England and Wales Care Standards Tribunal

Holly House & Anor v National Assembly for Wales [2005] EWCST 371(EA-W) (15 May 2005)
Schedule Schedule 1 cases: Establishments and Agencies - Category Cancellation of registration (fitness)

Puretruce Health Care Limited

-v-

National Assembly for Wales

[2004] 0371 EA-W

Before:

Mrs M Tudur (Chair)

Mrs M Martin

Mr C Wakefield

Hearing at Newport on the 18th - 20th, 22nd, 25th - 29th April, 3rd and 4th May 2005.

Representation:

For the Respondents:
Mr Jonathan Furness Q.C., instructed by Rachel Stephens, the National Assembly for Wales.

For the Appellant:
Mr Roger McCarthy Q.C., instructed by Alison Castrey, Solicitor, Bristol.

1. The appellant, Puretruce Healthcare Limited, appealed under Section 21 of the Care Standards Act 2000, against the Notice of Cancellation of Registration of Holly House Nursing Home. The Notice of Cancellation is dated the 14th September 2004 and the appeal form, B1 is signed by the Appellant on the 12th October 2004.

1. On the 25th February 2005, the Tribunal Chair made a Restricted Reporting Order prohibiting the publication (including by electronic means) in a written publication available to the public or the inclusion in a relevant programme for reception in England and Wales of any matter likely to lead members of the public to identify any vulnerable adult.
2. The letter of notification of cancellation dated the 14th September 2004 and signed by Sally Bond, Regional Director of the Care Standards Inspectorate for Wales (CSIW), South East Wales Region, identified 23 breaches of the Care Homes (Wales) Regulations 2002 ("the Regulations") as the basis for the decision to cancel the Appellant's registration in respect of Holly House Nursing Home, Fleur de Lys, Blackwood, NP12 3UP. On the first day of the hearing, the Tribunal was invited to visit the home and in the absence of any photographs or plans indicating the layout and location of the building, the Tribunal visited the home at the end of the first day of the hearing.

Background

3. Puretruce Health Care Limited is the owner of Holly House Nursing Home and is one of a group of companies of which Dr P. B. Das and his wife are directors. The parent company L'Giri is the owner of another local home, Brithdir Care Home and another company, Puretruce Care Limited was the owner of about 15 other care homes in South Wales and has been in administration since October 2003. Currently, the companies are responsible for five care homes in South East Wales.
4. Holly House has been operating as a care home since about 1986. It was originally registered as a care home under the Registered Homes Act 1984, but was later closed and reregistered on 28th November 2001 as a nursing home. The registration certificate indicated that the home could accommodate 32 care home (Nursing) Dementia/Mental infirmity residents and 3 care home (Older People) Dementia/Mental infirmity residents.
5. The 2001 registration notice was subject to a staffing notice dated the 14th November 2001. The registration formally transferred under the Care Standards Act 2000 on the 9th January 2003. The home was subject to the inspection regime of the CSIW from April 2002, and in June 2002, Mrs Alison Price became the lead inspector in respect of the home.
6. From the date of her first involvement with the home, Mrs Price identified non-compliances with the National Minimum Standards for Care Homes Wales 2002 (NMS). (The NMS were subsequently amended in 2004) She undertook the first announced annual inspection of the home on the 29th October 2002.
7. On the 1st November 2002, Mr Philip McCaffrey was appointed as Acting Manager. His registration as manager was confirmed in December 2003.
8. The draft report following the 2002 annual inspection was issued on the 6th February 2003 and indicated that none of the 36 NMS audited had been fully met. Despite the numerous issues identified, neither the Acting Manager nor the provider responded to the report with an Action Plan, although Mr McCaffrey did identify to CSIW four factual errors in the report.
9. An announced annual inspection took place on the 8th July 2003 and the report was issued in November. Once again, neither the home nor the provider responded to the draft report with the production of an Action Plan to address the issues raised.
10. In the summer of 2003, Mr Paul Black was appointed Chief Executive of Puretruce Health Care Limited.
11. During the period between September and December 2003, Mrs Price issued about 20 Notices of Action Required in respect of non-compliances with the Regulations at Holly House.
12. Between October and December 2003, several complaints were received regarding the care of residents at Holly House resulting in Protection of Vulnerable Adults (PoVA) meetings being arranged by Caerphilly County Borough Council (CCBC) Social Services Department. A police investigation was undertaken in respect of one of them but no further action taken.
13. As a result of a PoVA Strategy meeting on the 11th November 2003, Rhondda Cynon Taf County Borough Council decided to suspend further placements at Holly House, and following a further PoVA meeting on the 19th November 2003, CCBC and Caerphilly Local Health Board (LHB) also decided to place an embargo on further placements there. The embargo was confirmed following a meeting with Dr Das on the 24th November 2003.
14. On the 9th December 2003, Mr Derrick Powell from the CCBC Social Services Contracting Section, prepared an Action Plan to address the main issues identified within the CSIW report.
15. A further meeting with Puretruce representatives and the Caerphilly LHB on the 10th December 2003 identified 12 priority areas where the action plan was to be met before the embargo could be lifted. The company was given six months to comply with the Action Plan and a period of six months' monthly monitoring against the Action Plan was identified, commencing in February 2004, in order to decide whether the company could make sufficient progress to satisfy the CCBC that it would comply with its contractual obligations.
16. Before Christmas 2003, CSIW identified concerns about the management of the home by Mr McCaffrey and indicated that they were considering whether to cancel his registration as manager. He resigned from his post in January 2004, writing to the National Assembly for Wales direct to inform them of his resignation on the 26th January 2004, and stating that "Unfortunately, I did not have the authority nor the support to resolve and to maintain the resolution of a considerable number of the outstanding issues."
17. An Acting Manager, Mr Alun Owen, was in post following Mr McCaffrey's departure until the appointment of Mr James Adeniyi as Acting Manager on the 26th April 2004.
18. A review of the Action Plan was conducted on the 5th February 2004 and CCBC agreed to lift the embargo provided that they were satisfied of the current staffing levels. In view of the close monitoring taking place by CCBC, the embargo on placements was lifted from the 11th February 2004.
19. On the 1st May 2004, Mrs Rachel Pritchard was appointed Clinical Nurse Manager for Puretruce Health Care Limited to be based at Holly House. She worked for a period of about five weeks before taking five weeks of sick leave which extended to the 30th July 2004.
20. In May 2004, the CSIW expressed further concerns about the situation at Holly House and a meeting was held on the 27th May 2004 to identify progress against the Action Plan. Because of the concerns expressed by CSIW, Nigel Barnett, Assistant Director of Social Services, CCBC wrote to Dr Das on the 14th June 2004 informing him that the embargo had been reinstated from the 11th June 2004. The letter notified him of the further breaches of the NMS and regulations which had taken place.
21. Two further PoVAs were raised during May 2004, both of which were identified by the CSIW inspectors.
22. A further meeting was held on the 14th July between Puretruce, CCBC and LHB to review the Action Plan and to discuss concerns that the home would not meet the target set in the Action Plan. It was agreed that a team of Gwent Healthcare NHS Trust nurses, under the leadership of Mrs Karen O'Grady, would be placed in the home to support staff and to protect the interests of the residents for the remaining month of the period of monitoring by CCBC.
23. On the 2nd August 2004, Mr John Powell, Senior Inspector with CSIW, issued a Notice of Proposal to Cancel Registration to Puretruce Health Care Ltd in respect of Holly House as a response to the continued failure to comply with the regulatory framework.
24. An overarching multi agency PoVA strategy meeting was convened on the 12th August 2004, and the meeting concluded that Holly House was responsible for institutional abuse of the service users placed there. The meeting also concluded that CCBC and Caerphilly LHB should terminate their contract with Puretruce Health Care Ltd. on grounds of serious breach of contract.
25. Following queries arising from consideration of his curriculum vitae, Mr Adeniyi resigned his post in August 2004.
26. On the 25th August 2004, a meeting was held at Holly House to discuss the final monitoring report prepared by Collin Grant against the Action Plan with the representatives of Puretruce Health Care Ltd. Also present were representatives of the Social Services Directorate CCBC, the Caerphilly LHB and Gwent Healthcare NHS Trust. During the meeting, Dr Das maintained that the report was factually incorrect, despite the fact that both Rachel Pritchard and Paul Black, accepted that the report was factually correct at the time that it was written.
27. Mrs Susan Greening was appointed Acting Manager for Holly House from the 1st September 2004.
28. On the 1st September 2004, a meeting was convened between the Nigel Barnett, Assistant Director of Social Services for CCBC, the Director of Nursing of Caerphilly LHB and Puretruce Health Care Ltd to consider the alleged breach of contract and termination of it. The outcome of the meeting was that CCBC agreed to commission a joint report from an independent health care consultant to identify whether the contractual standard of care, namely the standard set out in the Care Homes Wales Regulations 2002 and the National Minimum Standards for Care Homes for Older People as issued by the National Assembly for Wales, was being met.
29. A joint letter of instruction was sent to Mr Gordon Cole on the 14th September 2004, requesting that he carry out a visit as soon as possible to establish the current position with a follow up meeting four weeks later with an NHS nurse to assess the degree and speed at which any new processes noted at the first visit were being embedded and to comment on clinical standards. Mr Cole was not offered any of the documentation produced by the CSIW in the course of their inspections as part of the background information, but was given, inter alia, the Final Action Plan dated the 6th August 2004, the Gwent Healthcare NHS Trust final report dated 11th August 2004 and the Puretruce Health Care Limited response to the final action plan dated the 1st September 2004.
30. Mrs Greening submitted an application to become the registered manager of Holly House in November 2004 and at the date of the hearing, she continued to be unregistered and Acting Manager.

The inspection process.

31. One of the main planks of the case put forward in the paperwork by Dr Das, the senior managers of Puretruce Health Care Ltd and to a lesser extent the managers of Holly House is that the regulation by Alison Price has been oppressive, amounting to harassment and bullying and has had a detrimental effect on the smooth running of the home. Starting from her first introductory visit on the 12th June 2002, the number and frequency of her visits increased proportionately to the concerns expressed about the care provided at Holly House.
32. Between June and December 2002, there were a total of 9 visits: two announced and 7 unannounced. During 2003, there were about 15 visits: one announced and 14 unannounced. During 2004, there were about 27 visits of which 3 were announced or prearranged and 24 unannounced. During 2005, up to the date of the hearing in April, there had been one visit every month, all of them unannounced.
33. By her own evidence, Mrs Price confirmed that the visits varied in length from two hours to all day. Set against the statutory requirement of one announced and one unannounced visit every year, the number of visits has been significant. Mrs Price herself gave evidence that she thought that her visits and letters were supportive and helpful to the management of the home.
34. On several of her visits, Mrs Price issued Notices of Work Required, identifying matters which she considered required immediate attention or should be addressed in the near future. In evidence, she stated that she made positive comments about areas of progress during the oral feedback at the end of her visits. The Acting Managers responded to some of the notices issued, but not to all of them.
35. The oral evidence of both Mrs Price and Mr John Powell, the senior inspector, was that at the end of each announced annual inspection, they would deliver a detailed and comprehensive feedback to the Acting Manager, identifying the areas where further progress was required. Similarly, at the end of each monitoring visit, a discussion would take place with the Acting Manager or Nurse in Charge to discuss issues arising. The response from Holly House was not consistent, and was very sparse until Mrs Greening's appointment in September 2004.
36. At the same time, other visits were being conducted by other agencies, some in conjunction with CSIW and others quite independently of them, such as the CCBC monitoring visits.
37. Throughout the monitoring period from June 2002, breaches of regulations and failures to attain the NMS had been identified and letters sent to Dr Das making reference to them. The monitoring visits identified that there were inconsistencies in the attainment of targets, with standards initially met not always being maintained at a later date. More significantly, there was a lack of evidence that the provider or the home were consistently engaging in the regulatory process by working towards the goal of improved provision and services for the service users.

Events since the Notice of Cancellation 14th September 2004.

38. The cancellation decision was notified to Puretruce Health Care Ltd by letter dated 14th September 2004, signed by Sally Bond, Regional Director of CSIW. The letter accompanying the Notice of Decision to Cancel Registration, confirmed that 22 allegations of breaches of the Regulations had been made out and that, on that basis, the decision made to cancel registration. The letter referred specifically to breaches of Regulations 7, 10, 12, 13, 14, 15, 18, 19, 24, 25 and 27.
39. Subsequent to the Cancellation decision, Mrs Price undertook further monitoring visits. Visits undertaken on the 13th and 24th September were reported in a letter dated the 7th October 2004. On these two visits, Mrs Price identified 12 alleged breaches of the regulations.
40. Three further monitoring visits were undertaken in October and November and reported to the company in a letter dated the 17th December 2004. Again numerous alleged breaches of the Regulations were noted with timescales identified for their rectification.
41. On the 21st November 2004, Mr Gordon Cole completed his report based on the joint instructions issued to him by CCBC and Puretruce Health Care Ltd. Mr Cole visited Holly House on the 29th and 30th September 2004 to make a baseline assessment for his evaluation. He then made follow-up visits on the 4th and 9th November 2004.
42. In his report, he noted that there was evidence of a lack of integration in the implementation of policies, procedures and management systems, that some aspects of systems and documentation that required further work and integration. He commented however, that "There is no evidence that these impact negatively on the care being provided or adversely affect the outcomes for residents".
43. From his two follow up visits, he reported that most of the items relating to the audit of the final Action Plan had been actioned. He concluded that considerable progress had been demonstrated between his initial visit and his follow-up visits and that "there is no doubt that the quality and standards of care more than comply with regulatory requirements." He stated that the management of Holly House "..is strong currently and the staff are capable of meeting all the regulatory requirements." He went on to stress that the sustainability of the progress made depended essentially on three factors: a suitably qualified and experienced manager; maintaining staffing levels and stability and providing all the other resources necessary and maintaining the financial viability of the Home by enabling it to operate near or at full capacity.
44. Mr Cole attended a meeting at the office of Nigel Barnett on the 24th November 2004 to report back on his conclusions following his inspections of Holly House. The minutes of the meeting were produced in evidence and reflected that Mr Cole was favourably impressed with the improvements that he had seen at Holly House during the six weeks in which he was involved there.
45. On the 1st December 2004, Mr Nigel Barnett and Mrs C Hayes wrote to Mr Paul Black to confirm that CCBC were prepared to lift the current embargo up to a maximum of 29 beds pending the Tribunal decision.
46. On the 17th December 2004 and 13th January 2005, Mrs Price again visited with Mr John Powell. A further 10 alleged breaches of the Regulations were identified in the follow-up letter sent on the 24th January 2005.
47. Mr Cole undertook a further visit on the 14th February 2005, this time under the instruction of the Appellant's solicitor, to evaluate the continuity and progress on the matters detailed in the original report; the willingness and ability to co-operate with and respond to compliance requirements or recommendations and compliance with the regulatory requirements in 16 identified areas (where concern or non-compliance had previously been identified by CSIW).
48. In the summary conclusion of his report, Mr Cole indicated that the premises were cleaner and tidier than on previous visits; the insulation of hot surfaces had not been completed; progress on the residents' records had been maintained with reviews of care plans and risk assessments being maintained; staff supervision was not yet in place.
49. Mr Cole made several recommendations to target areas where further work was required. He concluded his report by stating that the registered manager now required support systems and the provision of the necessary resources to meet and maintain the NMS.
50. Mrs Price, John Powell and Colleen Forse, the Pharmacy Inspector, undertook two further monitoring visits to Holly House on the 17th February and 1st March 2005. The follow-up letter from Mrs Price was dated the 4th March 2005 identified a further 19 alleged breaches of the Regulations. The letter from Colleen Forse was dated the 4th April 2005. Mrs Forse identified six alleged breaches of the Regulations in relation to medications at the home and made seven good practice recommendations to address them.
51. Mrs Price and Mr Powell undertook a final visit to Holly House prior to the tribunal hearing on the 4th April 2005. In her letter dated the 8th April 2005, Mrs Price identified another 15 alleged breaches of the Regulations and gave timescales for their rectification of periods ranging from immediate to two weeks.
52. Mr Cole undertook his final visit to Holly House during the course of the tribunal hearing, on the 21st April 2005. He concluded following a further unannounced inspection that progress has continued to be made on improving the condition of the premises and on some procedures.

The complaint.

53. On the 30th December 2004, CSIW received a formal complaint from an individual who wished to remain anonymous about the Acting Manager, Mrs Greening.
54. Mrs Price carried out an unannounced complaint investigation on the 13th January 2005 and interviewed Mrs Greening. Although her evidence was that Mrs Price had conducted the interview professionally and courteously, Mrs Greening was very upset by the complaint and allegations and offered her resignation (which was not accepted) to Paul Black at the end of the interview.
55. Mrs Price, as the lead inspector, undertook an investigation of the complaint. Her draft report with its conclusions that one element of the complaint was upheld, two not upheld and two unsubstantiated, was sent to the Appellant's representatives in March 2005.
56. In response to the draft report, Mr Paul Black wrote to Mrs Price on the 16th March 2005 stating that there were several factual inaccuracies in the draft report and expressing the view that the manager is "..a honest responsible and competent person and has the full support of the senior management group."
57. Mrs Price issued the final report on the 30th March 2005 and referred the matter back to the company. The report identified nine areas where actions were required to be undertaken by the registered provider and the responsible individual. CSIW were to be notified of any action undertaken and provided with a copy of the report.
58. Following receipt of the report from Mrs Price, Rachel Pritchard, Clinical Nurse Manager undertook her own investigation of the allegations and exonerated Mrs Greening completely.
59. Because of the distress caused to Mrs Greening, the Appellants instructed a solicitor to write to CSIW informing them that Mrs Price would not be admitted to Holly House again although any other inspector would be welcome. Although a draft letter was sent to Mr Black towards the end of March, the letter wasn't sent to CSIW until Mrs Greening gave a copy to Mrs Price on the 1st April 2005.

Issues relating to individual service users.

60. A was a resident placed at Holly House prior to Mrs Price's involvement. She suffered from a personality disorder and had diagnosed mental health problems, and was not therefore within the definition criteria to be accepted as a resident of Holly House. Mrs Price had been concerned about the suitability of her placement for a considerable period and frequently referred to her in the context of alleged breaches of the Regulations in relation to her care plans and assessments.
61. From time to time her behaviours would deteriorate and become more difficult to manage. Because of her concerns, Mrs Price referred A to a PoVA meeting on the 11th March 2004. The meeting concluded that she was inappropriately placed and the Social Worker was charged with finding her an alternative placement. She remained a resident at Holly House until 2005.
62. B's placement was also problematic. He had initially been placed at Holly House as a result of an emergency arising from an injury to his carer. He was also the subject of several allegations of breaches in respect of his care planning and assessments. The most significant incident in relation to B occurred in March 2005. During the course of an unannounced inspection, Mrs Price and Mr Powell observed practices which they considered were breaches of the resident's privacy and dignity and indicated these as breaches in letters dated the 4th March and 8th April 2005. There was also an issue identified by Mrs Price in relation to the use of unsuitable cot-sides for nursing B and the use of pillows to close gaps between the cot sides and the sides of the bed. Mrs Greening maintained that this was a temporary measure whilst new cot sides were on order, however, when the new sides were fitted, Mrs Price again wrote stating that they were inappropriate.
63. Mrs Greening's evidence was that B had been assessed prior to the admission but that there had been a change to his psycho-geriatrician, resulting in a change of medication during his period there. This led to his being increasingly violent and Mrs Greening raised this as an issue with the social services department in March 2005. They called a meeting and notified the home that his movement from there was dependent on Holly House themselves and the service user's wishes.
64. On a subsequent visit, B's condition had deteriorated and Mrs Greening agreed with Mrs Price that the situation warranted a PoVA meeting on the basis that B's current needs were not being met, but prior to its being convened, B was transferred to hospital for treatment and assessment. Following the visit, Mrs Price and Mr Powell jointly made a referral in respect of both B and E. Mrs Greening's evidence was that she had contacted B's social worker and community psychiatric nurse as his condition deteriorated to expedite his move to hospital.
65. C was admitted to Holly House despite the fact that she did not appear to have a formal diagnosis of dementia. Alison Price expressed her view that C was inappropriately placed there. C was later moved at Mrs Greening's insistence and it was her evidence that the reassessment and move had been at her instigation. When Mrs Greening visited her in hospital prior to her admission, she had already had an assessment from a nurse who identified her as being an EMI resident.
66. D was initially admitted to Holly House with an EMI residential categorisation. At Mrs Greening's request he was subsequently reassessed and his categorisation changed to EMI nursing. His behaviour did deteriorate, however, and there was an incident between him and A, which Mrs Price alleged should have been reported to CSIW as a Regulation 38 incident.

Activities for the service users.

67. One of the areas of concern to Mrs Price was the lack of activities arranged for the service users. Although activities co-ordinators had been appointed, it was unclear who was in post and what activities had been arranged for the service users, from looking at the logs. The Appellants produced a list during the hearing of the names of the activities co-ordinators at different times. Mrs Greening gave evidence that the current co-ordinator works for three days a week and arranges entertainment for the residents on a regular basis. She has also found that the residents respond better to certain types of entertainment and is intending to provide more of the favoured activities in the future.

The Responsible Individual

68. Under the Care Homes (Wales) Regulations 2002, Regulation 7 (1) states that a person shall not carry on a care home unless he or she is fit to do so. Regulation 7 (2) states that a person is not fit to carry on a care home unless the person is an organisation and it has given notice to the appropriate office of the National Assembly of the name address and position in the organisation of an individual (the "Responsible Individual") who is a director, manager, secretary or other officer of the organisation and is responsible for supervising the management of the care home and that individual satisfies the requirements set out in paragraph 3 of the same Regulation.
69. In her letter of notification of cancellation, Mrs Bond found that one of the grounds made out was that Dr Das was not a fit person to carry on the care home.
70. It was the appellant's case that Dr Das was not and had never been the responsible individual in respect of Holly House.
71. In oral evidence before the tribunal, Dr Das stated that he was not aware that he had been nominated as the Responsible Individual in respect of any of his care homes and that he had not consented to such a nomination. The Respondent produced a copy of the Notice of Determination of Registration dated 13th January 2003, which was addressed to Dr Das and in paragraph 3 identified that "The staffing notice issued on 14 November 2002 is a condition of registration. In the case of a company/organisation currently registered as the provider the person nominated as the "responsible individual" is: Dr PB Das c/o Valley Manor Nursing Home Southend Terrace Pontlottyn, CF81 8RL whose suitability is to be determined."
72. On the 3rd February 2003, an appeal was lodged with the Care Standards Tribunal against the condition of registration that the responsible individual was Dr Das, "suitability to be determined." On the 15th April 2003, His Honour Judge David Pearl, President of the Care Standards Tribunal, heard Ms Rachel Stevens on behalf of the Respondent, the National Assembly for Wales. The Applicant, Holly House, was represented or present. An amended Notice of Determination of Registration dated 15th April 2003 was provided, removing the sentence "In the case of……Suitability to be determined" from the condition and replacing it as a separate paragraph in the determination notice. On being presented with the amended notice, the President made an order that unless the Applicant wrote to the Secretary to the Tribunal within ten working days after receiving a copy of the order, the appeal should not proceed because there had been no decision taken by the Respondent on Dr Das's suitability in relation to Holly House. No representations were made and on the 14th May 2003, the appeal was struck out.
73. At the hearing, Dr Das denied any knowledge of the appeal and denied having been party to it at all. He also alleged that Mr A Yelland, the Appellant's Operations Manager, did not have authority to sign the appeal documentation on his behalf. In the event, the copy documents produced in evidence were unsigned.
75. The Respondent produced copies of the application to register in respect of Brithdir Care Home where Dr Das was nominated as the responsible individual and notes of a fit person interview undertaken in respect of the nomination. Dr Das alleged in oral evidence that the minutes were incorrect.

Financial Viability.

76. One of the concerns raised by Mrs Bond was about the financial viability of the appellant company. CSIW had requested information about the financial situation of the company, but only some of the information had been forthcoming. This was not therefore, a ground that she found made out for the purposes of cancellation.
77. By the date of the hearing, fresh issues had arisen in relation to this matter. A statement was filed by Mr Mark Sly, an employee of Companies House, confirming that enforcement proceedings were being contemplated because no accounts had been filed for the company for 2002 - 2004. There were also allegations that the company were from time to time experiencing difficulties in paying their bills. There was hearsay evidence that bailiffs had entered two of the homes owned by the group seeking to recover a debt owed, and Mr Derrick Powell of CCBC had received a telephone call from Dr Das on the Friday morning prior to the commencement of the hearing, stating that he was unable to pay his bills because no new service users were being placed by CCBC in Holly House.

The hearing

78. During the hearing, oral evidence was heard from: Carole Reece Williams, Joyce Micklewright, Sam Bansal, Mary Walsh, Eileen Owen, Karen O'Grady, Ceri Harris, Cenydd James, Ian Bellamy, Collin Grant, Derrick Powell, Nigel Barnett, Alison Price, Dr Niall Moore, John Powell, Sally Bond, Gordon Cole, Gwilym Kane, Pamela Evans, Rachel Pritchard, Mr Bakshi, Susan Greening, Phillip McCaffrey, Anthony Yelland, Dr Das, Written evidence in the form of a statement was also received from Elisabeth Majer, Christine Hayes, Beverly Mock, Maria Pinch and Mark Sly.
79. Mrs O'Grady gave clear evidence about her perception of the situation at Holly House. She referred to the resistance of the qualified nursing staff to engage with the advice and support offered to them by the team of NHS nurses who went to support them during July and August 2004, but confirmed that the care staff were prepared to accept help and advice to improve the quality of their care for the service users. She identified as her main concerns the lack of basic training about nursing and care practice, but felt that progress had been made as a result of the input. She identified part of the problem as being the limited input from the qualified staff leading to bad practice being passed on to new care staff on induction. In oral evidence, she expressed the view that the difficulties were due to the failure of the manager and qualified staff in their professional duty to ensure that the care was proper and adequate.
80. One recurring problem was the qualified staff's resistance to locking the clinic door, and it was her perception that although it was locked when the nursing team were about, she wasn't sure that that was the case when they were not. She had concerns about the manager Mr Adeniyi's ability to do his job, but confirmed that there was no lack of willingness on the part of the care staff to get any problems sorted.
81. She expressed her concern about service users' safety when the home is fully occupied and service users on each of the three floors. She had seen incidents when there was only one care assistant on a floor for instance during breaks and if anything happened then the other service users could be placed at risk because there is little interaction between floors and qualified staff were seldom seen on the upper two floors. At the end of the month's support, she had remained working at Holly House for a further fortnight to help with the progress there. She identified areas of progress as being respect for the service users' privacy and dignity,
82. Mr Cenydd James, Environmental Health Officer, in his written evidence, stated that he had visited Holly House on the 5th August 2004 and had made recommendations regarding the use of the kitchen there and that he had returned on the 20th August to find that all his recommendations had been carried out to a satisfactory standard. He had subsequently left his employment and had not had any further involvement with the home.
83. A six monthly inspection had been carried out by Maria Pinch, his successor and in a statement made on the 21st April 2005, she gave evidence that she had visited Holly House on the 7th March 2005 to carry out a routine food hygiene inspection. A few days later she received a telephone call from Julia Jones a qualified nurse, who requested a further visit to discuss some other issues with her and the manager. She had drawn to her attention the fact that the food indicated on the menu wasn't always what was served, and that the food preparation also raised issues of food safety. Ms Pinch agreed to arrange a further meeting with the cooks and the administrator in order to advise on food safety.
84. Collin Grant's evidence was that little progress had been made against the 12 areas set out in the Action Plan. He confirmed that there was improvement in the record keeping. When he visited in Feb 2005, the only area where he could find an improvement was in the record keeping. He denied having been affected in his view by comments of CSIW. He would have been informed of PoVA meetings if they happened but did not receive any information directly from CSIW. He said that he tried to be as objective as possible and in his reports reported only that which he personally saw. He expressed his opinion that only awareness training was necessary for staff in relation to the Data Protection Act.
85. Derrick Powell gave evidence that it was never his intention to see Holly House closed but rather to raise standards of care for the service users. He confirmed that no plans had been put in place to move the residents and that he wasn't aware of any such arrangements being discussed. He described the process whereby CCBC determine whether additional beds are available for EMI residents on a week by week basis. He had been aware of only three homes embargoed since1986. He also gave evidence that he had received a telephone call from Dr Das on the Friday prior to the hearing saying that he wasn't able to pay his bills and that it was CCBC's fault because they weren't placing service users in his homes.
86. Oral evidence was received from Mr Nigel Barnett about the procedures to be put in place in the event that a decision was made to close Holly House. He also described the actions instigated by him to deal with the concerns about the financial position of Puretruce Health Care Ltd as a result of both the telephone call from Dr Das and the statement of Mr Sly. He had written to Dr Das requesting a reference from his bankers.
87. Mr John Powell, Senior Inspector, gave evidence that there had been prolonged difficulties in attaining an acceptable level of care at Holly House. He also suggested that privacy and dignity has been a major issue there for a long time. He suggested the possibility that the management were actually feeding care staff anxieties about the situation because CSIW inspectors only fed back to the manager or nurse in charge, consequently, the staff would only know what that person told them. He confirmed that no issues about bullying or harassment were raised by the management at the time of the various inspections.
88. Mrs Sally Bond gave oral evidence about her involvement in the cancellation decision. In her written statement to the Tribunal, she acknowledged that the report of Gordon Cole suggested that much had been done at Holly House to improve the standard of care. She also acknowledged Mr Cole's view that the management is currently strong. She flagged up concerns however about the sustainability of the improvements and the factors identified by Mr Cole as being dependent on three interdependent factors.
89. In oral evidence, Alison Price described herself as forthright and honest. She explained that none of the managers at Holly House had indicated to her that they felt bullied or harassed by her and there is a system in place for a manager to make such representations to CSIW if they are unhappy. In her view, the standards remain not good enough. She confirmed that the paperwork has improved greatly, but that there still need to be further improvements. Staff have undertaken manual handling training and made a good start on the staff supervision and appraisal. She said that the reason why so many of the visits were unannounced was because she wanted a transparent overview of the situation within the home. Her role was to protect the service users and consequently, she did not consider that the number of visits that she carried out at Holly House to be oppressive.
90. With reference to her annual reports and the multiple references to various regulations and NMS, she explained that she tried to direct the home towards good practice and evidence of the procedures necessary to show compliance with the NMS. She saw herself as being facilitative and providing an interpretation of the regulations to make it easier for the appellant to show compliance. She explained that her report on the formal complaint had not been completed until March because a police investigation had been ongoing until February in to the same matter so that she could not complete her own report until the outcome of the police investigation was known.
91. The Tribunal heard evidence from Dr Niall Moore, Consultant Psycho-geriatrician regarding the effect of a decision to close Holly House on the service users. He had carried out a paper review of 10 residents at Holly House and concluded that any move form their present home without adequate preparation could potentially result in mortality and morbidity unless properly supervised and prearranged. Dr Moore was clear however, that he could only indicate potential risk because most of the service users at Holly House are within a high risk category and if a move was done properly, the risk would be reduced to an acceptable level.
92. The Appellants called Mr Bakshi, the company's accountant, who gave evidence that the accounts were ready to file and that the complications had arisen following the collapse of Puretruce Care Ltd, and trying to unravel the finances of the company had led to delay. He confirmed that he was now in a position to file the L'Giri Ltd. Accounts for 2002/03 and that these were composite accounts for the group.
93. Mrs Rachel Pritchard gave evidence about her work at Holly House undertaken with Mrs Greening to try to deal with the issues raised by Mrs Price. Initially, she had a high level of input when Mrs Greening was appointed, but this had reduced as a result of the improvements made in the running of Holly House. She described the situation in relation to Dr Das's involvement with the running of the five homes within the group and her perception of his and her own role in relation to Holly House.
94. Susan Greening gave evidence about the work that she and Rachel Pritchard have undertaken since her appointment to address the issues at Holly House. She confirmed that she does not have an NVQ Level 4 qualification and that she will be commencing that course on the 5th May 2005. She had encountered some difficulty when she started in post with staff attitudes, but was confident that progress had been made with implementing staff training, appraisal and supervision. She confirmed that she had appraised every member of staff herself in March 2005 and the staff appeared to be more amenable to supervision now that they had an opportunity to understand what it entailed.
95. Mrs Greening gave evidence that both Alison Price and John Powell had acted professionally and politely in relation to the complaint investigation and that she had accepted that they had an obligation to investigate. The experience had nevertheless upset, angered and mortified her. She also confirmed that she and the care staff felt negatively about the CSIW regulatory role.
96. Mrs Price had raised an issue regarding the notification of CSIW of serious injury or incident under Regulation 38. Mrs Greening did not agree with Mrs Price's definition of "serious incident", but did consider, on reflection that an incident involving D and A was of sufficient severity to warrant information being passed on to CSIW. She also explained why it was that she did not always agree with Mrs Price's view on when risk assessments should be reviewed and revised.
97. Mrs Price also raised an issue regarding the Regulation 27 visits undertaken by Mr Yelland, the Operations Manager. Although copies of the reports were produced from April 2004, Mrs Price did not consider that the forms evidenced compliance with the requirements of Regulation 27.
    
    98. Mr McCarthy made submissions about the Human Rights implications for the service users, should the Tribunal decide to cancel the registration of Holly House. He argued that the structure of the appeal under Section 21 of the Care Standards Act denied the service users party status, in breach of the requirements of Article 6 of the European Convention on Human Rights (right to a fair trial by an independent tribunal). He submitted that under Section 7(1) of the Human Rights Act 1998, the service users would be the victims and went on to suggest that there is no legal restriction preventing the Appellant from raising the service users rights as relevant issues in the appeal. Once raised, he submitted that the Tribunal has to take the same approach to assessing potential breaches as it would if an appellant was himself the victim. He went on to argue, on the basis of Dr Moore's evidence, that to dismiss the appeal would breach Articles 2, (the right to life), Article 3 (right not to be subjected to torture, inhuman or degrading treatment) and Article 8 (right to respect for private and family life, home and correspondence) of the service users' rights, on the basis that Holly House is their home.

Concessions.

99. In his written closing submissions, Mr McCarthy made several concessions regarding the situation at Holly House: he confirmed that the Appellants, at that point, accepted that there is sufficient evidence for the Care Standards Tribunal to conclude, as of the 14th September 2004, (the date of the cancellation notice) that Holly House had from time to time been carried on otherwise than in accordance with the relevant requirements (the Regulations) and that the Tribunal is entitled to consider the exercise of a discretion to cancel the registration.
100. The Appellant also conceded that the continuing state of affairs since is that there have from time to time been further failures to carry on the home in accordance with the Regulations.
101. Mr Furness confirmed in his written submission that the Respondent accepts that not every breach of the regulation justifies cancellation. The material considerations for the registration authority are the seriousness of the breach and whether it has been or can be expected to be remedied.

Tribunal's conclusions with reasons.

102. It was acknowledged by Mr Furness that not all breaches of the Regulations would justify the cancellation of registration and it was Mr McCarthy's submission that the Tribunal should be circumspect in dealing with Mrs Price's allegations because she did not discriminate between the Regulations, the NMS, good practice guidelines and her own personal opinions.
103. In the light of the concessions made by the Appellant, we have dealt with the situation as it was prior to August 2004 as background and relevant historical information, concentrating on the period from August 2004 to the date of the hearing to consider whether the cancellation continues to be justified. What is clear from the evidence is that it was not only CSIW who were concerned about the quality of provision for service users at Holly House up to August 2004. We have noted that CSIW have relied entirely on their own evidence and investigations in compiling both the Notice of Proposal and the Cancellation Notice, despite the fact that other bodies had produced evidence which would have supported their case.
104. We found the process of extracting from the letters sent by Mrs Price to the Appellant, the relevant evidence to enable us to decide upon the existence and then the severity of the alleged breaches a laborious process. This involved deciding from the narrative in the body of the letters whether the alleged breaches were shown and then untangling the cross references to identify the relevant Regulations and NMS. On making an analysis of the evidence, we found that we could not always understand why certain Regulations were quoted and were not always satisfied that the evidence supported the alleged breach.
105. Mrs Price herself gave evidence that she thought that her visits and letters were supportive and helpful to the management of the home. In view of the fact that there was little recognition in any of the reports or letters of the progress made at Holly House, we do not entirely subscribe to that interpretation of the situation. In her written statement to the Tribunal dated the 3rd February 2005, Mrs Price acknowledged that there had been some improvement in the physical environment, care plan documentation, morale and statutory training of staff at Holly House. Nevertheless she expressed her opinion that it is unlikely that the improvements will be maintained.
106. Whilst we do not criticise the dedication of Mrs Price in securing the safety and well being of the residents at the home, and we do not accept the criticism levelled at her by Dr Das that she was harassing the staff there, it is our view that the visits could have been more effective, had some of them been arranged beforehand, so that the staff could have concentrated on addressing particular standards of the NMS at a given time and would have been better prepared to focus on meeting those standards appropriately.
107. From a consideration of Mrs Price's evidence in detail, we concluded that she had employed a "shotgun" approach to the Regulations, on the basis that any breach found, regardless of frequency or severity, should be highlighted. We do not consider that this approach provides as much support for the staff and management as would have a more targeted approach over a period of time. At the same time, we can only guess at the increasing frustration that Mrs Price must have felt during 2003 and 2004 when the management of Puretruce Health Care Ltd failed to respond constructively to her concerns and the issues she raised about the running of Holly House and the standards of care there.
108. The situation was allowed to continue for a very long time, bearing in mind the nature of the difficulties that Mrs Price identified and the number of issues that had been identified. If we had been asked to consider the case in September 2004, there is little doubt that our decision would have supported closure. CSIW were entirely justified in making their decision at the time that it was made.
109. To decide whether there has been sufficient progress made in dealing with the outstanding issues between the cancellation decision and the date of the hearing to justify the cancellation decision not being confirmed, we took as our starting point those issues identified by Sally Bond in the letter of decision as the grounds made out for breach of the regulations. We then considered the evidence we received from all sources: the unannounced inspections by Alison Price and John Powell, the reports of Gordon Cole, both as jointly instructed by CCBC and Puretruce Health Care Ltd and as a privately instructed expert for the Appellant; the reports of the Gwent Health trust Nurses, monitoring by the Health and Safety Inspectorate, Environmental Health Officers and Collin Grant on behalf of CCBC and the evidence of Mrs Greening, Mrs Mock, Rachel Pritchard, Tony Yelland and Paul Black and Dr Das.
110. Karen O'Grady's perception was that there was resistance to regulation, advice and assistance among the qualified staff at Holly House during the summer of 2004. Her evidence was that the care from the care staff was adequate and even good but that the qualified nursing staff were resistant to engage in the process of seeking compliance with the Regulatory framework. She went into Holly House with the knowledge gained from the CSIW and CCBC reports, and in her view many of the issues could have been easily resolved with the appropriate supervision and training from qualified staff and did improve with input from the Gwent Health Trust team.
111. Mrs O'Grady's involvement with Holly House continued for a further two weeks beyond the original agreed period, and in oral evidence she expressed her opinion that the staffing levels at Holly House were a cause for concern because of the physical layout of the building and the nature of the needs of the residents there. She referred to the risk posed to residents because of inadequate cover over three floors. She also suggested that with a team of enthusiastic and proactive qualified nurses, Holly House could provide adequate care.
112. Mrs Walsh, the Health and Safety Inspector, identified her concerns and noted an improvement in attitude at her meeting with representatives regarding Holly House in November 2004. She had issued notices in regard to manual handling, violence and aggression, slips and trips and bed rails. By November, the issue of manual handling training had been addressed - a training schedule is in place and the refresher training arranged. In oral evidence, she indicated that she was confident that the notices would be complied with and did not appear to be unduly concerned about the situation in Holly House any more.
113. In considering the documentary evidence, we were conscious of a difference in approach by Alison Price in her most recent inspection report and letters. We noted that instead of referring to absence of care plans, she refers to the care planning being inappropriate. Such examples can be seen in the letter of the 7th October 2004, when referring to MS's care plan and in the letter of the 4th March 2005 where reference was made to D requiring a more detailed and robust care plan. This implies that there were care plans in existence, but that she did not agree with their content. In the absence of specific examples or explanations about why they are inappropriate or not robust enough, we are unable to judge whether this amounts to a stylistic difference of opinion or a substantial breach of the Regulations. Because the burden lies on the Respondent to show that the breaches have occurred, we cannot find that all the alleged breaches have been proved. This needs to be identified clearly and she should have been more explicit in her letters, evidence and notices to refer specifically to the reasons why she was not satisfied with the care plans/daily notes or training plans. Despite the fact that they were working to the same set of standards, Mrs Price's perception of the situation at Holly House and that of Gordon Cole differ significantly.
114. Other areas of difficulty arose where there were requirements to review and/or revise care plans or risk assessments and to report or record incidents involving service users. In the absence of specific guidance to registered managers about precisely what constitute serious incidents or at what point an incident becomes sufficiently serious to warrant recording, there will be an element of personal judgement on the part of the manager to decide what should be recorded or reported and this may not always accord with the perceptions of the inspector. Again we find it difficult on the basis of the evidence presented to find all the allegations of breach of Regulations proved.
115. Finally, we found that there were numerous instances where we could not correlate the evidence in the narrative contents of the paragraph to the quoted Regulation. We have therefore concluded that between September 2004 and April 2005, there were significantly fewer breaches of the Regulations than were alleged by Mrs Price. We have concluded that the type of difficulties that she has identified in relation to care planning, reviews, Regulation 27 inspection reports are matters which Mrs Greening should be able to rectify in the short term, with appropriate support. We looked at the outcomes for the service users and concluded that there did not appear to be any adverse effects identifiable from the breaches identified and consequently, we should consider whether there is another option apart from cancellation.
116. Looking specifically at the matters contained in the letter of the 14th September confirming the cancellation notice, we have concluded that we accept the evidence that the moving and handling training has now been undertaken by all but one of the staff; we were not satisfied on a balance of probabilities that service users are now being admitted to the home without assessment and therefore no breach of Regulation 14; we found that the care planning is improved and that clear steps have been taken to address this issue and that with appropriate support it can be fully addressed in the short term.
117. We did not accept any of the submissions made by Mr McCarthy under the Human Rights Act. Although the Tribunal heard from two members of service users' families and received a written statement from a third, Mr McCarthy was not instructed to make representations on behalf of all the service users and should not have suggested that he had a mandate to do so, without evidence to back up the statement. It was our view that if the Tribunal had concluded that there were serious breaches of the Regulations, such as to place the service users in danger, the points raised by Mr McCarthy would have had equal validity if made on behalf of the Respondent. We consider that the basic human rights of the service users are at the core of the Regulations and Care Standards Act when considering issues leading to cancellation.
118. We are unable to make any finding in relation to the allegation that Dr Das is not a fit person to run a care home under Regulation 7. Although there was a copy of the order made by His Honour Judge Pearl on the 15th April 2003 in the documentary evidence, the position was that the Notice of Determination of Registration indicated that whilst Dr Das had been nominated as the Responsible Individual, his fitness was yet to be determined, and we were not presented with evidence to support the contention that his fitness was determined in relation to Holly House. From the evidence presented to the Tribunal, it appears that Holly House's registration has been on the basis that the responsible individual's suitability would be determined at a future date, but that this has not been done. Mr Yelland was nominated in 2004 and Mr Black has been nominated in February 2005 as the Responsible Individual's suitability still remains to be determined. Consequently, we cannot make a finding in relation to Dr Das's suitability.
119. At the same time, we were unimpressed by the evidence of the senior management team at Puretruce Health Care Limited. The difference between the contents of their written statements, their second statements and the oral evidence during the hearing was striking and we concluded that we could not rely upon the factual correctness of all of their evidence.
120. The complaint was the least satisfactory of all aspects of the case. CSIW received a complaint by a person who wished to remain anonymous abut Susan Greening. The complaint made allegations of theft against Mrs Greening and alleged that she had been responsible for breaches of residents' privacy. Alison Price carried out her own investigation into the allegations, took three months to report and found some part of the allegation proved, before referring the matter back to the company for consideration of further issues arising. In our view, the complaint was an employment issue, and once the police were satisfied that there were no grounds for the allegation of theft, CSIW should have referred it immediately to the company for their consideration first. Once she had their report, Mrs Price could have made a more objective decision about the veracity of the allegations. As it was, the whole matter deteriorated into a tit for tat situation, with Mrs Price writing a report "on behalf of the service users" and Rachel Pritchard responding with a report exonerating Sue Greening because that was what she set out to do. For this reason, neither of the reports can be described as objective.

Individual service users.

121. Mrs Price had an issue about A's placement and made a PoVA referral in respect of her on the 11th March 2004 because she does not suffer from dementia or mental infirmity. Despite the concerns and the finding of the meeting that A was not properly placed, she remained a resident at Holly House until 2005, and from the evidence would have been a very difficult resident to place in any event.
122. Some specific incidents referred to which were clearly of concern particularly, the lack of protection of B's dignity and privacy. We accept the evidence of Alison Price and John Powell about the situation that they witnessed on the visit. We were amazed at Dr Das's explanation about the issues of privacy and dignity, which is significantly at variance with anything said by anyone who had been to the home. It appeared to be little more than an attempt to justify by any means a situation that is clearly unacceptable. We also accept Mrs Greening's evidence that she has learnt from her experiences with B and that the issue is being addressed.
123. Mr Furness in his written submission suggested that the material considerations for the registration authority, and therefore the Tribunal in considering an appeal, are the seriousness of the breach or breaches of the regulations and whether they have been or can be expected to be remedied. In assessing the case in respect of Holly House, the Tribunal must look at and determine issues about how the home has been run in the past and how the management of the home have responded (if at all) to issues raised in the past. He invited us to consider the following as issues for determination: Were there breaches of the Regulations? Did those breaches make the cancellation permissible? In the light of the Appellant's concessions the answer to both of these questions is Yes.
124. The next issue that we were invited to consider by Mr Furness was whether the cancellation was appropriate. At the time the decision was made and given the information available at the time and the attitude of the directors of Puretruce Health Care Ltd, the answer was, probably, yes.
125. As a Tribunal we must look at the situation down to the date of the hearing, and in doing so, we have the benefit of a great deal more information than was available to Sally Bond in reaching her decision in September 2004.
126. The next question we were invited to consider is whether there have been improvements in the running of the home since the cancellation decision was made? Again, we have the benefit of information from several sources to consider this question. On a balance of probability and on the basis of the evidence which was presented to us, we have concluded that the answer is yes, although we would qualify that answer with the view that there are still significant improvements which need to be made to bring Holly House up to the necessary standards.
127. The most important question is whether cancellation is still appropriate? The burden of proof is on the Respondent to prove that the cancellation remains appropriate. In the light of the evidence presented, our conclusion has been reached on the finest of margins.
128. In our view, Holly House is a home with a history of serious difficulties in attaining the appropriate standards of care. The attitude of Dr Das has been a major stumbling block to the improvement of standards there. He has, throughout the period when CSIW have been involved with the home, showed resistance in engaging with the regulatory process, has not responded to concerns raised on inspection and has sought to promote the view that standards at Holly House were sufficient, at times when they were clearly not so. Despite the practical difficulties, the senior management team at Puretruce Health Care Ltd have managed to make some improvements in Holly House, although this has been as a result of an unusual level of input by several agencies to try to help and improve standards. We also consider that the appointment of Mrs Greening and her efforts to respond positively to the inspection and regulatory process have helped to bring about improvements since September 2004. We have concluded that in the light of the evidence that we have seen, that there is scope for some further improvements because full compliance cannot be achieved from such a low base in a very short period of time. Holly House has only recently put in the necessary work to address the remaining issues, and some progress is shown. We have concluded that with additional support, full compliance is attainable within a realistic time frame, so that closure of the home is not necessary. The decision is very borderline, and our decision will now probably offer Holly House a last chance to put their house in order.
129. Were it not for the appointment of Mrs Greening and the perseverance and persistence that she has shown to try to improve the situation, the cancellation notice would have been confirmed by the Tribunal. She appears to be a firm and capable manager, who has shown herself ready to engage in the inspection and regulatory process and to accept the advice and guidance that Holly House requires to ensure that it meets and maintains the NMS. She has also stayed at Holly House despite the fact that the threat of closure has been a real possibility.
130. She will, however, need more help than she has been getting to manage the workload that she has. The staffing levels within the home have been criticised in the course of the hearing and we believe that if a condition was imposed on the registration that a Deputy Manager should be appointed to assist the manager in dealing with the paperwork issues imposed by the NMS and to ensure that the relevant policies and plans are in place to evidence the progress already made as well as that to be achieved in the future. We also considered Mrs Karen O'Grady's evidence about her concerns that the staffing levels posed potential dangers to the residents when they are living on three floors as separate units. In our view, an additional person on duty will give greater flexibility and cover to the carers. Such an appointment will be in addition to the current staff identified in the staffing notice of the 14th November 2001.
131. The main object of the appointment will be for the purpose of offering administrative support to the Manager, to ensure that within a short period all of the evidential paperwork regarding the NMS is in place. We have accepted the evidence of progress having been made however we would anticipate that once the Deputy Manager is appointed (and we would not anticipate that such an appointment would take longer than 3 months to make), the rate of progress will significantly increase.
132. Mr McCarthy proposed the continuing involvement of Mr Cole within the process to identify areas where further action is required and to report on progress. He also proposed a greater level of cooperation between CSIW and Puretruce Health Care Ltd, starting with around the table discussions about the future. We do not consider that we are able to name Mr Cole within the registration conditions because we do not have his consent to do so nor would it be wise to limit the involvement to one named individual. We do, however, consider that it would be helpful to the provider to have imposed upon the registration a requirement for input and supervision from an independent health and/or social care consultant. This will be at a level that the provider considers appropriate, and we would expect that they would use the expertise to identify areas of priority and identify relevant time limited targets to address the remaining issues at Holly House. For the purposes of the continuing registration, however, we propose to identify that an independent health and/or social care consultant provides reports to the company identifying areas of progress against identified targets and areas where further work is required to meet and maintain the NMS within a specified time frame and that a copy of the written report must be provided to CSIW every two months, by the last day of the month. If and when the CSIW conclude that the imposition of such a condition is no longer necessary, they will be able to vary or remove condition.
133. Concerns were raised about the financial viability of Puretruce and evidence given about the lack of accounts for the period 2003 - 2004. We also heard evidence about Dr Das's telephone call to Mr Powell saying that he couldn't pay the bills on the Friday prior to the hearing. We were also aware that the funding for the appeal wasn't forthcoming until the Friday prior to the hearing either. Nevertheless, it had been released, and the evidence presented was that the debts had been paid. The evidence that we heard was that Puretruce Care Limited going into receivership had caused problems for the accountants and had taken some time to resolve. We are therefore satisfied that with the certainty of continuing operation, Holly House is financially viable for the time being.
134. We were concerned about the lack of real planning undertaken to facilitate the movement of service users had the decision been made to close Holly House. Such a decision would have necessitated a quick response from CCBC and Caerphilly LHB, and perhaps a clearer attempt should have been made to prepare service users and their families for the possible closure.

Decision

Appeal allowed.

It is ordered that two further conditions be imposed on the registration of Holly House Care Home, Fleur de Lys, Blackwood as follows:

1) A full time home specific Deputy Manager be appointed for Holly House Care Home;
2) The registered provider to provide to CSIW before the last day of the month, every two months, commencing on or before the 31st July 2005, a report from an independent Consultant in Health and/or Social Care Services, identifying progress made against set targets (such targets to be specific, measurable, achievable, relevant and time limited) to meet and maintain the National Minimum Standards for Care Homes (Wales) 2002 and the Care homes (Wales) Regulations 2002.

This is the unanimous decision of the Tribunal.

Mrs M Tudur (Chair)
Mrs M Martin
Mr C Wakefield
Dated 15th May 2005.