TKSD Care Homes & Training Ltd & Anor v Care Quality Commission [2025] UKFTT 1410 (HESC)

First-tier Tribunal Care StandardsThe Tribunal Procedure (First-tier Tribunal) (Health, Education and Social Care) Rules 2008NCN: [2025] UKFTT 01410 (HESC) 2025-01430.EA
Between
TKSD CARE HOMES & TRAINING LTDAppellantDANIEL AGBETORWOKAAppellantCARE QUALITY COMMISSIONRespondent
Before
Tribunal Judge S GoodrichSpecialist Member Mr M CannSpecialist Member Dr E YeatesHearing at the Royal Courts of JusticeOn 3 to 7 November 2025DECISION AND REASONSDate 2025-11-24
[1]The Appellant company is a registered provider in respect of the regulated activity of “Accommodation for persons who require nursing or personal care” (the Regulated Activity) at three different locations including Ruth Lodge. The appeal only concerns Ruth Lodge which is a residential care home providing personal care for service users who have complex learning disabilities and care needs, including autism.[2]There are two decisions under appeal:• That made by the Respondent on 27 February 2025 to adopt the Notice of Proposal (NoP) dated 3 January 2025 regarding the provider registration because of breaches of standards of care under the 2014 Regulations (the “provider appeal”);• That made by the Respondent on 15 May 2015 to adopt the NoP dated 3 March 2025 regarding the registration of the manager because of breaches of standards of care under 2014 Regulation (the registered manager appeal).[3]Both appeals were consolidated to be heard together by order of Judge Khan on 10 July 2025.

The Parties

[4]Mr Agbetorwoka is the owner and sole director of the company and, at the time the decisions were made was (and is now) the registered manager (the RM) at Ruth Lodge. He was then, (and is now), the Nominated Individual (NI). In the circumstances we will refer to “the Appellant”, or to Mr Agbetorwoka, rather than the first and/or second Appellant.[5]The Appellant’s background is that in 1991 he qualified as a Registered Mental Nurse (RMN) at St George’s Hospital. He told us that between 1991 and 1998 he had worked in the forensic unit at St George’s Hospital (Springfield) in the care and treatment of mentally disordered criminal offenders. His role progressed from staff nurse to charge nurse and then to ward manager. In 1998 he then joined the prison service at manager level to set up a suicide awareness programme at HMP Belmarsh. He was promoted in about 1999 to work at Governor grade in the Prison Service before he then left in 2010 after 11 years’ service.[6]The background to the Appellant’s career as a provider of care services is that he was first registered by the CQC in October 2010 as a service provider for the regulated activity of Accommodation for persons who require nursing or personal care at Steven Lodge.In 2012 another location was added to the registration: The Brookland. On 12 August 2013 Ruth Lodge was added as a location under the overarching registration and with the Appellant as the registered manager.[7]The Respondent is the statutory body responsible for the registration of those who seek to provide regulated activities i.e. activities connected with the provision of health or social care. The main statutory objective of the Commission in performing its review and investigative functions is to protect and promote the health, safety and welfare of people who use health and social care services.

Restricted Reporting Order

[8]The Tribunal made a restricted reporting order under Rule 14(1) (a) and (b) of the 2008 Rules, prohibiting the disclosure or publication of any documents or matter likely to lead members of the public to identify the service users or their family members so as to protect the rights of service users.

The Chronology of Inspections

[9]The key dates regarding Ruth Lodge are as follows: 19 January 2016: inspection in relation to all five domains (Safe, Effective, Caring, Responsive and Well Led). Ruth Lodge was rated Good. 6 June 2018: inspection of all five domains. It was found the provider required improvement in the Safe and Well Led domain and the overall rating changed to Requires Improvement. CQC identified breaches of Regulations 12, 17 and 19 of the 2014 Regulations. 13 August 2019: it was found the provider had met the breaches of Regulations 12, 17 and 19 of the 2014 Regulations but a new breach was found relating to ‘Notifications of other incidents.’: Regulation 18 (Registration) Regulation 2009. The overall rating remained Requires Improvement. 03 December 2024: Inspection conducted by Mrs Creech and Mrs Alina-Robinson, who found breaches of Regulation 10, 12, 13, 17, 18 and 19 of the 2014 Regulations.

The Notices of Proposal (NOPs)

[10]The NOP dated 3 January 2025 set out in detail the basis for the Respondent’s proposal to vary the condition on the provider's registration so as to remove the location from the registration. The NOP was supported by 62 appendices. On 31 January 2025 Mr Agbetorwoka submitted written representations under section 27 of the Act.[11]The NOP regarding the registered manager was dated 3 March 2025. Essentially it relied upon the same matters.[12]In essence, both NoPs was made on the basis that the regulated activity “is being, or at any time has been, carried on otherwise than in accordance with the relevant requirements.”

The Decisions under Appeal

[13]We need not refer to these in detail as they are a matter of record. In short the decision maker decided to adopt each NoP. We note here the reality that the variation of conditions so as to remove a location from a registration amounts to a (location specific) cancellation. When (as here) registration includes other locations, variation of the conditions contained in the certificate of registration is more appropriate than consideration of the overall cancellation of registration.

The Appeal

[14]In the grounds for appeal lodged on 26 March 2025 at section G the Appellant accepted the findings of the inspection on 3 December 2024. He sought the opportunity to improve the service and he relies on evidence of continuing improvement. In section H he made clear that he did not consider the decision was wrong. He relied on various matters including that:• the service was still trying to understand and implement the new Single Assessment Framework (SAF).• “one of the two residents who lives in Ruth Lodge, presents very challenging behaviours which causes physical damage to property and poses potential harm of risk to others and himself. His challenging patterns of behaviours also affect the smooth running of the home. All those factors also directly or indirectly contributed to our non-compliance with the regulations. And we have learned lessons as result of the outcome of the inspection.” The Appellant listed the improvements relied on and referred to there having been a mock inspection by Total Advisory Care, who would be recruiting a new registered manager and supporting the service over the next six months to ensure high compliance.

The Respondent’s Reply

[15]In summary, the Respondent continued to oppose the appeal. Its action was appropriate due to the persistent failures of risk assessments of service users, inaccurate records, concerns with policies and a failure to meet the needs of service users at the service. Amongst other matters, the Respondent expressed concerns about the sustainability of any improvements due to the historic non-compliance of the Appellant.

Attendance

[16]Mr Agbetorwoka appeared in person for the Appellant company and in his personal capacity as the registered manager. The Respondent was represented by Ms Stevenson of counsel, instructed by Ms Frampton-Anderson, solicitor, CQC Legal Services.[17]The judge took time at the start of the hearing to explain the nature of the appeal and the hearing process. In particular, she explained that the panel is not engaged in a review type process but would make its own decisions as to whether to confirm or effectively set aside the decisions under appeal in the light of the evidence as at today’s date. She also explained the burden and standard of proof as well as the procedure regarding witness evidence and how the hearing would be conducted. She explained that if there was any dispute regarding the facts described or the findings or opinion of any witnesses, then the evidence of the relevant witness had to be challenged so that the witness had the opportunity to respond.

Litigation Support

[18]Mr Agbetorwoka was supported by his wife who was present throughout. The panel adjusted the time-table so that he was able to prepare questions over lengthy breaks or overnight. During the hearingwe made sure that regular breaks were taken, and also suggested that breaks were taken when it appeared that Mr Agbetorwoka might need to confer with his wife and/or Mr Dzvairo. We acceded to all requests for a break or more time made by the Appellant. He accepted the judge’s offer to assist with the introduction/adoption of his evidence and that of his witnesses. She also asked Mr Agbetorwoka and Mr Bello supplementary questions regarding their background and experience as these aspects had not been covered in their witness statements.

Late Evidence and Bundles

[19]We had received and read the e-bundle consisting of 851 pages before the hearing as well as the Respondent’s skeleton argument. Pursuant to the order made by Judge Khan on 21 October 2025 we also had before us a second bundle lodged by the Respondent consisting of some 640 pages.[20]The Respondent had made a further application on 29 October 2025 to adduce new evidence:• the termination of both supported living and residential contracts by Medway Council dated 27 October 2025• The draft CQC inspection report dated 27 October 2025 to which no factual accuracy challenge had been made.• The Service Improvement Plan relied on by the Appellant dated 23 October 2025[21]There was no objection by the Respondent to the reception of this new evidence. We duly received it because it was plainly relevant to the evolving situation and it was fair to do so.[22]A T109 application to adduce further evidence had been made by the Appellant on 29 October 2025 and he had provided a number of appendices in support in numerous separate emails. The judge had issued a direction on 31 October 2025 that a decision would be made by the panel at the start of the hearing on 3 November 2025, and which required that the (proposed) new evidence be provided in paginated and indexed bundles at the start of the hearing for the use of the panel and the witnesses.[23]On 3 November 2025 the Appellant provided paper bundles but made clear that he had other evidence that he wanted to rely on which he did not have with him because it had not yet been photocopied.[24]We directed that the Appellant provide the additional material on which he sought to rely on by 10 am on 4 November 2025 and that, in the meantime, we would hear part of the evidence in chief of Mrs Creech.

The Appellant’s position at the start of the hearing

[25]Given the very recent evidence regarding the position of Medway Council and the Appellant’s “Response to Medway Council’s Contract Termination Letter (27 October 2025)”, the judge asked the Appellant about his current position. The panel had noted that in his response (as above) the Appellant was critical of Mrs Creech and Mrs Contla-Robinson regarding the conduct of an inspection at Brooklands, and that allegations of procedural unfairness, maladministration, bias, and collusion (with Medway Council) had been made. The cumulative effect of various other decisions by Medway Council had left the Appellant with no other choice than to declare provider failure on 17 October 2025. In brief summary, Mr Agbetorwoka told us that: he was very unhappy with the inspection process at Brooklands; he wholly accepted the findings regarding the December 2024 inspection at Ruth Lodge, but he had issues with the process at Brooklands. The Inspector had asked him about the (female) SU’s dental history but he is not a dentist; there had been unrealistic demands by CQC: the inspector (re Brooklands) had accused him of taking money from an SU to build a shower: he felt bullied and had asked for a change of inspector; the CQC had not investigated the complaint; this had denied him natural justice.[26]The Appellant agreed that these concerns were regarding the inspection at Brooklands, rather than that at Ruth Lodge. The judge explained that our task involves a redetermination of the decisions regarding Ruth Lodge on the merits as at today. Mr Agbetorwoka went on to say that one of the factors regarding the inspection at Ruth Lodge in December 2024 was that this had been under the new inspection framework. It had been “a learning experience” for him.[27]The judge asked the Appellant if he disputed the inspectors’ findings at the 30 September 2025 inspection at Ruth Lodge. He said he disputed all of them. He had put a lot of work into action plans. He was “about to improve”. He then said that the company was going into liquidation. Asked what he sought to achieve in the appeal in this new context he said it was important to him to maintain his reputation.[28]On 4 November 2025 the Appellant provided an unindexed further lever arch file containing a number of appendices within dividers. We rose for a period to enable the parties to liaise together.[29]In the event, and in the spirit of the overriding objective, the Respondent raised no issue regarding the reception of the Appellant’s documents into evidence (the orange and red files - as described below) and we therefore agreed to receive the Appellant’s additional evidence.[30]On 3 November 2025 the Judge had asked the parties to work together so as to provide a document that identified the service users (for forensic purposes only) and gave brief details as to relevant dates and local authority placement. This was provided on 4 November 2025. We are grateful to the parties for their cooperation.[31]By 4 November 2025 the bundles received by us, and numbered accordingly, were: 1. The original bundle (851 pages pdf) 2. The further bundle – as per Judge Khan’s order (640 pdf) 3. The Respondents’ new evidence (53 pages pdf) 4. The Appellant’s (indexed and subdivided) bundle of 12 items (orange file) 5. The Appellant’s further (unindexed but subdivided) file (red file).[32]Starting on 3 November we heard evidence from the following witnesses and in the following order. For the Respondent:• Mrs Creech: Inspector• Mrs Contla-Robinson: Inspector• Mrs Montgomery: Operations Manager and the decision maker regarding the decisions under appeal• Mrs Jupp: Deputy Director of the South East Region For the Appellant:• . Mr Bello: manager from 1 July 2025 - whose evidence was taken out of turn at the Appellant’s request.• . Mr Agbetorwoka: the registered provider and registered manager.• . Mrs A, mother of SUA.• . Mr Dzvairo: consultant at Total Advisory Care, engaged by the Appellant. Nominated Individual from 12 May 2025 until recently.

The General Legislative Framework

[33]Amongst other matters s. 2 of the Health and Social Care Act 2008 (the Act) invests in the CQC “review and investigation functions….” – see section 2 (b).[34]Section 3 provides that:
“(1) The main objective of the Commission in performing its functions is to protect and promote the health, safety and welfare of people who use health and social care services. (2) The Commission is to perform its functions for the general purpose of encouraging– (a) the improvement of health and social care services, (b) the provision of health and social care services in a way that focuses on the needs and experiences of people who use those services, and (c) the efficient and effective use of resources in the provision of health and social care services…” (a) the improvement of health and social care services, (b) the provision of health and social care services in a way that focuses on the needs and experiences of people who use those services, and (c) the efficient and effective use of resources in the provision of health and social care services…”
[35]Section 4 provides: Matters to which the Commission must have regard “(1) In performing its functions the Commission must have regard to—(a) views expressed by or on behalf of members of the public about health and social care services,(b) experiences of people who use health and social care services and their families and friends,(c) views expressed by Local Healthwatch organisations or Local Healthwatch contractors about the provision of health and social care services,(d) the need to protect and promote the rights of people who use health and social care services (including, in particular, the rights of children, of persons detained under the Mental Health Act 1983, of persons who are deprived of their liberty in accordance with the Mental Capacity Act 2005 (c. 9), and of other vulnerable adults), (e ) the need to ensure that action by the Commission in relation to health and social care services is proportionate to the risks against which it would afford safeguards and is targeted only where it is needed, (f) any developments in approaches to regulatory action, and (g) best practice among persons performing functions comparable to those of the Commission (including the principles under which regulatory action should be transparent, accountable and consistent).”

The Regulated Activity Regulations

[36]The regulations made under s. 20 of the Act are the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, SI 2014/2936 (the Regulations). Part 3 contains various provisions under the heading “Fundamental Standards”. The requirements of each regulation is then explained in some detail. We set out the “headline” elements of each standard by way of overview.• Regulation 9 - Person centred care The care and treatment of service users must—(a) be appropriate,(b) meet their needs, and(c) reflect their preferences.• Regulation 10 - Dignity and respect (1) Service users must be treated with dignity and respect.• Regulation 11 - Need for consent (1) Care and treatment of service users must only be provided with the consent of the relevant person.• Regulation 12 - Safe care and treatment (1) Care and treatment must be provided in a safe way for service users.• Regulation 13 - Safeguarding service users from abuse and improper treatment (1) Service users must be protected from abuse and improper treatment in accordance with this regulation.• Regulation 17 - Good governance (1) Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part.• Regulation 18 - Staffing (1) Sufficient numbers of suitably qualified, competent, skilled and experienced persons must be deployed in order to meet the requirements of this Part.• Regulation 19 - Fit and proper persons employed (1) Persons employed for the purposes of carrying on a regulated activity must— (a) be of good character, (b) have the qualifications, competence, skills and experience which are necessary for the work to be performed by them, and (c) be able by reason of their health, after reasonable adjustments are made, of properly performing tasks which are intrinsic to the work for which they are employed. (2) Recruitment procedures “must be established and operated effectively to ensure that persons employed meet the conditions…”

Self-Direction

[37]The right of appeal lies under section 32 (1) of the Act. The panel takes into account evidence as at the date of the hearing and considers the current position.[38]The burden of proving the breaches of the standards on which reliance is placed rests on the Respondent. The standard is the balance of probabilities.[39]The burden of satisfying us that the decision is today justified, necessary and proportionate, lies on the Respondent.[40]If a party makes an allegation, such as bias or bad faith, it bears the evidential burden of adducing evidence to prove that allegation on the balance of probabilities.[41]The panel can receive hearsay evidence. This can include records made by staff or others. The weight to be attached to such evidence falls to be evaluated in the context of all the evidence.[42]The panel can also receive opinion evidence. The weight to be attached to such evidence is a matter for evaluation in the context of all the evidence. In very general terms the panel considers issues such as the extent and/or basis of the knowledge and/or experience of the person giving their opinion as well as factors that may affect their objectivity.[43]On consideration of the appeal the Tribunal may confirm the decision or direct that it is to cease to have effect – see s. 32 (5). Under s. 32 (6) of the Act the Tribunal has power to vary any discretionary condition for the time being in force in respect of the regulated activity to which the appeal relates. A “discretionary condition” means any condition other than a registered manager condition required by s. 13. The Respondent’s Policy/Guidance on enforcement[44]In this appeal it is appropriate to summarise the main elements of the Respondent’s guidance on enforcement. We recognise that the Decision Tree (DT) must be read in the context of the Enforcement Policy (EP). Both policies provide guidance but emphasise the need for judgement in the individual circumstances of each case. The Enforcement Policy[45]The Introduction to the EP recognises that:
“there will be occasions, when, depending on the facts of an individual case it will not be appropriate to follow the precise steps described in this policy. It should be read as a general guide to good practice when carrying out or considering enforcement action. It cannot substitute for judgement in individual cases.”
[46]The purpose and principles of enforcement are described at pages 7 and 8 of the policy. The main features of the EP are that: a) The two primary purposes of the CQC are: 1. To protect people who use regulated services from harm and the risk of harm to ensure they receive health and social care services of an appropriate standard. 2. To hold providers to account for failures in how the service is provided. b) The principles that guide the use of enforcement powers make clear that the starting point for considering the use of all enforcement powers is to assess the harm or risk of harm to people using the service. c) As to Proportionality section 3 (at page 9) of the EP states:
“We will only take action that we judge to be proportionate. This means that our response, including the use of enforcement powers must be assessed by us to be proportionate to the circumstances of an individual case. Where appropriate, if the provider is able to improve the service on their own and the risks to people who use the service are not immediate we will generally work with them to improve standards rather than taking enforcement action. We will generally intervene if people are at an unacceptable risk of harm or providers are repeatedly or seriously failing to comply with their legal obligations.”
The Decision Tree[47]Stage 3 of the Decision Tree (DT) concerns the selection of appropriate enforcement action. Amongst other matters, this states:
“…the decision-making process seeks to ensure that we take consistent and proportionate actions without being too prescriptive. It should not result in mechanistic recommendations but should guide decision makers to reach appropriate decisions.”
This stage uses two criteria which are: · “Seriousness of the breach · Evidence of multiple and/or persistent breaches”. · “Seriousness of the breach · Evidence of multiple and/or persistent breaches”.[48]The DT then addresses Stage 3A (1) “Potential impact of the breach” which concerns the assessment of the level of the potential impact that would result if the breach of the legal requirements was repeated. It states:
“The focus is on reoccurrence to assess if we should act to protect people using regulated services from harm in the future.”
It provides three categories regarding the risk of harm: Major, Moderate and Minor.[49]“Major” is defined as:
“The breach, if repeated, would result in a serious risk to any person’s life, health or wellbeing including: · permanent disability · irreversible adverse condition · significant infringement of any person’s rights or welfare (of more than one month’s duration) and/or · major reduction in quality of life” · permanent disability · irreversible adverse condition · significant infringement of any person’s rights or welfare (of more than one month’s duration) and/or · major reduction in quality of life”
[50]“Moderate” is defined as “The breach, if repeated, would result in a risk of harm including: · temporary disability (of more than one week but less than one month’s duration · reversible adverse health condition · significant infringement of any person’s rights or welfare (of more than one week but less than one month’s duration); and/or · moderate reduction in quality of life.” · temporary disability (of more than one week but less than one month’s duration · reversible adverse health condition · significant infringement of any person’s rights or welfare (of more than one week but less than one month’s duration); and/or · moderate reduction in quality of life.”[51]“Minor” is defined as:
“The breach, if repeated, would result in a risk of: · Significant infringement of any person’s rights or welfare (of less than one week’s duration; and/or · minor reduction in quality of life · minor reversible health condition.” · Significant infringement of any person’s rights or welfare (of less than one week’s duration; and/or · minor reduction in quality of life · minor reversible health condition.”
[52]The next stage 3A (2) refers to the assessment of “Likelihood that the facts that led to the breach will happen again”. The likelihood should be based on the control measures and processes in place to manage the risks identified, including changes in practice.[53]Stage 3A (3) deals with the “Seriousness of the breach”. It provides a chart which, by reference to the assessment of the potential impact of the breach (3A (1) above), and the likelihood that the fact giving rise to the breach will happen again (3A (2)) above, produces a description of the potential impact in grid form ranging from low, medium, high and through to “extreme”.[54]Stage 3A (4) is then used to reach an initial recommendation about which enforcement powers should be used to protect people using the service from harm or the risk of harm. The initial recommendation where the seriousness of the breach has been identified as “Extreme” is:
“Urgent cancellation Urgent suspension Urgent imposition… of conditions.”
Urgent suspension Urgent imposition… of conditions.”

Urgent suspension

[55]Where the risk is judged to be “high” the initial recommendation is for the same actions as above but on a non-urgent basis (i.e. by reference to the ordinary enforcement measures, which require service of an NOP as a first step). This affords time (28 days) for any appellant to provide representations and to show how it will address issues going forward.[56]Stage 3B involves “Identifying multiple and/or persistent breaches.” This can result in a change to the initial recommendation for enforcement action by increasing or decreasing the severity. This stage involves consideration of the 3B factors: · 3B(1) Has there been a failure to assess or act on past risks? · 3B(2) Is there evidence of multiple breaches? · 3B(3) Does the provider’s track record show repeated breaches? 3B(4) Is there adequate leadership and governance? The DT guidance is that, depending on the answers to each of the above, inspectors should make an overall assessment about the most appropriate action to take. The answers to the 3(B) questions above may increase or decrease the severity of any recommended enforcement action.

Our Consideration

[57]We have considered all the witness statements, documentary and oral evidence before us, as well as the Respondent’s skeleton argument and oral closing submissions, in the round. If we do not refer to any particular part of the evidence or submissions, it should not be assumed that we have not taken all material before us into account.[58]The original Scott Schedule before us setout a number of allegations under separate headings regarding breaches of Regulation 10, 12, 13, 17, 18 and 19.[59]The Appellant’s responses in the original SS did not challenge the alleged breaches found on inspection in December 2024 but focused on improvements made since then. The Appellant confirmed at the outset of the hearing that he agreed with the inspector’s findings in December 2024. Indeed, we noted that at the post inspection feedback call on 6 December 2024 he had said:
“I accept everything you have said. When you are in service all the time you don’t see it. I accept it and will work on it to improve it.”
We find all the findings of the inspectors regarding the December 2024 inspection proved.[60]So far as the 30 September 2025 inspection was concerned the Appellant said at the start of the hearing that he did not accept the inspectors’ findings that the service was still in breach. He considered the service has improved and will continue to improve. The 30 September-2 October 2025 Inspection Report[61]The draft report before us was not the subject of any factual accuracy challenge by the Appellant. On this basis it was provided in these proceedings as a draft which was to be published (and was published) on 31 October 2025.[62]We set out some elements only from the Inspection report. (Where this refers to “people” this refers to either SUB (i.e. pre-May 2025) or SUA. Safe The service was in breach of legal regulations in relation to people’s safe care and treatment including the safety of the environment, cleanliness, the management of incidents and risks to people’s health. The service was also in breach of legal regulations in relation to people not being protected from abuse, safe staff levels, staff not receiving appropriate training and supervision, recruitment processes not being robust, and the lack of adherence to the principles of the MCA. Learning Culture The provider did not listen to concerns about safety and did not investigate safety events. Lessons were not learnt to continually identify and embed good practice. At the previous inspection we found accidents and incidents of distress were not recorded or completed in detail. At this inspection, we found this concern still remained. The provider failed to ensure when incidents relating to distressed behaviours occurred, sufficient action was taken to investigate what the triggers may be. There had 18 recorded incidents of distressed behaviour between February 2025 and May 2025. Whilst there was evidence the provider had reviewed all of these, there was very little action taken to reduce further occurrence. The majority of the incidents recorded that as a result the person was asked why they behaved in this way and for staff to monitor the person’s behaviour. This was not sufficient mitigation from the provider to ensure the person and others were protected from the risk of further incidents occurring. There was also no evidence that detailed debriefs were taking place with staff to understand and learn from incidents. Safe systems, pathways and transitions Where people required medical procedures there was a lack of planning to reduce the distress this may cause. For example, the management team told us 1 person was due to attend a health appointment at hospital. We saw from the records the person had anxiety when attending particular medical appointments. However, there had been no planning undertaken to reduce the stress this may cause the person such as attempts at de-sensitisation or a ‘Social Story’ (an individually created story to help a person individual understand a situation and so reduce their distress. When we raised this with the leaders, they told us had used ‘Social Stories’ for the person before and would ensure this was done for the hospital appointment. However, staff we spoke to said they had never used ‘Social Stories’ with the person and said, “We bring something that he likes maybe a cartoon on the phone. Just play it and hold his hands.” Safeguarding The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. At the previous inspection we found safeguarding incidents were not investigated appropriately or reported to the local authority. We found on this inspection this had not improved sufficiently. People were being deprived of their liberty without appropriate authorisation to do so. One person had multiple restrictions placed on them including their wardrobe doors being locked by staff, having to hold staff’s hands all the time they were out and the front door being locked when they were in their home. There were no decision specific capacity assessments in relation to this or evidence of any best interest meetings to determine what least restriction options had been considered. There was no evidence these decisions had been re-visited to ensure they remained the least restrictive options in line with the MCA. Involving people to manage risks There was no formal monitoring of a person’s bowel movements. Their care notes showed multiple incidents of where either the person had not opened their bowels for 3 to 4 days or at times recording the person had a Type 6 or 7 bowel movement which could indicate the person was constipated. There was also no risk assessment in place for staff with guidance around signs to look out for should the person be constipated. Staff were also not knowledgeable around the monitoring of constipation. One told us they would raise concerns if the person had not opened their bowels for 2 days and when asked if they understood how to record types of bowel movements (based on the Bristol Stool chart) they said, “I don’t know about types.” They did however say that they would raise concerns if the person had loose bowels or struggled to pass a bowel movement. People with a learning disability are at a significantly higher risk of constipation compared to the general population, and it can have serious or even life-threatening consequences if left unaddressed. Safe and Effective Staffing The provider told us, “We are taking into account the recommendations from the last inspection so that staff are not overworked.” However, we saw from the rotas for September 2025 that 1 member of staff worked 5 awake nights and 4 awake nights in a row. This risked the member of staff being fatigued and placed people at risk. In addition, staff fed back they were allowed to work 4-5 nights in a row and had not been told that 3 nights were the maximum. Staff lacked a good understanding of autism and learning disability. Although work had been completed by the provider to update staff files following our last inspection, we still found that checks did not comply with Regulation 19, specifically schedule 3. Of the 4 staff files we reviewed, only 1 had the complete work history. One member of staff did not have a fully completed interview form, including information of who caried out the interview. One staff file had a reference from an employer that was not listed on their work history. This meant the provider could not be assured of the staff’s suitability to work at the service. Providing Information The provider did not supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs. People did not have information provided in a format that they would understand. Leaders also lacked understanding of how best people communicated. Leaders told us that people did not use any alternative communication aids. The manager showed us a stack of ‘British Sign Language’ (BSL) books for a person they supported that they said they wanted staff to teach the person. However, the person would have been more suited to a simpler version of sign language including ‘Makaton’ (a language program that uses a combination of speech, signs, and picture symbols to help people with learning and communication difficulties to communicate and understand.) A relative told us, “In secondary school (person) used Makaton and picture exchange, doesn’t use any of that here, I don’t think the staff are trained.” During the visit we did not see staff using any alternative communication aids for people. One member of staff told us they just relied on the person’s body language to interpret what they wanted and that, “I don't know much about Makaton.” When asked if they felt they and the person could learn more Makaton signs they said, “Yeah, I could learn more and then (person) can learn.” Yet no action had been taken to give the person (i.e SUA) this opportunity.[63]We heard oral evidence from all the Respondent’s witnesses. In the circumstances of this appeal we summarise the particular points of Mrs Creech’s witness statement regarding the new breaches found at inspection on 30 September 2025. Regulation 9 – Person-centred care[64]Mrs Creech considered that the service was in breach of Regulation 9, for reasons that included that: a) There was no detailed information in the care plan about SUA’s life history. SM9 had said that the care plan was detailed but when asked if aware of SUA’s life history and had spoken to relatives SM said they had not got to that. b) SUA did not have a meaningful everyday life, and the care and support was not person-centred, planned, proactive and coordinated. He was not given opportunities to go out in the evenings or have a good quality of life, in line with nationally recognised best practice guidance in “RSRCRC” and the Reach Standards. Day time activities recorded over 19 days were limited. Activities within the home were limited to playing with 1 sorting game, watching television, using a sensory light on 1 occasion and kicking a football. c) There were no separate sensory spaces, (other than SUA’s bedroom), where he could move to when at a heightened state of anxiety, or to enjoy interactive sensory sessions. SUA’s bedroom was stark and just contained the bed and wardrobes. There was 1 sensory light on the ceiling however according to their electronic care notes between 11 - 29 September 2025 this had only been used once. This meant that SUA was not supported with activities to assist them with their sensory needs. d) In the Appellant’s witness statement of 9 July 2025 it was stated they were actively seeking the views of service users about how they were spoken to and treated. The provider and SM9 told Mrs Creech that SUA was not able to verbally communicate, and this was confirmed in their care plan. There was limited information as to how SUA expressed himself in the care plan. There was a lack of guidance for staff around how to understand SUA’s alternative way of communicating in a meaningful way. Mrs Creech did not observe staff using any other alternative communication to assist SUA to make choices. On 30 September 2025, SM9 told her there were no alternative communication aids in the home, including pictorial aids or communication boards. Staff told the inspectors that SUA was able to use some simple Makaton signs however no staff had received any training in Makaton. On 2 October 2025, SM9 emailed a letter from the Speech and Language Therapist (SaLT) dated 16 December 2015 relating to when SUA first moved into Ruth Lodge. This stated that SUA had been provided with a communication passport, visual times tables and advice on ‘intensive interaction’. None of this information or guidance was available at Ruth Lodge and no action had been taken to contact the SaLT for more updated advice and guidance on this. This meant that SUA was not supported with their communication needs.

Regulation 11 - Need for Consent

[65]Mrs Creech considered that the Appellant failed to ensure SUA’s rights were protected because the service lacked understanding of the Mental Capacity Act 2005 (MCA), its Code of Practice and how to apply it to service users’ individual circumstances. There was no capacity assessment undertaken in relation to the following matters or evidence or any best interests’ discussion around what other least restrictive options had been considered: a) On the 30 September 2025, the provider and SM9 told Mrs Creech that SUA required a cavity to be filled in their tooth. The provider said that as SUA had a fear of needles the treatment for this had been arranged at St Thomas’s hospital in London in October 2025 because SUA would require a general anaesthetic (GA) due to their fear of needles. We were informed that it was considered that the hospital would take consent on the day. In our view the main point here is that undergoing a GA is a very significant procedure, that should be avoided unless it is truly necessary. In our specialist experience there are programmes readily available that can, over time, be used to seek to overcome difficulties in advance. There was no evidence that any consideration had been given by leadership and management at Ruth Lodge as to the need to seek to prepare SUA over time so that he might be able to undergo a simple filing without GA. b) There were locks on SUA’s bedroom wardrobes. The provider and SM9 said the reason for this was because in the past SUA had pulled clothes out of the wardrobe. There was no understanding this amounted to a restriction that required assessment under the MCA.[66]There was little or no effective challenge to the evidence of Mrs Creech or Mrs Contla-Robinson. (When he later came to give evidence Mr Agbetorwoka confirmed that he accepted all of the breaches found during the inspection on 30 September 2025.)[67]In her statement dated 2 July 2025 Mrs Montgomery had stated that when she was briefed on the findings made by the inspectors she was “alarmed by the complete lack of any robust risk assessments, the use of unlawful restraint, widespread undignified treatment of service users, an unsafe environment, very poor infection control, a complete lack of oversight from the provider, and significant shortfalls in staff deployment and staff training. This was particularly concerning to me given the complex needs that service users in the service user group lived with. There was nothing in place to ensure they were supported safely, and they were at significant risk.”[68]With specific regard to Regulation 10 she stated she:
“was also shocked by the complete lack of care, compassion, dignity and respect afforded to service users. At the very least CQC would expect to see a culture and foundation of true care and support, which had service users at the centre of everything. I would expect there to be robust and holistic policies and practices underpinning this, including visible role models who set clear expectations for staff, and challenged practice that was disrespectful, uncaring, and lacked compassion. The Appellant demonstrated the complete opposite of this: there was nothing approaching that in the service…”
[69]The Appellant asked Mrs Montgomery a number of questions regarding the challenges presented by SUB and that this accounted for the situation that the inspectors found. Her response was that, as at December 2024 and to date, staff have not undertaken any significant training in positive behaviour support. There was a real lack of guidance or strategies for staff to employ to provide consistent support.[70]In her witness statement, and with specific regard the breach of regulation 17 (governance) Mrs Montgomery stated she was “concerned by the Appellant’s completely inadequate governance arrangements. Not only were systems not in place to ensure that service users received safe and effective care, but the Appellant also made it clear that he did not put any importance on having such systems in place. He operated in a haphazard manner, seemingly oblivious to the poor care and treatment service users received, with no regard to meeting previous breaches, or recognising the current breaches. There was a disconnect between the service received by service users and the Appellant’s responsibility to ensure the service was well-run and well governed. There was a lack of monitoring, quality assurance, and liaising with stakeholders and oversight, all of which exacerbated the risks to service users and led to the breach of Regulation 17 of the 2014 Regulations.”[71]Mrs Montgomery said in her statement that she had come across very few service providers like this in her career. In her oral evidence she said that in the course of her role she has been involved in decision making regarding in about 1,000 services. She believed that this was the only time she had ever referred to a “complete lack of care, compassion, dignity and respect.”[72]Mrs Montgomery said that nothing in the March 2025 mock inspection document recently produced reassured her. Her overall comment was that it was very superficial. There were major gaps such as the issue regarding management of constipation which was not mentioned at all. Despite the fact that the NOP could not have been clearer few actions were recorded. The completed columns were aspirational and not factual.[73]The Appellant asked Mrs Montgomery why, if the service was so bad, Medway Council (the local authority/LA) had “not taken SUB away” (when that had been requested by the Appellant over a long period) and/or why the service was still running. Mrs Montgomery explained that the CQC had considered urgent action but this could only be done if the local authority agreed. Both SUB and SUA had complex needs and the need to find new placements urgently could be detrimental to their interests. The expectation is that the provider and the LA will manage the risks at the service (pending enforcement on a non-urgent basis). In our experience a regulatory body has to consider a wide range of balancing factors when considering the action it needs to take.[74]In her oral evidence Mrs Jupp explained that the inspection framework introduced in 2023 had altered the process, but the principles of inspection have not fundamentally changed. The regulations regarding the fundamental standards have been in force since 2014. She explained she was concerned by the lack of strategic approach or drive towards improvement at Ruth Lodge. Her view was that the evidence regarding improvement since December 2024 was a low-level attempt to fix breaches but there was no evidence of good governance or a drive to improve. She appreciated that there had been good faith attempts to fix some of the issues, and some environmental aspects had been changed, but the service was inadequate. When a service lacks the skills or competence to deliver care it impacts upon the entire life of a vulnerable service user. There had been serious health inequalities in SUA’s care.[75]Following an adjournment over midday Mr Agbetorwoka said he did have any questions for Mrs Jupp. He thanked her for explaining matters in a clear and courteous way. He said “I will go back now I have a direction to go to. I can really see the way forward.”[76]In answer to the panel Mrs Jupp said that she had not seen anything in the mock inspection that caused her to amend of vary her view. The March 2025 mock inspection was quite old and was superseded by the September 2025 inspection.[77]We considered the evidence of Mr Bello carefully. We are very circumspect regarding our findings because we recognise that Mr Bello has the individual right to make representations in response to the NoP dated 31 October 2025 to refuse his application to be the RM at Ruth Lodge. If the ultimate decision on his application were to be adverse, he will have a right of appeal.[78]Mr Bello told us that he had been a registered manager employed by a provider between 2019 and 2021 working in accommodation for about seven service users. He then changed employment because he wanted to live nearer to home in London and he had moved to a role managing a supported living service for 10 service users run by a local authority.[79]In our view Mr Bello had relatively limited relevant experience when he was appointed as a manager (i.e. aspiring to be registered as a manager at Ruth Lodge by the CQC) for the provision of care for those with complex learning disabilities and autism. He had limited experience and/or training regarding complex LD and autism. We were told that he had been interviewed by Mr Dzvairo. It emerged that Mr Bello was engaged by the Appellant to act as manager, not only for all three locations under the registration, but also for a number of unregulated supported living (SL) services run by the Appellant company. We noted that most of Mr Bello’s experience as a manager had been in supported living services. We consider that this is a very different skill-set to the skills, competence and experience required to manage or lead (amongst other roles) a home for a person/persons with complex learning disabilities (LD) needs and autism.[80]In answer to a question from the Appellant, Mr Bello gave a lengthy answer which tended to focus on the improvements made to basic matters regarding the physical environment. In our view he was unable to satisfactorily address the fundamental issues regarding the quality of care provided.[81]As part of his appeal Mr Agbetorwoka relied on a document that he said was a document used in training by Mr Bello (item 28 red file). Although partly cut off in printing we find that this document was headed “RSRCRC”. The contents did not purport to address the underlying principles of “Right Support, Right Care, Right Culture” but, in our view, reflected a very basic summary regarding Rights, Safety, Responsibilities, Confidentiality and Respect (the next “C” was not before us). We stress that there was nothing wrong with the document as a training aid as such, but overall it tends to suggest that leadership and management at the service had a limited understanding of the real import of the statutory guidance in RSRCRC.[82]We considered Mr Dzvairo’s evidence. His statement, made in July 2025, was remarkably brief. This stated that he became the NI for Ruth Lodge on 12 May 2025. We were told that he had recently resigned because of other commitments. The startling feature is that Mr Dzvairo’s witness statement plainly referenced his observations at Brooklands, rather than at Ruth Lodge because he referred to a particular female resident. He told us that when, in his statement, he referred to the mock inspection at Ruth Lodge he was relying on the views of his team. He said that he was not 100 % sure when he last attended Ruth Lodge but had been there once in the summer. He went to meet Mr Agbetorwoka and had had a quick walk around the care homes.[83]We were very unimpressed by Mr Dzvairo ’s evidence. When someone seeks to support the continuance of a service from the viewpoint of having become the NI, as well as in the role of consultant in an external consultancy service recruited to provide advice and support, we would ordinarily expect to see cogent evidence contained in a witness statement that addresses the core issues, including that of risk. In our view this was wholly lacking. In our view Mr Dzvairo’s approach both in his statement and oral evidence was superficial. We attach no weight to his opinion.[84]Given the relative lack of challenge to the evidence of the CQC witnesses and the explicit acceptance of Mrs Jupp’s evidence we took time to ensure we understood Mr Agbetorwoka’s current position. In particular, the judge explained to him that if he was saying that all facts and breaches regarding the 30 September inspection were admitted (all breaches relied on by the Respondent re the December 2024 inspection having already been admitted) then the reality was that the outstanding issues for the panel would be the assessment of risk and proportionality. He confirmed that this was his position. His overarching point was that, having heard Mrs Jupp explain matters, he now understands more: the service will improve so it is proportionate that the appeals are allowed. When he gave evidence the judge helped him to introduce his statements, and other responses, as well as his background[85]For the avoidance of any doubt, we should say that in so far as there had been any relevant conflict between the evidence of the Appellant and/or his witnesses, and those for the Respondent we prefer the evidence of the inspectors. In our view the evidence of each of the inspectors was evidence-based, clear and cogent. Mrs Creech and Mrs Alina-Robinson were consistent, credible and reliable witnesses. Their opinions regarding breach of the relevant standards were measured and reasonable. We accept their evidence. We find all the breaches alleged regarding the December 2024 inspection proved on the Appellant’s admission. We find that the Respondent has proved all the breaches alleged regarding the 30 September 2025 inspection.[86]Having found the breaches of the standards contained in the SS (updated) proved as set out above, we turn to our consideration of the potential impact of such breaches and the issue of risk. In our view Mrs Montgomery and Mrs Jupp were very impressive witnesses. We accept that the opinions expressed by each of them were evidence-based and sincerely held.[87]Overall, we consider that the nature and extent of the admitted breaches amount to serious, multiple and repeated departures from fundamental standards set out in the regulations, and on a persistent basis.[88]Section 4 (b) of the Act requires the Respondent (and so the panel) to have regard to the views of service users. Mrs A, the mother of SUA, attended the hearing via video, and had heard the evidence given by the CQC witnesses, Mr Bello and the Appellant.[89]Mrs A told us that a social worker from Medway Council had very recently asked to meet with her regarding finding a new home for SUA. She had asked the social worker to postpone this meeting pending the decision of the Tribunal. We noted Mrs A’s evidence that she had not read the September 2025 inspection report. She said that Mr Bello spoke to her about it. In very broad summary, her view is that her son has always been happy to return to Ruth Lodge (i.e. after home visits). She has never had any basis for comparison in terms of residential care. She told us that when he came to Ruth Lodge from his residential school her son been used to communicating with Makaton. Generally, she welcomes the recent improvements that have been made at Ruth Lodge. She wants her son to remain at Ruth Lodge, provided that the service continues to improve.[90]It is wholly understandable that Mrs A is extremely concerned about the prospect of her son having to leave Ruth Lodge. The reality is that SUA has lived at Ruth Lodge since 2013 when he was 19 years old. He has spent all of adult life there. We recognise that risk is necessarily involved whenever it is proposed that a vulnerable service user has to move and adjust to a new home. However, it is very clear to us that the care with which SUA has been provided at Ruth Lodge has been consistently below fundamental standards. It was also very clear to us that Mrs A’s support for her adult child remaining at Ruth Lodge is dependent on improvements continuing. As we explained to her, the issue of improvement, risk and proportionality are ultimately are a matter for us to assess, but we take into account her views and wishes.[91]When considering the discharge of our functions, standing in the shoes of the Commission, we are also required to have regard to the views of contractors - see s. 4 (c). On the evidence before us the only contractor is Medway Council. They have contracted and paid for the services provided by the Appellant for many years at public expense. As we have said notice of termination was given by Medway Council for both supported living and residential contracts on 27 October 2025.[92]We have considered the overall context of the service provided and have considered the Enforcement Policy and the Decision Tree. It appears to us today on the basis of all of the material before us that:• the potential impact of the breach in terms of the risk to life, health or wellbeing to which SUA or any future service user will or may be exposed if enforcement measures are not taken is at least moderate and the likelihood of future breach is at least probable. The seriousness is, therefore properly categorized as (at least) “high”. This gives rise to an initial recommendation of cancellation, suspension or more significant conditions.• the analysis of each of the 3B (1) to (4) factors is not in the Appellant’s’ favour. In summary we find that: 1) There has been a repeated failure to assess or act on past risks. 2) There is clear evidence of multiple breaches. 3) The provider’s track record shows repeated breaches. 4) Leadership and governance is inadequate.• Although there have been some improvements in the service provided, the service is still in significant breach of regulations 10, 11, 12, 13, 17 and 19 which the Respondent found in December 2024, and is also in breach of regulations 9 and 11 which were new breaches found at the inspection on 30 September 2025. Mr Agbetorwoka’s case is that he has learned a lot during the hearing, and having heard Mrs Jupp’s evidence, he now understands what is needed and he can, and will, improve. The effect of his evidence was that her evidence represented a “light-bulb” moment. However, it has to be recognized that the Appellant has repeatedly said before that he now understands and will improve: he said this in December 2024; in his representations to the NoP; in his appeal in March 2025; in his witness evidence in July 2025, and in this appeal.• In our view the improvements that have been made largely relate to the physical premises/environment. There have been some other efforts to improve but these are not complete or embedded. In any event we consider that the nature, range and extent of the continuing and new breaches (found at inspection on 30 September 2025) are so fundamental that they cause very significant concern regarding the ethos and culture of the service provided.• The Appellant relies on various changes in relation to training and/or audit processes. We have very little confidence that such improvements as have been made will be sustained because of our overarching and profound concerns about the adequacy of the leadership and management at Ruth Lodge.• A central issue is that of governance – regulation 17. In our view the overall response to the range and seriousness of the matters raised by the Respondent shows has been both reactive and tokenistic. We agree that some improvements have been effected but, in our view, such changes can fairly be described as “too little and too late”. In our view the bulk of the breaches proved are very serious and go to the very heart of the quality of SUA’s life/experience, health and well-being. We consider that the continuing and new breaches arose because the engrained culture at Ruth Lodge was not, and is not, to place SUA at the centre, or to strive to improve the quality of care provided to him or the quality of his life and experiences. In our view there is no realistic prospect that this engrained culture will change. We have no confidence at all that the Appellant is able to effect or drive the necessary improvements.• In our view a particularly disturbing feature in this case (amongst many) is the lack of any effort from 2013 to give SUA with any choice or voice by using simple communication aids. The extent to which this has been addressed since the inspection in December 2024 appears to be based on an assumption that Pictorial BSL is commensurate to Makaton and, further, that SUA would be able to benefit from this without in-depth support and training. The evidence of the Appellant and Mr Bello indicated a lack of understanding of how gestural communication systems may provide effective means of communication for people with a learning disability and/or autism. SUA had some functional communication using Makaton when he arrived at Ruth Lodge but this was not developed by the service run by the Appellant.[93]We consider that the Appellant’s stated intentions regarding voluntary liquidation lack coherence. The effect of his evidence was that a petition had been lodged by his solicitor the day before but with a request that it be put on hold until January 2026. At its core, the Appellant seeks that the decision to vary the registration (which amounts to cancellation) is set aside so that, at some stage, the service at Ruth Lodge might, by some means or other, continue to be managed by another provider/someone other than himself. He told us that he no longer intends to be involved in the provision of social care. He nonetheless contends that it is in the interests of SUA that he continues to be cared for at Ruth Lodge. He relies on the evidence of Mrs A. He considers it proportionate that the service is given the opportunity to improve.[94]In our view Mr Agbetorwoka has no proper understanding of the 2014 regulations. We also find that he has no understanding of the extent to which the quality of SUA’s life had been adversely impacted by the very inadequate level of care that has been provided to him at Ruth Lodge. We have found that the engrained and closed culture at the setting is such that little or no respect has been shown for the rights of SUA. In our view the quality of care provided to SUA has been, and continues to be, very poor indeed. We do not consider that the needs of SUA are, or have ever been, at the center of how Ruth Lodge has been run.[95]We are satisfied that the Appellant has had very ample opportunity to address the issues but the evidence regarding the 30 September 2025 inspection shows that, although there has been some improvement this has been very limited. Significant breaches of the fundamental standards of care have continued and new breaches have emerged. It might be said that the Appellant has shown some insight in accepting the breaches found regarding both the December 2024 and the 30 September 2025 inspection. In our view this is not true insight. We consider that such insight as has been shown was a reaction to regulatory action. We consider that, as amply shown at the hearing, Mr Agbetorwoka does not understand the extent to which the care he has provided has failed to meet the fundamental needs of SUA. He relies on the evidence of Mrs A to support his wish to continue the service for as long as possible. We are unable to attach any weight at all to his assurances that he has learnt a lot, now understands what is required, and will now deliver.[96]We must have regard to the issue of risk in a number of respects and must seek to protect the safety, needs and interests of both current and future service users. We consider that it is a matter of very serious concern that on 30 September 2025 breaches of fundamental standards under regulations 10, 12, 13, 17, 18 and 19 persisted, and new breaches regarding regulation 11 and 19 were found. This is disturbing given that since 13 May 2025 there has only been one service user (SUA) living at Ruth Lodge, SUB having moved to a new placement.[97]We find that the continuance of the regulated activity at the location by the Appellant poses serious risk to the health and well-being of SUA and any service user who might come to live there in future. In terms of proportionality we have considered whether other conditions might address the risk we have identified. Given our findings above we consider that there are no conditions that could realistically be devised to reasonably address the risk to the health, safety and well-being of SUA and/or any other service users which might otherwise come to live at Ruth Lodge in future. We have no confidence at all in the leadership and management at Ruth Lodge. We have no confidence that Mr Agbetorwoka, in his capacity as provider and/or as RM, is either willing or able to address the multiple and serious wide-ranging issues which have led to the needs of SUA not being met in the past, or even now.[98]The Appellant’s personal and business interests are such as to engage the protection of the ECHR by reference to Article 1 of Protocol 1 and Article 8. 1) The Respondent has satisfied us that that the decision taken was in accordance with the law. 2) We are also satisfied that the decisions were objectively justified and necessary in order to protect the safety, wellbeing, and needs of vulnerable persons such as SUA. The decisions made are also justified in order to maintain and promote public confidence in the system of regulation. 3) In reaching our decision on the issue of proportionality, we recognise that the impact of this decision is very serious. The decision made will bring an end to the Appellant’s registration as a provider, and as a registered manager, at this location and with significant impact upon his reputation, career and business interests beyond Ruth Lodge. The decision will also affect Mrs A and her son. It will also affect current employees of the Appellant company. 4) We have balanced the impact of the decision upon the Appellant and all concerned against the public interest. The Respondent has satisfied us that the decisions to vary the condition of registration so as to remove Ruth Lodge from the current registration, and to remove Mr Agbetorwoka as the registered manager were (and remain) justified, necessary and proportionate to the risks against which safeguards should be provided. Decision Both appeals are dismissed. The Respondent’s decisions dated 27 February 2025 and 15 May 2025 are confirmed. Judge Siobhan Goodrich First-tier Tribunal (Health Education and Social Care) Date Issued: 24 November 2025