFA. It is clear from the report from her current line manager that she is willing to learn and indeed has done so as she has been operating effectively in a different area of social work.

127. Accordingly, the Panel has decided to impose a Conditions of Practice Order for three years. It considers that three years is required to allow Ms Kaabale the opportunity to fully remediate her misconduct and also to uphold the public interest.

128. The Panel considered a Suspension Order but has decided that this would merely be punitive and not allow Ms Kaabale the opportunity to remediate her misconduct. It considered that there is a public interest in allowing a Social Worker to practise if this can be achieved safely.

Order

The Registrar is directed to annotate the Register to show that, for a period of three years from the date that this Order comes into effect (“the Operative Date”), you, Maureen Kabaale, must comply with the following conditions of practice:

1. You must place yourself and remain under the supervision of a workplace supervisor registered by the HCPC or other appropriate statutory regulator and supply details of your supervisor to the HCPC within 14 days of the Operative Date. You must attend upon that supervisor every fortnight for the first 12 months and monthly thereafter.

2. You must work with your supervisor to formulate a Personal Development Plan designed to address the deficiencies in the following areas of your practice:
• Risk analysis – identifying and mitigating risk
• Maintaining accurate and timely records
• Following statutory and local timescales relating to the progression of casework
• Working and communicating in a multi-agency environment

3. Within three months of the Operative Date you must forward a copy of your Personal Development Plan to the HCPC.

4. You must allow your supervisor to provide information to the HCPC about your progress towards achieving the aims set out in your Personal Development Plan.

5. You must provide an updated Personal Development Plan to the HCPC on a 12 monthly basis.

6. You must maintain a reflective practice log on a monthly basis detailing your learning in relation to the matters identified in condition 2 above.

7. Within three months of the Operative Date you must provide the HCPC with a written reflective piece on the impact of your misconduct on vulnerable service users.

8. No later than three months before the expiry of this order you must provide the HCPC with a written reflective piece to demonstrate how you have remediated your misconduct including actual examples from your practice.

9. You must promptly inform the HCPC if you cease to be employed by your current employer or take up any other or further employment.

10. You must promptly inform the HCPC of any disciplinary proceedings taken against you by your employer.

11. You must inform the following parties that your registration is subject to these conditions:

A. any organisation or person employing or contracting with you to undertake professional work;

B. any agency you are registered with or apply to be registered with (at the time of application); and

C. any prospective employer (at the time of your application).

Notes

The order imposed today will apply from 23 August 2017 (the operative date).

This order will be reviewed before its expiry on 23 August 2020.

Hearing history

History of Hearings for Ms Maureen Kyama Kabaale

Date Panel Hearing type Outcomes / Status
19/07/2017 Conduct and Competence Committee Final Hearing Conditions of Practice
19/06/2017 Conduct and Competence Committee Interim Order Review Interim Conditions of Practice
30/03/2017 Conduct and Competence Committee Interim Order Review Interim Conditions of Practice
06/01/2017 Conduct and Competence Committee Interim Order Review Interim Conditions of Practice
14/10/2016 Conduct and Competence Committee Interim Order Review Interim Conditions of Practice
27/07/2016 Investigating committee Interim Order Review Interim Conditions of Practice
28/01/2016 Investigating committee Interim Order Application Interim Conditions of Practice