Advinia Care Homes Limited v Care Quality Commission [2026] UKFTT 706 (HESC)
[1]Prior to the hearing, the Tribunal made an order pursuant to Rule 14(1)(a) and (b) of the Tribunal Procedure Rules 2008, prohibiting the disclosure and publication of any matter likely to lead members of the public to identify persons the Tribunal considers should not be identified, namely any service users.The appeal
[2]This is Advinia Care Homes Limited’s (‘Appellant’ or ‘Advinia’ hereafter) appeal against a decision of the Care Quality Commission (‘CQC’ or ‘Respondent’ hereafter) to vary its conditions of registration as a provider in respect of the regulated activities of accommodation for person who require nursing or personal care and treatment of disease, disorder and injury from the location of Gorton Parks Care Home, 121 Taylor Street, Manchester, Lancashire, M18 8DF.[3]The Appellant appeals the Respondent’s decision of 25 July 2025 pursuant to section 32 of the Health and Social Care Act 2008 (‘the Act’) to the First-tier Tribunal (‘the Tribunal’).The hearing
[4]The hearing took place over four days from 21 to 24 April 2026. The parties and their witnesses attended the hearing remotely throughout, following an order dated 15 April 2026 from Judge Khan.[5]In advance of the hearing, the Tribunal had read the digital hearing bundle (running to 9972 pages), concentrating in particular on the evidence set out in the recommended reading list. The Tribunal had also read the supplementary hearing bundle of 85 pages, containing the two skeleton arguments.Attendance
[6]The Appellant was represented by Mr David Pojur, instructed by Ms Jenny Wilde from Acuity Law and the Respondent by Mr Oliver Connor, instructed by Mr Ian Leslie from Hill Dickinson LLP.[7]The Respondent called one witness, Mrs Alison Chilton, Deputy Director of Adult Social Care, North region. The Tribunal also heard oral evidence from Mrs Linda Jackson, lead inspector. Mrs Victoria Bennett, operations manager, and Mrs Avril Frankl, medical inspector, also attended the hearing on behalf of the Respondent, but the Tribunal did not require them to provide oral evidence.[8]The Appellant called six witnesses, as follows:• Mr Anthony Carlin, interim home manager of Gorton Parks Care Home;• Miss Kate McKenna, head of quality and compliance at Advinia;• Mr Sanjeev Kanoria, owner and Chair of Advinia;• Mr Stephen Baker, Chief Executive Officer at Advinia and nominated individual with the CQC;• Mr Michael Donvan, former Chief Operating Officer at Advinia; and• Miss Doriann Bailey, director of delivery at Fulcrum Care Ltd.Preliminary issues
[9]At the beginning of the hearing, Mr Pojur confirmed that the Appellant accepted the factual concerns raised by the Respondent at the 2025 and 2026 inspections ad did not seek to contest the evidence in that regard. The Appellant’s position as made clear, the Appellant considered the regulatory concerns, identified at the two most recent inspections, to be historic and due to the steps taken by the Appellant at a local manager level and at a senior leadership level, since approximately February 2026, it was no longer proportionate to effectively cancel the ability of Gorton Parks Care Home to operate.Background
[10]The Appellant is registered to provide regulated activities from a number of locations, or care homes, throughout England and Scotland. In England, it has regulatory responsibility for 22 care homes and in Scotland the number is 14.[11]The location of Gorton Parks Care Home (‘Gorton Parks’) can accommodate 120 service users to provide the regulated activities of accommodation for persons who require nursing or personal care and treatment of disease, disorder and injury. Gorton Parks has been registered as a location since 30 November 2017. It is a multi-site care home, with six sites, staffed by nursing and care staff. In the past, one site was operated by a NHS service, there were then four houses to provide residency for service users and then a sixth site with reception and kitchen services.[12]Between 20 and 22 November 2018, an inspection took place which resulted in an overall rating of requires improvement. Between 10 and 11 June 2019, an inspection took place which resulted in an overall rating of requires improvement. A targeted inspection took place on 5 November 23019 with a rating of requires improvement. Between 10 and 13 May 2021, a targeted inspection took place which resulted in a rating of requires improvement. A targeted inspection took place between 27 September and 4 October 2022 which resulted in a rating of good.[13]A responsive inspection took place on 8 July and 7 August 2024, which resulted in an overall rating of requires improvement, with breaches of Regulations 9, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (‘the Regulations’) identified. As a result, the Respondent issued a warning notice for failure to comply with Regulation 12 (safe care and treatment). The warning notice was not completed with by the set deadline for compliance.[14]Between 13 February and 5 March 2025, an unannounced comprehensive inspection took place which led to an overall rating of inadequate. The inspection team identified breaches of Regulations 9, 12 14, 17 and 18. As a result of this, a notice of proposal was issued to the Appellant on 21 May 2025, which proposed to vary the conditions of registration to remove the location of Gorton Parks from providing the aforementioned regulated activities. The Appellant sent detailed representations on 18 June 2025, which were considered by a different decision-making department at the Respondent and on 25 July 2025, the notice of decision notified that Appellant that the CQC had decided to adopt the proposal.[15]On 21 August 2025, the Appellant sent its appeal application to the First-tier Tribunal (Care Standards). A key point made in the appeal application, as made in the earlier representations to the notice of proposal, was the fact that the concerns identified at the inspection in February 2025 were historic, with the need for a new inspection to take place.[16]Between 5 and 16 January 2026, a comprehensive inspection took place, led by Mrs Jackson, with Mrs Frankl also in attendance, as they both had been during the inspection process of February 2025. The inspectors identified breaches of Regulations 9 (person centred care), 12 (safe care and treatment), 14 (meeting nutritional and hydration needs), 17 (good governance), 18 (staffing) and 19 (fit and proper persons employed) and rated Gorton Parks as inadequate.[17]The inspection report was published on 11 March 2026.The legal framework
[18]Section 2 of theHealth and Social Care Act 2008 (‘the 2008 Act’) invests in the Respondent registration and review and investigation functions. By virtue of section 3(1) of the 2008 Act, the Respondent’s main objective is to protect and promote the health, safety and welfare of the people who use the health and social care services.[19]Section 4 of the 2008 Act sets out the matters to which the Respondent must have regard, including the views expressed by or on behalf of the members of the public about health and social care services, experiences of people who use the health and social care services and their families and friends and the need to protect and promote the rights of people who use health and social care services. Any action taken by the Respondent should be proportionate to the risks against which it would afford safeguards and is targeted only where it is needed.[20]Section 17 of the 2008 Act empowers the Respondent to cancel the registration of a service provider in respect of a regulated activity on a number of grounds, which includes on the ground of the regulated activity being carried out otherwise than in accordance with the relevant requirements and on any ground specified by regulations. It was common ground between the parties that section 17 was relevant to this appeal, given that the variation of the conditions of registration for Gorton Parks amounted to cancellation for that particular care home.[21]Under section 20 of the 2008 Act, the Secretary of State is empowered to make regulations in relation to the regulated activities by way of regulations. The Regulations made under this section are the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, SI 2014/2936 (‘the Regulations’) and The CQC (Registration) Regulations 2009.[22]Sections 26, 27 and 28 of the Act set out the procedural requirements in relation to notification of the Respondent’s decision.[23]Section 32 of the Act provides for a right of appeal to this Tribunal against a decision to vary conditions of registration of a service provider in relation to a regulated activity. The Tribunal may confirm the decision or direct that it is not to have effect. Under section 32(6), the Tribunal also has power to direct that any such discretionary condition as the Tribunal thinks fit shall have effect in respect of the regulated activity. A ‘discretionary condition’ means any condition other than a registered manager condition required by section 13(1) of the Act.[24]Part 3 of the Regulations sets out the Fundamental Standards that registered providers must comply with when carrying on a regulated activity, namely Regulations 4 to 20.[25]The Respondent bears the burden of establishing that it is more likely than not that the 2014 Regulations have not been complied with at the date of the hearing, including ‘by having regard to’ guidance issued under section 23 of the 2008 Act. On appeal, any findings of fact are made on the basis of whether or not the Tribunal is satisfied as to the facts on the balance of probabilities.[26]The Tribunal is required to determine the matter afresh and make its own decision on the merits and evidence as of the date of hearing. Subject only to relevance and fairness, this can include new information that was not available or presented at the time when the decision under appeal was made and the information can be admitted as evidence in the appeal, even if it were not admissible in civil proceedings in England and Wales. The fresh determination in this appeal includes consideration of the detailed documentary evidence provided by both parties, as well as the oral evidence, subject to questioning over the four days of the hearing.[27]The key question for the Tribunal is this: was the decision proportionate and reasonable at the time it was made, and does it remain so, in light of the steps taken by the Appellant since the decision was made?[28]We have considered all of the evidence and the written submissions before us, even if we do not mention every point of it in our decision. We refer only to the parts of the evidence which were of particular importance in reaching our findings, noting that the proceedings were video recorded throughout the public hearing and both parties had made arrangements to take notes of the evidence.The parties’ positions
[29]With the benefit of skeleton arguments and closing oral submissions from Mr Connor and Mr Pojur, their respective positions were clear.[30]The Appellant contended that there had been difficulties with Gorton Parks in the past, but it was now in a position to demonstrate full compliance with the Regulations within the next six months, on the reckoning of most of the witnesses for the Appellant. The Appellant had expended and continues to expend significant resources to provide a level of support with the ultimate goal of turning around Gorton Parks. The Appellant is carrying out a process of consolidation, having completed refurbishment work on two of its sites. The consolidation process also involves a redundancy exercise for staff who have been identified as underperforming and/or not possessing the attitude and competence required to support vulnerable services users. The primary position of the Appellant is that because of its dedication to improvement in care standards, the Tribunal should allow the appeal with no further conditions on the registration for Gorton Parks. In the alternative, if the Tribunal continued to have concerns about safe and effective care, the Tribunal should consider varying the conditions of registration to place a cap on the number of service users at Gorton Parks or a staged admissions process, in consultation with the Respondent. The Appellant placed weight on the need to continue to provide the regulated activities at Gorton Parks due to the limited options open to Manchester City Council, a position the Appellant submitted was supported by a letter dated 2 April 2026 from Mr Paul Bickerton, head of commissioning for older people and prevention.[31]The Respondent defended the appeal on the basis that its decision-making process and the decision subject to appeal have been fair, reasonable and proportionate at each stage. The Respondent relied upon the outcomes of the two most recent inspections, as well as the wider regulatory history for Gorton Parks, including the warning notice from 2024 and the response to it. The Respondent took the view that while some improvement had been noted, it was not such a significant improvement to justify the Respondent considering a less serious regulatory response than varying the conditions to prevent Goron Parks from delivering regulated activities.[32]The Respondent submitted that it reviewed its position after the most recent inspection, as well as the further evidence from the Appellant in advance of the hearing and the oral evidence during the hearing. It did not consider the improvements made to Gorton Parks sufficient to allay its evidence informed belief that the Appellant does not have the competence, skills, processes and systems to ensure any improvements are embedded, can be sustained and will demonstrate full compliance with the Regulations in the near future.Evidence
[33]The oral and documentary evidence is referred to only as it is required to explain our findings and conclusions. The Tribunal noted that the public hearing was recorded and therefore we do not consider it necessary to set out a lengthy summary of the oral and documentary evidence.The Tribunal’s conclusions with reasons
[34]For the reasons which follow, we have decided to direct that the Respondent’s decision is confirmed pursuant to section 32(5) of the Act.[35]The Tribunal found all the witnesses to be helpful and credible in their oral evidence, in particular Mr Carlin and Mrs Chilton.[36]Two watchwords for the Tribunal throughout the appeal were reassurance and sustainability. This was often referred to by the Appellant’s witnesses as embedding changes and improvements. This was central to the Tribunal’s assessment of the steps taken by the Appellant since the inspection in February 2025. During the Appellant’s closing submissions, Mr Pojur invited the Tribunal to consider the proposition that we could divorce the regulatory history from the steps undertaken since the most recent inspection’s feedback became clear to the Appellant, when the Respondent shared its draft report in February 2026. To be clear, the regulatory history of a service provider or a service which is providing regulated activities is highly relevant to the proportionality of the decision being appealed. It goes directly to the Tribunal being able to conclude, with confidence, that the service will be able to sustain any improvements or changes it has made to lead to full compliance with the Regulations. It also helps the Tribunal make an informed assessment of the Appellant’s responsiveness to concerns. The Tribunal took into account the fact that by September 2024, Gorton Parks had been warned by the CQC of its failure to comply with Regulation 12 of the Regulations – safe care and treatment. A review of the publicly available enforcement policy (taking effect from 23 December 2024, following a previous enforcement policy first published in 2015), sets out that if a registered person has not made the necessary improvements within the timescale in a warning notice, the CQC will consider further enforcement action.[37]In this appeal, the Appellant’s witnesses were frank and transparent with the Tribunal. No one considered that Gorton Parks is currently operating at an acceptable level. This was underpinned by the steps taken by the Appellant to consolidate. The steps were taken for two clear reasons, which were understood from the oral evidence of Mr Kanoria, Mr Baker and Mr Donovan, in particular – for financial reasons and in order to ensure appropriate staff were in place to deliver safe and effective care. On any reading, the staffing issue was still not resolved at the point of the hearing, as it was accepted that Gorton Parks had made progress on limiting its use of agency staff, but it was still employing staff who were not competent and did not possess the right attitude to care for vulnerable people. This was set out most starkly in Mr Kanoria’s email exchange with Mr Bickerton. In an email dated 7 April 2026 from Mr Kanoria to Mr Bickerton, Mr Kanoria indicated that there should be no further delay on the consolidation of Gorton Parks, indicating that ‘delaying this poses a big risk for residents and the service particularly when we know that there are no enough competent, right attitude staff and we need residents to be in consolidated units for right staff to look after them’. Mr Carlin confirmed in his oral evidence that the work is still ongoing, through a redundancy exercise and through disciplinary investigations. Mr Carlin also made the point that he has not started any audit work with the staff due to more pressing concerns, including the need to ensure the appropriate staff in place and because there are training needs before even moving to the point of quality assuring the skills and competence of the staff cohort.[38]Good governance is the foundation of providing safe and competent care to service users. The Tribunal was concerned about the Appellant’s approach to good governance. We heard that Mr Baker came into his post as CEO in August 2025. Prior to that date, Mr Kanoria was fulfilling elements of the CEO role to ensure he was kept abreast of developments with the various care homes operated by Advinia. It was heartening to hear from Mr Baker that when he started, it was clear that Gorton Parks was a top priority, in terms of risk. However, Mr Donovan confirmed that when he started a chief operating officer (COO), Gorton Park and the extent of the issues were not explained to him, as part of the recruitment process. It was not until the first week, when he started in employment, on 1 May 2025, that he became aware of the issues at Gorton Parks. This was concerning to the Tribunal as by that stage, Gorton Parks was in the process of preparing its written representations to the Respondent in the proposal to effectively cancel it. This was also in a context where there was no CEO in place. This did not give the Tribunal confidence in good governance and effective leadership. We knew that at that time, Gorton Park’s manager was Ms Selina Ali. She had communicated concerns about her ability to manage the issues at Gorton Parks. Mr Donovan was directly involved in the recruitment process for the next home manager, on an interim basis, Ms Barbara Cameron, who came into her post in September 2025, with Ms Naomi Curley starting at a similar time as the interim deputy home manager. Mr Donovan explained that by the end of December 2025, he had concerns about Ms Cameron’s capability in the role as she appeared overwhelmed. Despite this, the day after the Respondent commenced its most recent inspection, so on 6 January 2026, Ms Cameron submitted an application to the CQC to become the registered manager for Gorton Parks. Mr Donovan's explanation for this was that it was a condition of employment for the person performing the manager role to apply to the Respondent to become a registered manager. The Tribunal found it concerning, from an effective leadership perspective, that the COO was concerned about Ms Cameron’s capability in post and yet she was supported to submit a registered manager application. This did not give the Tribunal confidence on the governance and leadership of Gorton Parks on a local level or at a senior leadership level.[39]Miss Bailey, from Fulcrum Care Ltd, confirmed that the external consultancy service provided its services in December 2025 to carry out a mock inspection and produce a report, which the Tribunal did not have in the hearing bundle or supplementary hearing bundle. Miss Bailiey was of limited assistance on this as she did not start working at Fulcrum Care Ltd until the beginning of January 2026, so she was not involved in the reassurance work Fulcrum completed in December 2025. This was important as the Fulcrum mock inspection report rated Gorton Parks as requires improvement. The evidence from Miss McKenna and Mr Baker, who must have been closer to the contents of the report, was that they were confident that Gorton Parks had made the improvements required to result in a more positive inspection and rating from the CQC when it returned in January 2026. This is despite the fact that Mr Donovan was losing confidence in Ms Cameron by the end of December 2025, after the mock inspection was completed.[40]The Tribunal appreciated that the Appellant did not seek to contest the evidence base or the findings of the CQC, from its comprehensive inspection in January 2026, but it warrants close attention as it resulted in no overall improvement in Gorton Parks’ rating and, in fact, a conclusion that Gorton Parks presented as more high risk than before. This is further relevant given that the inspection happened relatively close to the hearing. The Tribunal did not view the inspection from January 2026 as historic in nature. It was recent and highly detailed evidence of ongoing concerns about service user safety and effectiveness of care. It also helped the Tribunal to weigh up the oral evidence from Miss McKenna, Mr Baker and Mr Donovan as to the quality of the improvement work undertaken in the past month, since Mr Carlin started in his role as interim care manager and auditing which was in place at Gorton Parks in the lead up to the inspection.[41]Mrs Jackson found that a number of service users had been moved to another site and were recorded as having capacity, did not appear to have been consulted with in advance of the move. There were no records of the discussions in their records or of an informed assessment about the likely impact on them. The call systems for service users, who continued to reside on the relevant site, were not functioning properly, covert medications had been dispensed into a hot drink which was then left unsupervised in a communal area. Two service users with recently changing behavioural needs (from mid-December 2025 to 2 January 2026 in one case and November onwards in the other) did not have an updated behavioural care plan which reflected the changes in needs and to support staff in their responses. The records maintained by staff in relation to diabetes management, wound care management (including pressure sores) and the management of hydration and nutrition needs of service users at high risk of malnutrition, choking and aspiration demonstrated a lack of understanding. This was to the extent that on 6 January 2026, Ms Curley, the deputy manager expressed concerns about the competency of nursing staff, citing an example of having to phone the nurse on duty on 3 January 2026. This was because Ms Curley had reviewed the electronic records system remotely and noted that blood sugars had not been recorded and she became concerned that insulin was not being administered as it prescribed, putting diabetic service users at real risk of harm.[42]Mrs Jackson found significant issues with the auditing processes at Gorton Parks. She explained that she found this disheartening as she had held a meeting with Advinia, attended by Miss McKenna, Mr Baker and Mr Donovan, on 6 November 2025, at which there had been reassurances given about the improvements being made. The Tribunal noted that for the inspection in February 2025, Gorton Parks was caring for 90 service users and by the January 2026 inspection, it was 57 service users; a significant reduction in its admission number, which may have given some confidence to the view that improvements could be demonstrated. Mrs Jackson’s view was supported by the oral evidence from Mrs Chilton. She indicated that if the January 2026 inspection had resulted in an overall rating of requires improvement, the CQC would have reviewed its response to the appeal and would no longer have pursued the variation of conditions to prevent Gorton Parks from operating.[43]The issues with the audits were in spite of the oral evidence from Miss McKenna and Mr Donovan that by the stage of the CQC inspection in January 2026, the senior leadership team was working directly to support Ms Cameron in her role. The reason this is significant is because at the point when Gorton Parks received its inadequate rating and had received the notice of decision, it considered it had remedied the issues by bringing in a new interim home manager and interim deputy home manager in September 2025. However, this reassurance, of itself and to the CQC, was not supported by the empirical evidence gathered during the inspection in January 2026.[44]The Tribunal did not take reassurance from the fact that the COO of Advinia had concerns about Ms Cameron’s capability, certainly by December 2025, and yet there had been a decision to have Ms Cameron submit a registered manager registration application on or around 6 January 2026. This is highly relevant as it goes to the leadership decisions being made at that point, which must have involved a senior leadership team that viewed Gorton Parks as a top priority, in terms of its risk profile. That was the oral evidence from Miss McKenna, Mr Baker and Mr Donovan (all in the senior leadership team). In oral evidence, Mrs Jackson indicated that three weeks after 6 January 2026, she was informed that Ms Cameron had left her role.[45]A further point which gave the Tribunal concern, from a reassurance perspective, was the oral evidence that the senior leadership team had received oral feedback from staff at Gorton Parks that characterised the CQC inspectors’ initial oral feedback in a different way from the eventual detailed findings in the draft report, sent to Advinia in February 2026. This was to such an extent that there was disappointment when the rating of inadequate was shared, which ran counter to the Fulcrum mock inspection from December 2025. Mrs Jackson’s evidence was that at the end of the inspection, she raised five safeguarding referrals with Manchester City Council’s safeguarding team and a whole home safeguarding referral due to her concerns about the clinical capability of nursing staff supporting service users with complex health conditions. Mrs Jackson’s evidence, which was not challenged, is that the safeguarding referrals resulted in five service users being identified by Advinia as no longer being able to have their needs met at Gorton Parks. It is positive to hear of this outcome, in terms of responding to risk, but it is of concern that it took safeguarding referrals to identify such a significant gap in care. In the Tribunal’s view, effective auditing should have identified these issues and responded with actions to minimise the risk of harm. This is because the issues were identified by Mrs Jackson following reviews of documentation for service users, precisely the mechanics of an audit. The Tribunal found Mrs Jackson’s evidence on these issues was credible and not disputed. Ultimately, the concerns with documentation and records of care corroborated the concerns with the effectiveness of the audit work going on at Gorton Parks.[46]The Tribunal considered Mr Carlin’s oral evidence very carefully. He was placed at the centre of the Appellant’s case, as the person who would be able to deliver the improvements required to reassure stakeholders of the improvements in care at Gorton Parks.[47]The Tribunal accepted the position that improvements to the environment are easily remediable with investment of time and money. It was clear to the Tribunal that Advinia has invested resources to renovate two sites at Gorton Parks, which demonstrates a commitment to improving the concerns with the environment. Furthermore, the Tribunal well understood, from the oral evidence of Mr Baker and Mr Kanoria in particular, that there is a commitment to investment to ensure appropriately placed staff have what they need to improve Gorton Parks. This was demonstrated through the oral evidence of Miss Bailey, who considered the work of Fulcrum Care Ltd to be crucial to turning Gorton Parks around. The recruitment of Mr Carlin, moving him from another registered service at Advinia to Gorton Parks, as an interim manager, the quality assurance support from Ms McKenna and her quality team, as well as the constant updates to Mr Baker and Mr Kanoria and one of Mr Donovan’s predecessors in the operations restructure. It was clear to the Tribunal that the sheer quantity of people assigned to Gorton Parks and their level of seniority demonstrated that Advinia wanted to improve it.[48]We appreciated that a commitment to improvement and a desire to do so is commendable and went some way to reassuring the Tribunal of the good intentions of Advinia. However, that it only part of the reassurance and sustainability picture. The other part comes down to the Tribunal’s confidence in the changes made to leadership and staffing and fundamentally to the culture in Gorton Parks.[49]Mr Carlin started in his post as an interim home manager on 2 March 2026, coming in a couple of days per week until he finished off his work with the other Advinia service. He started full time in post on 15 March 2026. It was clear from Mr Carlin’s helpful evidence that the work had only begun in earnest since he started as he did not consider that the previous interim manager had been able to manage to extent of the changes required. Mr Carlin identified legacy staff (from the time when Gorton Parks was owned and operated by its previous owners, 2018 and before), who had been working there for as long as 20 to 30 years, as having an ingrained resistance to change. This appeared to be a key reason for the redundancy exercise being undertaken by Advinia. The Tribunal found this concerning, as the staffing issues were clearly raised in the notice of proposal in May 2025 and yet it was still an issue, being tackled by Mr Carlin, at the time of the hearing in April 2026.[50]Mr Carlin had diagnosed the vast majority of the failures at Gorton Parks are tracking back to the person in the manager’s chair. In his view, Gorton Parks had not had strong leadership at home or unit manager level which had led to a culture of poor practice and a lack of oversight of that. The Tribunal could not ignore the fact that those issues would have been obvious to the informed members of the senior leadership team at the time when the notice of proposal was issued in May 2025. By that point, there should have been an immediate response to the staffing and leadership issues at Gorton Parks, instigated by the senior leadership team, really, to place a highly experienced team to begin turning around Gorton Parks. Despite the understanding of the senior leadership team, that did not happen with the urgency and strategic planning required. This had given the Tribunal limited reassurance of the ability of Mr Carlin to turn the service around, despite his experience and his commitment. As an example of this, the Tribunal was not reassured on the sustainability in Gorton Parks when as recently as 7 April 2026, when Mr Carlin had been in his full-time post for about three weeks. Mr Baker sent Mr Bickerton at the LA an email in which he informed Mr Bickerton that 'Tony Carlin will no longer be with us after today and Mariana Costea will start with us and working under Fulcrums [sic] direction from today’, fulfilling the home manager role. The explanation for this was a miscommunication or a misunderstanding and there was only one day when Mr Carlin was not in post. From the Tribunal’s assessment, we considered this a very recent example of the apparently precarious nature of the arrangements and a reflection of a lack of clarity about internal decision-making. For the first time, during the oral evidence from Miss Bailey, who joined Fulcrum Care Ltd in January 2026, the final witness on behalf of the Appellant, the Tribunal heard that Ms Costea had been working for Fulcrum Care Ltd, but she is now employed by Advinia and in post as an interim home manager, working alongside Mr Carlin.[51]Miss Bailey described Advinia as being crucial to the turnaround of Gorton Parks. The Tribunal did not have a live or up to date action plan, to help it understand what had been achieved, by whom and how it had been achieved. This would have been useful to the Tribunal. Miss Bailey had access to a live document which she used to refresh her memory and assist the Tribunal, but it was difficult for the Tribunal to afford significant weight to Miss Bailey’s oral evidence. This was because she has not been involved in the mock inspection carried out by Fulcrum Care Ltd in December 2026, which the Tribunal did not have in evidence and it was clear from her in the moment review of the action plan that she was not fully up to date with what was going on ‘on the ground’. This was also apparent as Miss Bailey confirmed she had last visited Gorton Parks in March 2026 before the improvement work of Mr Carlin, the Fulcrum Care Ltd consultants and Ms Costea had commenced. It was not clear to the Tribunal from the oral evidence of Miss Bailey or the two-page action plan (with no assigned owners) and the ‘Proposal for Turnaround & Stabilisation’ document as to what it was about Fulcrum Care Ltd’s work that made it crucial. Miss Bailey confirmed that in producing the action plan, no consideration had been given to the contents of the two second witness statements from Mrs Frankl and Mrs Jackson which detailed the breaches of the 2014 Regulations. Miss Bailey indicated that the concerns, now detailed in the final inspection report for January 2026 would be examined. Given Advinia’s acceptance of the findings from the CQC’s inspections from February 2025 and January 2026, in the Tribunal’s view, there was no reason not to review and incorporate the concerns raised by the CQC at the point of the most recent inspection, the oral feedback and the draft inspection report.[52]For those reasons, the Tribunal did not find Miss Bailey as helpful a witness as it had anticipated. Ultimately, we were not reassured by the oral evidence from Miss Bailey as to the ability of Fulcrum Care Ltd to turnaround Gorton Parks and why it was crucial to that process. Furthermore, the witness statement from Miss Bailey and the documents provided by her did not sufficiently illuminate the point that Fulcrum Care Ltd would be crucial to the turnaround. Miss Bailey had not visited Gorton Parks since March 2026, before Fulcrum Care Ltd was formally engaged in its role and her updates on the status of the action plan were not reassuring. The very recent changes in the proposals for the interim manager and the fact that the Tribunal heard, for the first time (from Miss Bailey), that Ms Costea would also fulfil an interim manager role with Mr Carlin as interim manager as well, did not give the Tribunal confidence that there were clear lines of accountability for delivering change which could be sustained.Regulation 9: person-centred care
[53]It was disputed that person-centred care involves care and treatment which is personalised and takes into account the service users’ preferences and caring needs.[54]At the point of the most recent inspection, Gorton Parks was still in breach of Regulation 9. A concern from the Respondent was that 15 service users had been moved on 5 January 2026, from one of the sites/units to others. The rationale provided was because of redecoration, but it was recorded in transition plans for three of the service users that it was for consolidation of the service in Gorton Parks. Two other service users, who had capacity, had no records to demonstrate that there had been a discussion with them or assessments carried out to inform a relocation. There was no evidence, in the records, that the service users, whether with capacity or not, had been assessed to understand the longer-term impact on them of a relocation, whether for redecoration (which would suggest a shorter-term move) or for consolidation (which would suggest a longer-term move). There was also no evidence, in the monthly reviews for the service users concerned, about discussions with family members/relatives about the relocation or any changes in the service users’ needs. Given the previous concerns about the failures in records and care planning for service users, it should have been apparent that this was an issue which required immediate changes and certainly by the point of planning to relocate vulnerable service users in the context of the wider regulatory concerns, set out in the notice of decision. The Tribunal did not have the benefit of reviewing updated records of care for relevant service users, alongside direct oral evidence from a witness to demonstrate the specific changes made to the ways in which staff had received updated training on person centred care (including records), with a robust system of quality assurance in place, the system for identifying training needs and responding to deficiencies. In the Tribunal’s view, this work was crucial to strengthening the confidence Advinia could have in its carer and nursing staff. This was particularly essential, given the ongoing concerns that there are still staff in post who do not demonstrate safe and competent care. This position was supported by Mr Carlin’s oral evidence and in Mr Kanoria’s witness statement and accompanying email of 7 April 2026 to Mr Bickerton.[55]The Tribunal considered that on the evidence available to it, Gorton Parks is more likely than not to remain in breach of the requirements of Regulation 9.Regulation 12: safe care and treatment
[56]The Tribunal accepted that Advinia has invested in Gorton Parks in an effort to remedy the issues identified with the physical environment. However, at the point of the inspection in January 2026, there remained breaches of Regulation 12 which concerned fundamental aspects of practice. For example, the incident involving a staff member administering medications covertly, as required from the service user’s medication care plan. However, the medications had been dispended into a cup of tea which was left in a communal area, creating a significant risk to other service users. A further service user was experiencing incidents of increasing aggression. From 5 December 2025 to 2 January 2026, staff had documented six incidents, some of which involved injuries and near misses to the service user and other service users. Despite this, the service user's behaviour care plan had not been adequately reviewed and updated, including the circumstances in which Lorazepam would be administered on a PRN basis or the effectiveness of this treatment decision.[57]There were several examples of staff recording incidents or readings for service users in line with the management of health conditions, which did not then lead to appropriate escalation or appropriate care and treatment responses. It had been made clear since the February 2025 inspection, that the staff’s ability to safely manage care to diabetic service users was a significant cause for concern. Mrs Jackson reviewed service user records for a service user with Type 1 Diabetes. On 6 January 2026, the records recorded a blood glucose reading of 3.8 mmol/L. There were no instructions in the care records to support staff with what to do when the reading was measured outside the target range for the service user (6 to 12 mmols/L), which presented a clear risk to the service user as staff were not directed on escalation steps for a service user at risk of hyperglycaemia. The same service user had not had their blood glucose level checked before meals on multiple occasions between 24 December 2025 and 7 January 2026. On several occasions, staff had recorded that the service user exhibited signs of agitation which were likely linked to nutritional intake or unsafe blood glucose levels. The link was not recognised by staff for escalation. the care and treatment for this service user demonstrated a lack of clear direction for staff to recognise risk in the context of care and even if the direction had been there, how to escalate the concerns or what steps to take.[58]There were further examples of this relating to dental care and hygiene for service users, as well as appropriate wound care, repositioning for service users at high risk of pressure injuries and examples of records recording that service users had been appropriately repositioned when Mrs Jackson observed directly that they had not. The integrity of the record keeping questionable, to such an extent that service users at high risk of pressure injuries, where placed at further risk.[59]For the Tribunal, the reassurance provided by Advinia at the hearing and in its evidence submitted in response to the inspection from January 2026 did not permit the Tribunal to conclude that the fundamental issues with effective care planning and safe delivery of care and treatment had been remedied to such an extent that service users were no longer at risk.Regulation 14: meeting nutritional and hydration needs
[60]During the inspection in January 2026, Mrs Jackson observed several examples of the hydration and nutritional needs of service users not being met, including records of meals and drinks consumed which did not correspond with that Mrs Jackson directly observed. As one example, a service user with Diabetes required a level 4 pureed diet and required a low-sugar, diabetic friendly diet. From a review of the service user’s daily notes, Mrs Jackson established that the service user had been served a breakfast of sausage, bacon and beans on 60 occasions between 1 November 2025 and 5 January 2026 – a meal which ran contrary to the requirements for the service user’s requirements.[61]There were concerns with Gorton Parks ability to meet the nutrition and hydration needs of service users at high risk of malnutrition, choking and aspiration. The concerns with the level of care provided supported the ongoing concerns with the level of staff competence and skills, confirmed by Mr Carlin and Mr Kanoria during the hearing.Regulation 17: good governance
[62]This is one of the fundamental Regulations for all services regulated by the Respondent, in the Tribunal’s view. A service provider that can demonstrate good governance through its systems, processes and policies and staff management, will go some way to allaying concerns in relation to breaches of other 2014 Regulations.[63]Gorton Parks’ system of quality assurance and auditing was deficient. As an example of this, Mrs Jackson reviewed Gorton Park’s most recent quarterly report, dated 30 September 2025. It identified that a number of checks/audits/actions were recorded as completed, when it transpired that they had not as Mrs Jackson was able to find evidence of gaps. From an easily remedied issue such as appropriate signs (recorded as compliant when there were no signs in place to support service users to find their bedrooms in one of the sites), through to the home manager recording all staff as compliant with mandatory training when several nurses were found to have not had clinical skills and competency check for some time. This was particularly relevant in the context of Gorton Parks, where it appeared to have been an issue for quite some time – the capability of caring and nursing staff. A concern that even the home manager spoke about to Mrs Jackson during the inspection in January 2026 in relation to nursing staff ensuring service users received insulin at night.[64]This was in a wider context of Mr Donovan having concerns about the home manager’s ability to make the improvements required, concerns he had by mid to late December 2025 and yet there was an application submitted on 7 January 2026 for Ms Cameron to become the registered manager. The changes to the leadership structures set out by the Appellant at the hearing did not reassure the Tribunal, given the extent of the issues and the length of time they had been identified as issues by the Respondent.Regulation 18: staffing
[65]As an example, Mrs Jackson found that on 28 December 2025, a nursing staff member had been recorded as receiving five competency assessments in a context where there had been one other nurse on duty at that time for the unit. As set out by Mrs Jackson, competency assessments for nurses require direct observation to assess clinical skills. The Tribunal was not reassured about an issue of this nature happening as recently as late December 2025.[66]Mrs Jackson found incomplete training records, which did not confirm that required training had taken place by end dates. 15 of the 25 care staff had no records of any one to one or clinical supervision taking place in 2025, which was concerning to the Tribunal given the issues identified in the inspection of February 2025.[67]By the point of the January inspection, the deputy home manager was directly raising concerns with the inspectors about the competency of nursing staff and their ability to support service users with complex medical conditions. This concern was not supported by the audits, which was concerning, given the extent of the issues with delivery of care. The clear inference to draw is that the audit records were not complete or reliable.[68]Mr Carlin confirmed, during his oral evidence, that there remained concerns about the staff having the competence and skills to deliver care. The Tribunal was not reassured that by the time of the hearing service users at Gorton Park would receive safe and effective care which could be sustained over time.Regulation 19: fit and proper person employed
[69]In the Tribunal's view, this is a Regulation for which compliance concerns can often be easily remedied. Nevertheless, the Tribunal was concerned that even on 7 January 2026, in Ms Cameron’s application for registration as the registered manager of Gorton Parks, there were gaps in the application (including the NMC PIN and a full employment history) which meant the Respondent had to reject it. It was also concerning to note that Advinia had no taken sufficient steps to assure itself of Ms Cameron’s suitability to fulfil the role of registered manager, for which an application was made on 7 January 2026.Improvements
[70]The Tribunal took into account the actions taken by the Appellant to start to make improvements at Gorton Parks, particularly since the most recent inspection, as this was a cornerstone of the Appellant’s case – that the Tribunal could not reasonably conclude that Gorton Parks was still not in compliance with the Regulations.[71]The Tribunal was not provided with the current action plan, to demonstrate the improvements made, when they were completed and the evidence to support completion. It was an action plan that Miss Bailey appeared to access during her oral evidence. From the Tribunal’s perspective, the absence of the up to date action plan did not reassure the Tribunal that the steps taken by Advinia in the approximate month before the hearing were sufficient to lead the Tribunal to conclude that Advinia and Gorton Parks would be able to make substantial improvements to care to be able to come into compliance with the Regulations and sustain the compliance.Proportionality
[72]The Tribunal took into account the fact that Advinia has made some improvements to the physical environment and to its local leadership team and the support available to it. However, the Tribunal has still concluded that as of today, the service remains in breach of a number of Regulations. The Tribunal could not be assured, on the quality of the evidence provided by the Appellant, that the service will be able to make further, significant improvements such as to come into compliance with the Regulations and to sustain compliance.[73]The Tribunal took into account that by the date of the hearing, there had been a deteriorating picture for Gorton Parks since the issuing of the warning notice in September 2024. The Tribunal also took into account that Gorton Parks now provides care to a much reduced number of service users and even with the passage of time and a reduction in the number of service users (including between the two most recent inspections), Gorton Parks has not complied with all of the fundamental regulatory requirements to assure the Tribunal that it can provide safe and effective care with stable leadership in place.[74]The Tribunal carefully considered its power at section 32(6) to direct that any such discretionary condition as the Trist-tier Tribunal thinks fit shall have effect in respect of the regulated activity. The Appellant urged the Tribunal to consider discretionary conditions such as staged admissions or a capped number on the number of service users or in effect an action plan, with a requirement for the Appellant to send updates to the action plan to the Respondent in set time periods. In light of the extent and nature of the breaches, the Tribunal concluded that workable, effective conditions would not be sufficient to meet the ongoing risk due to the outcome of the inspection in January 2026 and the limited and very recent changes made since then.[75]The Tribunal took into account the letters from family members of service users, noting their positive views of Gorton Parks, as well as the letter from Mr Bickerton concerning a stay in the proceedings and the feedback from professionals, including Dr Ahmed of Florence House Medical Practice. These views were not determinative when it comes to the ongoing risk to service users. We also considered very carefully the potential impact on the remaining service users of a relocation to another care home. In the end, the ongoing risk of service users receiving care which is not safe and effective did not lead the Tribunal to conclude, on balance, that the decision to vary the conditions of registration to remove Gorton Parks from providing the regulated activities of accommodation for persons who require nursing or personal care and treatment of disease, disorder and injury is no longer proportionate.IT IS ORDERED THAT:
[1]The appeal is dismissed.[2]The Care Quality Commission's decision of 25 July 2025 is confirmed, pursuant to section 32(5) of the Health and Social Care Act 2008. Judge S Brownlee First-tier Tribunal (Health, Education and Social Care) Date issued:13 May 2026