TKSD Care Homes & Training Ltd & Anor v Care Quality Commission

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.

There are two decisions under appeal:

Both appeals were consolidated to be heard together by order of Judge Khan on 10 July 2025.

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.

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.

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.

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.

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 key dates regarding Ruth Lodge are as follows:

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.

The NOP regarding the registered manager was dated 3 March 2025. Essentially it relied upon the same matters.

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.”

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.

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:

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.

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.

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.

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.

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.

The Respondent had made a further application on 29 October 2025 to adduce new evidence:

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

By 4 November 2025 the bundles received by us, and numbered accordingly, were:

Starting on 3 November we heard evidence from the following witnesses and in the following order.

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.

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).

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…”

Section 4 provides:

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.

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.

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.

The burden of satisfying us that the decision is today justified, necessary and proportionate, lies on the Respondent.

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.

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.

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.

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.

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 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.”

The purpose and principles of enforcement are described at pages 7 and 8 of the policy. The main features of the EP are that:

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”.

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.

“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”

“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.”

“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.”

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.

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”.

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.”

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.

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:

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.

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.

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.

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 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.

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.

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.

Mrs Creech considered that the service was in breach of Regulation 9, for reasons that included that:

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:

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.)

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.”

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…”

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.

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.”

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.”

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.

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.

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.

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.”

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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:

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.

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.

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.

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.

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.

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.