Silvergrove Nursing Home Ltd v Chief Inspector of Social Services and Health Information and Quality Authority [2019] IEHC 774 (31 July 2019)

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	High Court of Ireland Decisions
You are here: BAILII >> Databases >> High Court of Ireland Decisions >> Silvergrove Nursing Home Ltd v Chief Inspector of Social Services and Health Information and Quality Authority [2019] IEHC 774 (31 July 2019) URL: http://www.bailii.org/ie/cases/IEHC/2019/2019_IEHC_774.html Cite as: [2019] IEHC 774

CHIEF INSPECTOR OF SOCIAL SERVICES AND HEALTH INFORMATION AND QUALITY

Written judgment of ex tempore ruling of Ms. Justice Ní Raifeartaigh delivered on 31st

1. This case concerns a nursing home and a “notice of cancellation” which was issued to the

nursing home by the Chief Inspector of Social Services. The applicant seeks to quash the

notice of cancellation and to obtain a number of related declarations.

2. The most recent certificate of registration for the applicant entity is dated 7th October,

2016. In the normal course, this certificate would have been due to expire on 7th

October, 2019. It describes both the registered provider and the designated centre as

3. On 18th June, 2018, the Chief Inspector gave notice of a proposed decision to cancel in

accordance with s. 53 of the Health Act, 2007. This was followed on the 17th October,

2018 by a notice of decision to cancel registration under s. 55 of the Act. The decision to

4. The Health Act 2007 (“the Act of 2007”) established the Health Information and Quality

Authority (“HIQA”) as well as the position of Chief Inspector of Social Services (“the Chief

Inspector”). It also provided for a scheme of registration and inspection of residential

services in respect of various sectors. This included the registration and inspection of

nursing homes. The office of the Chief Inspector was dealt with under Part 7 of the Act of

2007. The Chief Inspector’s remuneration, expenses, period of office and terms of office

were placed under the control of HIQA subject to the approval of the Minister for Health

(and with the consent of the Minister for Finance). It provided that HIQA may dismiss a

Chief Inspector for any of the reasons set out in s. 40(6) of the Act of 2007.

5. Section 41 of the Act of 2007 set out the functions of the Chief Inspector which included

the establishing and maintaining of one or more registers of designated centres, and of

6. Section 43 provided that HIQA may, in accordance with the terms of the appointment of

HIQA employees under s.26, appoint “inspectors of social services” to assist the Chief

7. Section 46 of the Act of 2007 provided that it would be a criminal offence to carry on a

8. Part 8 of the Act of 2007 dealt with applications for registration and renewals of

registration. Central to the decision in this regard is that the Chief Inspector is satisfied of

the fitness of the registered provider and of the persons who participate in the

9. An appeal to the District Court from a decision to cancel registration is provided for by s.

10. The relevant chronology of events may be summarised as follows. On 7th October, 2013,

the applicant nursing home obtained a certificate of registration as a designated centre.

On 7th October, 2016, it obtained a subsequent certificate of registration.

11. A number of inspections were carried out at the nursing home over a period of time.

These inspections occurred on 2nd February, 2016; 16th June, 2016; 23rd January,

2018; 11th April, 2018; and 31st May, 2018. The pattern was as follows: the inspections

took note of various shortcomings in the running of the home; recommendations were

made as to how these shortcomings should be addressed; and the response of the

applicant on each occasion was not to dispute the findings in terms of their accuracy but

to seek some time to address the shortcomings that had been identified.

12. On 18th June, 2018, a notice of proposed decision to cancel was issued to the applicant.

The applicant was invited to make representations in accordance with the procedure

envisaged under section of 54 the Act of 2007. On 15th July, 2018, the applicant

submitted written representations which, again, did not dispute the factual findings in

respect of the state of affairs at the nursing home but stated that it was committed to

addressing the concerns and gave various detailed assurances in relation to the matters

13. On 3rd August, 2018, an unannounced inspection was conducted. A further unannounced

14. On 17th October, 2018, a meeting was held between HIQA and the Chief Inspector of

15. On 18th October, 2018, a notice of decision to cancel registration issued to the applicant.

16. On 7th November, 2018, a letter was sent by the applicant’s solicitors referring to steps

which had been taken since the meeting, including the appointment of a re-configured

senior management team. The letter requested that the Chief Inspector withdraw the

notice in order to afford the company a reasonable period of time within which to address

the matters without the necessity to engage valuable court time. The letter also

complained about errors on the face of the notice itself and set out in detail the correct

statutory provisions which should have been referred to, and attached a Schedule of

17. A response from the Chief Inspector refusing this request was received on 9th November,

2018. This letter pointed out that the first page of the notice had set out that the

cancellation was based on s.51(2)(b) of the Act of 2007 and the letter then quoted it as

follows: “that, in the opinion of the chief inspector, the registered provider or any other

person who participates in the management of the centre is not a fit person to be the

registered provider of the centre or to participate in its management”. It went on to say

that the Schedule to the notice contained detailed particulars regarding “the fitness of

18. A notice of appeal was filed in the District Court in accordance with the statutory

procedure set out under s.57 of the Act of 2007 on 13th November, 2018.

19. On 10th December, 2018, there was a further unannounced inspection, and a follow-up

report acknowledged some “recent improvements” and that there had been “decisive

action to change the management structure in the centre”. However, the report noted

that the new structure was “still in its infancy with roles and responsibilities not clearly

defined” which had contributed to the “repeated non-compliances” identified in the

20. Leave to bring judicial review proceedings was granted by the High Court (Noonan J.) on

21. A further unannounced inspection was conducted on 26th March, 2019, the report of

which stated that the applicant’s nursing home was deemed to be “compliant” or

(i) An order of certiorari quashing the decision in the notice of cancellation dated 17th

(ii) A declaration that the first and/or second named respondent failed to specify or

sufficiently specify the grounds/reasons for its decision in the notice of cancellation.

(iii) A declaration that the first and/or second named respondent failed to comply with

the principles of basic fairness of procedures and natural and constitutional justice

in grounding its decision in the notice of cancellation on issues of non-compliance

identified in February 2016 when the first and/or second named respondent

acknowledged in June 2016 that such issues had been “satisfactorily addressed

(iv) A declaration that the first named respondent was not entitled to rely on the

following reports of inspection conducted by the second respondent in its decision in

the notice of cancellation: 10th December, 2018; 8th and 9th October, 2018; 3rd

August, 2018; 31st May, 2018; 11th April 2018; and 23rd January, 2018.

(v) An order of certiorari quashing the reports of inspection identified above and/or the

regulatory judgments therein and/or the decision to publish the said reports.

(vi) A declaration that the first respondent had no registration and/or inspection

function (or ‘register’) under section 41(1)(b) and (c) of the Health Act 2007 in

respect of “designated centres” and/or “registered providers” until the Health Act

2007 (Commencement) Order 2017 (S.I No. 429 of 2017) or, in the alternative,

(vii) A declaration that the Notice of Cancellation was invalid, ineffective and/or

unenforceable as it sought to cancel the registration of an entity which was not the

“designated centre” and/or the “registered provider” identified in the opposition

(viii) An order extending time for judicial review of some of the reports insofar as this

(ix) A stay on the decision in the notice of cancellation taking effect until the hearing of

(x) A stay on the appeal of the decision in the notice of cancellation to the District

23. The grounds upon which the above reliefs are sought were as follows:-

(a) The grounds and reasons relied upon to cancel the registration of the applicant

were identified under a legislative provision which did not exist. In particular, the

decision in the notice of cancellation was grounded on s.52(1)(b) of the Health Act

(b) Ground number 1(1) in the notice of cancellation was grounded on an allegation

that the applicant “does not have adequate understanding of its regulatory

responsibilities under the Health Act 2017, and the Regulations and Standards

made thereunder.” No such Act exists nor do such regulations and standards exist.

identified on 2nd February, 2016 when the first and/or second named respondent

acknowledged on 16th June, 2016 that “the failings found on [2nd February, 2016]

had been satisfactorily addressed within the agreed timelines.”

(d) The minutes of a meeting held on 17th October, 2018 prepared by the second

respondent state that the grounds for the proposal to cancel the registration

“centred on the fitness of the registered provider and that the findings of last

week’s inspection [8th and 9th October, 2018] reiterated the lack of fitness of this

entity.” The latter ground found no expression in the notice of cancellation.

(e) The first respondent had no registration and/or no inspection function (or ‘register’)

under section 41(1)(b) and (c) of the Health Act 2007 in respect of “designated

centres” and/or “registered providers” until the Health Act 2007 (Commencement)

Order 2017 (S.I. No. 429 of 2017). Further or in the alternative, the first

respondent had no such functions and/or ‘register’ at all. The first respondent

cannot by the notice of cancellation lawfully cancel a registration which it has or

(f) The notice of cancellation was invalid, ineffective and/or unenforceable as it seeks

to cancel the registration of an entity which is not the “designated centre” and/or

the “registered provider” identified in the opposition papers and/or in the 2016-

24. The notice of decision to cancel registration was signed by the Deputy Chief Inspector,

Susan Cliffe, and consisted in total of a 7-page document. The opening section of this

Section 51(1)(a) and Section 55(1)(c) of the Health Act 2007 as amended (“the

Notice of Decision to Cancel Registration of a Designated Centre issued pursuant to

To: Silvergrove Nursing Home Limited, 5 Main Street, Leixlip, Co. Kildare

Having its registered office at: 5 Main Street, Leixlip, Co. Kildare

Being the registered provided of: Silvergrove Nursing Home, Main Street, Clonee,

You are hereby given written notice that the Chief Inspector has decided to cancel

the registration of Silvergrove Nursing Home as a designated centre on the grounds

specified in Section 51(2)(b) of the Health Act 2007 as amended, particulars of

which grounds are set out in the Schedule to this Notice. This Notice is given by the

Chief Inspector pursuant to Section 51(1)(a) and in compliance with the obligation

The notice then informed the applicant in some detail of its right of appeal to the District

Court. In the top right-hand corner of the front page of the notice was written “Office of

the Chief Inspector of Social Services”, underneath which featured the logo of, and

words; “Health Information and Quality Authority”. I do not intend to set out the entire

remainder of the 7-page notice in full, for obvious reasons, and hope that the following

That in the opinion of the chief inspector, the registered provider is not a fit

person to be the registered provider of the designated centre and to

participate in its management: Fitness of the registered provider –

Silvergrove Nursing Home Limited is not a fit person to be the registered

provider of the designated centre for older people due to its failure to govern

and manage the designated centre in a safe manner than ensure the welfare

(1) “Failure to demonstrate that it has the knowledge, understanding and ability to fulfil

its obligations under the Act and Regulations and Standards made thereunder. This

lack of knowledge has been brought to the attention of the registered provider by

and on behalf of the Chief Inspector on 13th February 2018 without improvements

(2) Failure to put in place a robust governance system and a clearly defined

management structure that supports the delivery of safe care for residents.

(3) Failure to put in place a responsive quality assurance and risk management process

(4) Failure to put in place effective management systems and processes to ensure it is

competent to provide a service to residents that is safe, appropriate, consistent and

(5) Failure to put in place actions and improvements identified in the monitoring

inspection reports of 23rd January 2018 and 11th April 2018 and where

improvements were put in place, the registered provider demonstrated inability to

sustain these improvements to ensure that the designated centre is in compliance

with statutory requirements under the Act, Regulations and National Standards.

(6) The registered provider has not demonstrated that it is competent or capable of

carrying on the business of the designated centre in compliance with the

requirements of the Health Act 2007, and the Regulations and Standards made

27. Further details were set out within each of (1) to (6) above. The second last page of the

notice contained a table in which different columns set out the precise regulations and

standards deemed to have been breached and which inspection reports had notified those

breaches. The last page of the notice contained a list of “relevant documentation” which

included reports of inspection of 2nd February, 2016, 16th June, 2016, 23rd January,

2018, 11th April, 2018 and 31st May, 2018. No reports of the inspections subsequent to

The submission that the inspection powers of the Chief Inspector were removed by

28. This far-reaching ground of challenge was added to the judicial review proceedings

subsequent to its commencement and was set out in the amended Statement of Grounds

dated 25th March, 2019. The applicant submitted that by virtue of a particular provision

within the Child and Family Agency Act 2013 (the “Act of 2013”), the Chief Inspector

ceased to have any power at all to carry out inspections of nursing homes under the

Health Act, 2007 during certain dates in the period 2014-2017. During oral argument,

counsel for the applicant accepted that if his argument were correct on this point, this

would logically render invalid not only the decision on cancellation but also the

registration of the nursing home in the first place, as well as the registration and

29. The inspection function in respect of nursing homes was conferred by the Health Act,

2007 and was discussed in Packenham v. Chief Inspector [2018] IEHC 715.

30. The applicant is correct in identifying a problem caused by the Act of 2013. It effected a

re-numbering of certain sections and sub-paragraphs in the Act of 2007 and thereby

created a situation where the Health Act (Commencement) (No. 2) Order 2009 (which

commenced the registration and inspection function with regard to nursing homes) no

longer corresponded to the same legislative provision as it had done prior to 2013. This

31. Section 2(1)(b) of the Health Act, 2007 provides that a “designated centre” means an

institution which includes a nursing home. The Health Act 2007 (Commencement) (No. 2)

Order of 2009 (S.I. No. 237 of 2009) then commenced with effect from 1st July, 2009: (i)

the definition of a “designated centre” provided for under s. 2(1)(b) of the Act of 2007

and (ii) the functions of the Chief Inspector as provided for under s. 41(1)(b) and (c) of

the Act of 2007 “in so far only as the functions under those paragraphs are performable in

relation to a designated centre to which paragraph (a)(iii) or (b) of the definition of

“designated centre” in section 2 applies”. Thus, from 1st July, 2009, the Chief Inspector’s

functions in respect of the registration and inspection of nursing homes came into effect.

32. However, the Child and Family Agency Act 2013 re-numbered the paragraphs within

section 2 of the Health Act, 2007 such that nursing homes were moved from the old

s.2(1)(b) to a newly created s.2(1)(c). The Act of 2013 was commenced by the Child and

Family Agency Act 2013 (Commencement) Order 2013 (S.I. No. 502 of 2013) with effect

from 1st January, 2014. The applicant submitted that from this date, 1st January 2014,

the Inspector ceased to have an inspection function because the commencement order of

2009 no longer applied to the legislative provision dealing with nursing homes.

33. The now-faulty cross-reference as between the 2009 commencement order and the

amended statutory provision, whatever its legal nature or effect, must have been noticed

by the authorities sometime between 2014 and 2017, because the problem was

addressed in the latter year by the Health Act 2007 (Commencement Order) 2017 (S.I.

No. 429/2017). This commenced the functions under s.41(1)(b) and (c) “insofar as the

functions under those paragraphs are not already performable” with regard to nursing

homes (I have not reproduced the precise cross-referencing of subparagraphs here in full

as it is cumbersome, but it is clear that it was intended to ensure that the inspection

function with regard to nursing homes was commenced “insofar” as it was not already

commenced); thus, in my view, it sought to remain neutral on the question of the

functions that were in force/commenced/performable or not prior to and as of the new

commencement in 2017. The applicant of course submitted that this legislative

amendment underscores the fact that there was indeed a lacuna and that the inspection

function with regard to nursing homes had ceased to be in force prior to the new

commencement date in 2017. However, the applicant’s counsel also accepted that the

registration and inspection functions stood or fell together in this respect, and that if there

had been, during a particular period, a gap in the law with regard to the inspection

function, there had been a similar gap with regard to the registration function. On this

view, all registration certificates issued between the relevant dates in 2014 and 2017

34. Even if the applicant were technically correct in his submission with regard to the re-

numbering of the legislation, I would exercise the discretion the Court has in judicial

review proceedings against granting the relief sought, which was a cancellation of its

notice of cancellation on the ground that it was based on inspection reports that were

legally invalid. In my view, there is no trace in the Act of 2013 of any legislative intent

whatsoever to remove the Chief Inspector’s functions with regard to the registration and

inspection of nursing homes, and the problem is much more likely to have been created

as a result of inadvertence. Secondly, there would be serious implications for third parties

who were not before the Court if the Court were to reach the conclusion that the Chief

Inspector’s functions with regard to nursing homes had been removed, insofar as all the

registrations of such third parties during the relevant period of 2-3 years would be invalid,

which would most certainly not be in the public interest. Thirdly, if the applicant’s

submission is correct, the logical implication would be not only that the cancellation notice

was invalid but also that applicant itself had no legal right to run the nursing home in the

first place because his registration certificate was invalid. Of course, the applicant seeks

to have the benefit of his submission (the quashing of the cancellation notice) because it

would suit him, without the logical corollary of it (the quashing of his registration

certificate), which would not suit him. However I do not see why, if the Court were to go

down this road and grant relief, it should limit itself to quashing the notice of cancellation

and not quash the registration itself. In all of those circumstances, I would have declined

to grant the relief sought even if I were convinced of the merits of the argument as a

35. However, and perhaps more importantly, I am not persuaded in any event, as a matter of

statutory construction, that where a legislative provision conferring powers on a

designated person or body has been validly commenced at a particular point in time, it

can somehow be ‘un-commenced’ at a later point in time simply by virtue of a subsequent

re-numbering of provisions in a statute, particularly when there is no evidence in the later

legislation demonstrating any intention to remove those powers from the designated

person or body. I agree with the submission on behalf of the respondent that the

commencement of a statutory provision conferring powers in this manner is a once-off

event which cannot be ‘rolled back’ by this mechanism and that the only way to remove

the already commenced inspection and registration functions of the Chief Inspector would

have been by enacting a clear and unequivocal legislative amendment. I am not

persuaded that the present situation is similar to the more usual kind of repeal or

substitution of a statutory provision or Directive (as was in issue, for example, in O’Flynn

Construction Co. Ltd v. An Bord Pleanála [2000] 1 IR 497, relied upon on behalf of the

36. I therefore refuse to grant the reliefs insofar as they are based on this ground.

The submission relating to errors on the face of the notice of cancellation

37. The applicant identified a number of errors on the face of the notice of cancellation which,

it was submitted, rendered the notice invalid by reason of errors on the face of the

Reference to the wrong section of the legislation with regard to the ground for

cancellation and/or reference to a section of the Health Act 2007 which did not exist

References to an entity which is not the designated centre and/or registered

provider (in this regard, the applicant submitted that the notice refers to

Silvergrove Nursing Home whereas the designated centre and registered provider is

38. The applicant relied on the following authorities in support of its argument in connection

with errors on the face of the record: Bannon v. Employment Appeals Tribunal [1993] 1

IR 500; State (O’Reilly) v. Delap (Unreported, High Court, Gannon J., 20th December

1985); Wu v. Minister for Justice (Unreported, High Court, Smyth J., 25th January 2002),

[2002] IEHC 163; ABM v. Minister for Justice (Unreported, High Court, O’Donovan J.,

23rd July 2001), [2001] IEHC 110; and EC v. Clinical Director of the Central Mental

Hospital (Unreported, High Court, Hogan J., 5th April 2012), [2012] IEHC 152.

39. The respondent submitted that the errors in question were clerical errors which did not

warrant the quashing of the order and which did not mislead or prejudice the applicant in

any way. It was submitted that while the notice did contain some errors as described by

the applicant, it also correctly recorded the section of the Act relied upon in other

locations in the notice as well as the terminology of the correct section. Further, the

applicant’s solicitor in his own letter of response to the notice had drawn attention to and

identified the errors in the decision and therefore was clearly not misled in any way.

Regarding the name of the nursing home (i.e. the absence of the word “Limited”), the

respondent submitted that Silvergrove Nursing Home is the trading name of the

registered provider (and had indeed been used by the applicant itself in the title of these

proceedings – “Silvergrove Nursing Home Limited t/a Silvergrove Nursing Home”). In all

of the circumstances, it was submitted that no question of any unfairness, prejudice or

misleading could possibly arise simply by virtue of the absence of this particular word (the

word “limited”). The respondent also pointed to the analysis of errors on the face of the

record engaged in by the Court of Criminal Appeal (O’Donnell J.) in the case of The People

at the Suit of the Director of Public Prosecutions v. Mallon [2011] 2 IR 544 which

concerned errors on the face of search warrants in criminal cases, and submitted that the

errors identified in the present case were errors of a type which, even on the Mallon

analysis, would not render the document invalid; and that there could be no more

rigorous analysis than that employed in cases involving search warrants in criminal cases.

It was further submitted that the notice of cancellation was a relatively lengthy document

which must be read in context of the previous ongoing engagement between the parties

and therefore, again, the applicant would not have been in any way misled having regard

40. It is true that on the third page of the notice, where the “Ground and Reasons for

Cancellation” were being set out, there was an error regarding the statutory provision

concerning the ‘fitness’ ground for cancellation; it refers to s.52(1)(b) when it should

have been s. 51(2)(b). On the other hand, the first page of the document did refer to the

correct section containing the ‘fitness’ ground, namely s. 51(2)(b) of the Health Act 2007

(I note also that when the applicant’s solicitor complained about this aspect of the notice,

the respondent’s letter of 9th November, 2018 in reply set out with complete clarity that

the ground relied upon was s. 51(2)(b) of the Act of 2007 and that it was the “fitness”

ground). Further, the document made several references to the correct statutory source

of the power to cancel (namely s. 51(1)(a) and s. 55(1)(c) of the Act of 2007). Also, the

document contains much detail and there could be no doubt whatsoever that the

complaint was about fitness based upon the findings in the inspection reports listed.

There were references to a Health Act, 2017, although one might assume this was a

typographical error. There were indeed references to regulations and standards, of which

there are apparently none. I can only deprecate what might be described as a

considerable lack of care in the drafting of the document. However, the effect, if any, of

those errors upon the validity of the notice is a different matter.

41. I agree with the submissions on behalf of the respondent in this regard and I am satisfied

that the errors would have passed the test of validity even on the Mallon criteria; bearing

in mind that the criteria in respect of search warrants are among the most rigorous

criteria in the legal system regarding errors on face, concerning as they do errors in a

document which purports to authorise the search of a dwelling which attracts a high

degree of constitutional protection. In Mallon, O’Donnell J. (delivering the judgment of the

Court of Criminal Appeal) distinguished between (a) situations where a statutory

precondition had not been fulfilled or the warrant itself did not show that the

preconditions had been satisfied and (b) errors in the body of the warrant. With regard to

“It is now clear that a mere error will not invalidate a warrant, especially one which

is not calculated to mislead, or perhaps just as importantly, does not mislead” (para

“It is now quite clear that although a warrant should be prepared with care, not

every error will lead to invalidation of the warrant. In particular, where the

substance of the warrant as opposed to the form is not open to objection, invalidity

will not necessarily arise. In such cases, the nature of the error or omission must

be scrutinised to see if it is of a fundamental nature. Among the factors which may

be taken into account are whether the error is a mere misdescription and whether it

“…even in those cases where the Courts appear to take a strict approach to errors

which may be grammatical, syntactical or in the completion of a standard form, the

test is not simply whether there has been an error, but rather whether the error

42. In the present case, no submission was made that any statutory precondition to the

cancellation notice had not been satisfied; rather the complaint about the notice of

cancellation was about the matters set out at paragraph 23 above. The errors on the face

of the notice do not, in my view, satisfy even the Mallon test(s). In any event, the present

case does not concern any document in a criminal context and the document in question

was created against a backdrop of an ongoing relationship between the parties such that

the addressee of the document could have had no doubt whatsoever what legislation was

being invoked, that this was a notice of cancellation provided for under the legislation,

and what the reason for the cancellation was. The errors were contained in a lengthy 7-

page document, most of which was entirely correct and appropriate. Errors such as the

absence of the word “Limited” seem to me to be trivial, especially in circumstances where

the company number and two relevant addresses were given. The addressee’s solicitor

wrote in response to the Chief Inspector pointing out the errors in the document, and the

Chief Inspector replied, setting out the correct statutory provision and the “fitness”

ground without any ambiguity. Such interactions simply do not arise in a criminal context;

the present one is an entirely different context. In all of the circumstances, I am satisfied

that the document did not mislead the applicant in any way. While I would criticise the

lack of care in the drafting of certain parts of the notice, in short I do not think the Court

should approach this document as if it were a search warrant or a criminal charge; but

even if it did, I do not think the document would fail the tests applied even in criminal

The submission that any inspections were carried out by HIQA (rather than the Chief

Inspector) and were therefore invalid because HIQA has no statutory function in

43. The applicant submitted (as an alternative to his first submission that the Chief Inspector

had ceased to have the inspection function by virtue of the Act of 2013, discussed above)

that the evidence before the Court suggested that inspections of the nursing home were

in fact carried out by HIQA, which has no inspection function under the Act of 2013,

rather than by the Chief Inspector, who was clearly intended to have the function under

the legislation (Packenham v. Chief Inspector [2018] IEHC 715). This submission was

based upon the appearance of the physical documents upon which the inspection reports

were produced, together with the absence of any averment in the affidavits on behalf of

the respondent that the inspections were in fact carried out by or on behalf of the Chief

Inspector. The inspection reports all bore the HIQA logo and had other evidence of

44. I am satisfied that there is no merit in this argument and that the inspections were, as a

matter of fact, carried out by inspectors within the office of the Chief Inspector and that

the reports (which bear the names of the inspectors in question) were prepared by those

inspectors. The fact that the HIQA logo appeared on their inspection reports does not

somehow taint their reports nor does it convert their inspections into HIQA inspections. I

have set out earlier the provisions of the Act of 2007 which show the clear relationship

between the Chief Inspector and HIQA, and there was nothing improper, invalid or

misleading in the fact that the inspector’s reports were produced on HIQA letterheaded

paper. I am quite satisfied to draw the inference from the inspection reports bearing the

names of individual inspectors that those inspectors did in fact carry out the inspections

themselves on behalf of the Chief Inspector and I do not think that the absence of a

positive averment on behalf of the respondent stating this fact establishes the opposite

Submission that the decision to cancel was unfair because it was based on historical

45. It was submitted that the decision to cancel was improperly based upon events in the

past which had been rectified long before the notice to cancel; in particular, it was

submitted in this regard that the nursing home’s shortcomings as identified in 2nd

February, 2016 report had been satisfactorily addressed by the 16th June, 2016 and that

it was therefore unfair and improper for the Chief Inspector to rely on the shortcomings

identified in February 2016 as one of the reasons for reaching the decision to cancel. The

inspection report of February 2016 was one of the reports listed in the notice of

46. The respondent pleaded that there was nothing improper in such reliance; that “particular

5” of the decision set out the applicant’s inability to sustain improvements; that it was

clear that the improvements made by June 2016 had not been sustained; and that

evidence of poor practice had re-emerged (namely, the repeated non-compliances

observed during 2018). It submitted that the Chief Inspector was perfectly entitled to

have regard to the overall history for the purpose of assessing fitness.

47. I agree with the respondent in this regard and take the view that a decision-maker who is

tasked with making an assessment of fitness is entitled to have regard to the overall

pattern emerging from a series of inspections when reaching his or her decision. Here, the

class of persons the decision-maker is entrusted with protecting is an elderly and

vulnerable population. Repeatedly, shortcomings in the nursing home had been found and

communicated, promises to improve had been given, and then further shortcomings had

been found. A person in charge of a nursing home is not somehow entitled as a matter of

right to continue in operation on the basis of repeated promises to improve; the

monitoring body is well within its statutory remit to take the view that, having regard to

the overall pattern, there comes a point when there has been too much postponement

and not enough compliance. He or she is entitled to have regard to the entire period of

what might be a series of peaks and troughs with regard to the institution and to take an

overall view. I would see the Court’s function as very limited in second-guessing the

decision-maker’s view in this regard; only if there was some manifest irrationality, such

as a clear divergence between the picture presented by the inspection reports and the

ultimate decision to cancel, should a Court consider intervening. This was not the case

here. While the applicant was anxious to point to the large number of areas where there

had been compliance on the occasion of each inspection, it was apparent that particular

areas of difficulty were also identified on each occasion. The decision-maker, who has an

overview of standards across the board in relation to nursing homes within the State, is

much better placed than the Court to decide when there is a serious issue about fitness of

a particular home based upon the overall pattern of problems, promises, compliance and

The submission that the decision to cancel had been based on unexpressed reason

48. The applicant’s complaint in this regard is that the minutes of a meeting between HIQA

(Ms. Susan Cliffe, Ms. Angela Ring and Ms. Evony Potter) and representatives of the

registered provider (Dr. Louise Boyd and Ms. Mary Boyd) of 17th October, 2018 states

that the grounds for proposal to cancel centred on the fitness of the registered provider

and a recent inspection of 8th and 9th October, 2018 in circumstances where the recent

inspection had not been mentioned in the notice of cancellation and the applicant had no

opportunity to address that inspection in his written submissions.

49. Again, I not persuaded by this argument. The applicant concedes that it does not dispute

the findings made during the October 2018 inspection. It was accepted on its behalf that

the sole purpose of being allowed to make submissions in relation to this inspection would

have been to seek to persuade the decision-maker that more time was needed to address

the shortcomings identified. This is not the kind of ‘new information’ that was in issue in

the authorities where it has been held that a decision was invalid by reason of the

decision being based upon a matter in respect of which the applicant had no opportunity

to make submission to the decision-maker. Further, it might be different if, for example,

the October 2018 inspection had found everything to be perfectly in compliance and

therefore a departure from the previous pattern. However, on the contrary, the inspection

continued to report negative features. Finally, even if I am wrong that the applicant

should, strictly speaking, have been given an opportunity to address the October

inspection issues, I would exercise discretion against granting relief in circumstances

where the applicant accepts that the factual findings were not in dispute and that its

response would have in any event been limited to persuading the Chief Inspector to give

50. Section 57 of the Act of 2007 provides for an appeal of a decision to cancel registration

to the District Court. In the present case, an appeal was lodged on 13th November, 2018

to Trim District Court. Leave to bring judicial review proceedings was obtained on 14th

January, 2019. The respondent pleaded that the application for judicial review should be

refused on the basis that the applicant has or had available to it an alternate and

51. With the exception of the legislative point, which was added to the judicial review at a

later stage, all of the points raised in the present proceedings could been raised in the

District Court. Further, the Court was informed that the practice in such appeals is to

consider the position of any appellant as of the date of the appeal; therefore, if a nursing

home has made serious efforts since the date of the notice of cancellation, this can be

taken into account at the appeal. In the course of this judicial review, the applicant

sought repeatedly to emphasise that it had always done its best to co-operate and comply

with the recommendations arising out of inspections; that the reports were more positive

than negative; and that it merely needed more time. Ironically, this position, which

focuses on the future rather than the past, would have much more resonance within a

District Court appeal than it has in a judicial review, the latter being limited in scope to

issues such as the procedures leading up to the issuing of the notice and its form. The

appeal process seems to me to be much more of an appropriate forum in which

substantive issues relating to the registration and the fitness of the provider should be

explored. On this ground also, therefore, I would take the view that the substance of the

case was about matters which were more suitable to the alternative avenue available to

52. Overall, the application in this case seems to me to have involved an applicant entity

making highly technical complaints about a process, and set of documents regarding a

process, where there was fundamentally no want of natural justice in that process and in

circumstances where there was in existence a perfectly adequate mechanism to challenge

the cancellation of registration under a cheap and efficient statutory procedure, which

would have been better able to focus on the substantive merits of the applicant’s fitness

to run a nursing home. From this point of view alone, I would exercise the discretion

which the Court has in judicial review proceedings to refuse relief even if I were to be

legally incorrect in respect of any of the very technical legal aspects of the submissions

made on behalf of the applicant.

Result: Reliefs refused.

High Court of Ireland Decisions