Charles Evans

REPORT BY CQC 

TO HM CORONER 

IN RESPECT OF THE PREVENTION OF FUTURE DEATHS REPORT IN 
RELATION TO THE DEATH OF MR CHARLES EVANS  

Background  

1.  I have prepared this report in respect of the Prevention of Future Deaths Report 
in relation to the death of  Mr. Charles Evans. I have been asked to do  so in 
order to assist HM Coroner and Interested Persons in understanding the role 
of  the  Care  Quality  Commission  (‘the  CQC’)  as  the  regulator  for  Health  and 
Social  settings  in  England,  and  CQC’s  involvement  with  Hibiscus  Housing 
Association Ltd regarding the risk that future deaths could occur unless action 
is taken. 

2.  I  am  employed  as  an  Interim  Inspection  Manager  in  the  Adult  Social  Care 
Directorate  of  the  CQC.  As  such  I  have  responsibility  for  engaging  with  and 
assessing the compliance of a range of health and social care services that are 
registered  under  the  Health  and  Social  Care  Act  2008  and  placed  on  my 
caseload.  CQC Inspector responsibilities  at  the  time  of  Charles Evans death 
included  the  assessment  of  compliance  with  the  fundamental  standards  of 
quality  and  safety  by  means  of  inspection  visits  and  to  undertake  regular 
engagement  with  the  providers  of  those  services,  as  the  relationship  owner. 
This includes taking action against providers if there were concerns about non-
compliance with Regulations and taking action if service users were not being 
protected from the risk of harm. This decision making was underpinned by the 
Commission’s enforcement policy, methodology and tools that were introduced 
from 1 October 2014. 

3.  The  role  of  CQC as  regulator,  CQCs  inspection  processes  and  enforcement 

action CQC can take is described in Appendix 1. 

Appendix 1: The role of CQC as regulator. 

Charles Evans 

1.  CQC had not received any statutory notification from the provider regarding the 
death of Charles Evans. CQC first became aware of Charles Evans death when 
we received a Regulation 28 report to prevent future deaths from the Coroner 
on 25  August  2022.  CQC  will  be  considering  the failure  to  notify during  their 
review of this specific incident. 

2.  When  CQC  receives  information  in  relation  to  an  incident  of  this  kind,  we 
consider  what  action  we  need  to  take;  firstly  in  relation  to  whether  the 
information received suggests that there may be ongoing risk which requires 
CQC  to  inspect  a  service  and  secondly  whether  the  information  received 
suggests  the  harm  sustained  was  avoidable  and  may  have  resulted  from  a 
breach of a prosecutable fundamental standard. 

 
 
 
 3.  Following the HM Coroners request for CQC to urgently review/revisit Hibiscus 
House given the concerns raised and previously identified regarding training in 
CQCs previous inspection report a decision was taken on 30 August 2022 to 
inspect Hibiscus Domiciliary Care Agency to look at our key questions of Safe, 
Effective and Well-Led.   

4.  CQC  have  determined  that  Charles  Evans  was  in  receipt  of  the  regulated 
activity of personal care. CQC  are currently gathering evidence to determine 
whether the serious incident which led to the death of Charles Evans could be 
a  result of  Provider failure  to provide  safe  care  and  treatment,  and  therefore 
whether any further criminal enforcement action may be required.  

Regulation of Hibiscus House 

‘Post  inquest,  the  Coroner  noted  the  CQC  Inspection  report  for  Hibiscus  House 
Domiciliary  Care  Agency  dated  July  2019  which  rated  the  facility  as  ‘requiring 
improvement’. The Coroner is concerned to establish whether the service provider put 
forward an action plan following the CQC Inspection setting out what they would do to 
improve  the  standards  of  quality  and  safety  and  whether  the  CQC  monitored  any 
progress towards said plan’.  

1.  Hibiscus House is registered with CQC as a Domiciliary Care Agency (“DCA”) 
under the location name Hibiscus Domiciliary Care Agency and is operated by 
Hibiscus Housing Association Ltd to provide the regulated activity of ‘personal 
care’. Hibiscus DCA provides personal care and support to people who have 
learning disabilities, physical and mental health needs living in their own homes. 
Not everyone who uses DCA services receive the regulated activity of personal 
care.  The  CQC  is  not  responsible  for  regulating  the  quality  of 
the 
accommodation.  

2.  CQC  carried  out  their  previous  inspection  on  4  June  2019.  The  service  was 
rated Requires Improvement overall and in our key questions relating to Safe, 
Effective  and  Well-led.  It  was  rated  Good  in  our  key  questions  Caring  and 
Responsive. A copy of this report has been provided in Appendix 2. There was 
a breach of regulation  17 (Good Governance) of the Health and Social Care 
Act  2008  (Regulated  Activities)  Regulation  2014  as  whilst  there  was  no 
evidence  of  harm,  systems  were  either  not  in  place  or  robust  enough  to 
demonstrate  quality  and  safety  was  effectively  managed,    There  was  also  a 
breach  of  regulation  18(2)  (Staffing)  of  the Health  and  Social  Care  Act  2008 
(Regulated  Activities)  Regulations  2014  for  failing  to  ensure  staff  received 
induction and training required. Requirement notices were issued and we asked 
the provider to send the CQC a report setting out what action they were going 
to take in order to become compliant with the regulations 

Appendix 2: Inspection report 2019 

3.  CQC  received  action  plans  on  8  August  2019  in  relation  to  the  breaches 
identified. These were reviewed by the lead inspector. The provider indicated 
these  concerns  would  be  addressed  and  completed  by  September  2019 
(Regulation  18  -  Staffing)  and  October  2019  (Regulation  17  -  Governance). 
CQC continued to monitor the location. It is standard practice for CQC to review 

 
 
 progress against action plans for requirement notices at the next inspection or 
sooner if further concerns arose from our monitoring activity.  

4.  Inspections  scheduled  for  4  June  2020  and  21  January  2021  were  both 
cancelled  due  to  the  pandemic  and  changing  priorities.  A  CQC  Inspector 
completed  a  ‘Portfolio  Review  Activity’  (PRA)  on  15  April  2021  which  was  a 
monitoring  tool  in  use  by  CQC  at  the  time  of  the  pandemic.  A  PRA  enabled 
Inspectors  to  record  they  have  reviewed  the  information  CQC  held  about  a 
service and to make a decision as to whether any further action is required to 
respond  to  risk  or  improvement.  The  outcome  of  the  PRA  was  that  further 
monitoring activity was required and consider inspecting. Unfortunately, due to 
changing priorities during the pandemic, Hibiscus DCA was not inspected.  
5.  CQC  inspected  Hibiscus  DCA  on  7  September  2022  and  found  concerns 
around the safety of people’s care. As a result, CQC requested the provider to 
submit an action plan to address their concerns and held a meeting with the 
Provider to discuss these following the inspection on 9 September 2022.  
6.  CQC are  currently  following  their  internal enforcement  processes to  take  the 
appropriate regulatory action to drive the necessary improvements needed and 
to monitor their progress  within their action plan. An inspection report will be 
published and in the public domain within the next month. CQC will continue to 
monitor this service, assess the risk and identify the appropriate action to take 
in our regulatory duties. 

The CQC takes the concerns raised seriously and is committed to ensuring health and 
care services provided to people are safe, effective, compassionate and high quality. 
The CQC will take action to improve the quality and service of care.  

We  trust  this  assists.  If  you  have  any  further  questions,  please  do  not  hesitate  to 
contact me. 

Report Prepared by 

Date 02 November 2022

Hibiscus Housing Association Limited

46 Yew Street, Graiseley, Wolverhampton, WV3 ODA

ME 211: info@hibiscus-housing.co.uk

Hibiscus Housing Association Limited (“Hibiscus”) provides this response in relation to the report
received under Regulation 28 of The Coroners (Investigations) Regulations 2013, following the
inquest touching upon the death of Charles Evans (“Mr Evans”).

Hibiscus is ‘a social landlord providing a sheltered accommodation scheme. The accommodation is
purpose built and comprises of ten self-contained flats, suitable for those over the age of 55, who
become tenants by way of self-referrals, or referrals from local authorities. Referrals from local
authorities are normally supported by an assessment of needs. The residents are paying tenants of
the housing scheme, a registered housing association. Hibiscus is a registered sheltered housing
scheme with the option of additional assistance, for those who wish to live independently, make
their own choices and have their own home. Some of the tenants will be provided with a contracted
package of care paid for by the Local Authority and is in accordance with an assessment of their
needs. The care package may include domiciliary, and/or domestic services.

Hibiscus is not registered as a nursing or residential care home and therefore does not provide
registered nursing services. It cannot accommodate tenants who are substantially limited in mobility
or require nursing care or a high level of personal assistance. The flats are designed for those who
can care for themselves. Those who reside at Hibiscus are largely independent, have the freedom to
come and go from the premises as they wish, and have the option to cook, clean and care for
themselves.

In addition to their rent, tenants can opt to pay for additional domestic or community support.
Hibiscus offers shopping, laundry, meal services. A Care Link pull cord is installed in each of the flats
and a concierge is also available. The tenants can also seek assistance with personal care, such as
getting in and out of bed and prompting medication.

Hibiscus employs 14 members of staff who provide domiciliary and personal care to those service
users living in the community and to those tenants that require this service. Staff providing this
service are required to be qualified to a minimum of Level 2 ina Diploma in Health and Social Care.

Hibiscus response to Regulation 28 letter

Hibiscus understands the concerns of Joanne Lees, Area Coroner for The Black Country, set out in
her Regulation 28 Report to prevent future deaths, following the inquest into the death of Mr Evans.
The independence and quality of life of the tenants at Hibiscus form the heart of its values. The
inquest provided the opportunity to examine the circumstances that led to the death of Mr Evans
and for Hibiscus to review its procedures and training available to staff.

Hibiscus has been working closely with the Care Quality Commission (CQC) who undertake
inspections at the premises, and it has engaged consultants Delphi Care Services (“Delphi”), who
have been contracted specifically to provide assistance with effecting change within Hibiscus’
practice and strengthening the quality of their care plans.

Hibiscus will outline the steps it has taken to address the concerns of the Area Coroner to ensure the
safety of its tenants. Hibiscus is committed to ensuring it is compliant with all of the rules and
regulations effecting the safe operation of its work and the safety of its tenants.

1. None of the carers employed at Hibiscus House had any training in CPR. The carer on duty
was qualified to Level 2 Diploma in Health and Social Care which does not include any
training in first aid.

Hibiscus have engaged Delphi to assist in creating a planned programme of training. All employees of
Hibiscus have now undertaken CPR training. CPR Awareness training commenced 29 July 2022 and
was complete by 5 August 2022. This will be refreshed every year.

It should be noted that there was no carer “on duty” at the time of Mr Evans’ incident. As Hibiscus is
not a nursing facility there is no requirement to always have a person on duty at the premises. On
the day, Mr Evans’ package of care services finished at approximately 7.00am and there was no
further care planned for him that day. In the afternoon Mr Evans chose to have his lunch in the
dining area which he was entitled to do. The dining area is a communal dining area and there is no
requirement for it to be supervised.

2. No staff members were trained in CPR at the time of incident (Coroner was told that this
had been rectified post Mr Evans death).

At the time of Mr Evans’ death, some Hibiscus employees did hold CPR training and so were aware
of what to do in the event of an incident. However, the records Hibiscus held, indicated that this
training was not up to date. Hibiscus have ensured that this training has been refreshed and all
employees of Hibiscus are now trained in CPR with refresher training planned to take place every
year.

3. There was no registered first aider at the premises.

On 17 October 2022 all employees of Hibiscus undertook First Aid Workplace Awareness training
provided by High Speed Training. Additionally, four employees of Hibiscus will undertake First Aider
Training via St John’s Ambulance which is scheduled for the end of October.

There is no formal first aid duty rota in place, however with all staff being trained and the overlap of
shifts which cover the week, there will always be at least one person who has first aid awareness on
site. After the four employees have undertaken First Aider Training with St John’s Ambulance, a
formal rota will be put in place.

First aid awareness training will be refreshed for all staff annually.

4. There was no defibrillator on site.

There is no compulsory requirement to purchase a defibrillator to comply with the Health and Safety
(First-Aid) Regulations 1981. Hibiscus however have actively sought quotes for the purchase of a
defibrillator which can be kept permanently on the premises. Once an appropriate defibrillator has
been purchased, Hibiscus will ensure that all staff are aware of its location when contacting the
emergency services and are fully trained in its use.

5. There was no requirement for any staff to be on duty in the communal dining room during
mealtimes despite the fact that Hibiscus House could cater for residents with special
dietary requirements.

Hibiscus is not a registered nursing home and as such does not provide as standard the full portfolio
of residential/nursing services. As such there is no requirement to have a “duty” member of staff on
the premises at all times. Whilst tenants at Hibiscus are largely independent and most choose to
cook or obtain their own meals, they can elect to pay a sum of money (a service charge) in addition
to their rent which provides them with meals from Hibiscus. Hibiscus is a black led landlord, and the
majority of tenants are black, Hibiscus therefore offer a kitchen service which provides a range of
meals as requested by the tenants, catering to their specific cultural needs.

@

A member of staff works in the kitchen to prepare and serve meals to those tenants who choose to
have the additional service. The duties of that employee are confined to preparing and serving meals
only. If a tenant could not demonstrate their ability to feed themselves, or otherwise had medical
issues with chewing and swallowing Hibiscus would not be able to accommodate that person.
Tenants needing this type of care are not eligible for placement with Hibiscus. Changes in a tenant’s
health, ability, mobility or behaviour can be observed by family, next of kin, or carers as well as other
staff within Hibiscus. If a tenant’s health or ability deteriorated during their time at Hibiscus this
would be noted the by the carer, reported to the manager and logged onto the online system. This
would encourage a reassessment of the tenant’s needs to ensure Hibiscus remained appropriate for
them.

6. There was no emergency bell/alarm or telephone in the residents dining room. Staff were
expected to use their mobile phone to call for help.

Hibiscus did and does have an emergency pull cord system called Care Link, this was in the dining
room at the time of the incident. There are also pull cords in each of the tenants’ flats and within all
other rooms at the premises. The Care Link system is an emergency call system which activates by
pulling a red cord. This connects the tenant to an operator who can communicate with them via
speakers in the room to ascertain what has happened and where the tenant can ask for help. The
operator will telephone Hibiscus House and the concierge will be notified which room the cord has
been pulled in. The operator can take action to help the tenant, such as call the tenant’s GP, the
emergency services and Keith Rawlings (Chief Officer) and Faye Cadogan (Acting Care Manager),
both of whom in any event are automatically notified by the concierge.

Given the emergency nature of the incident that took place concerning Mr Evans, the staff member
at Hibiscus on the day chose to call 999 instead of using the pull cord alarm which they are
permitted to do. Since Mr Evans’ death the CQC have attended Hibiscus to undertake an inspection
on the premises, which has established that the pull cord in the dining room (and those around the
property) are in working order. Weekly fire alarm tests also confirm that the Care Link system is in
working order.

Staff have been informed that should another incident of this nature happen then they can use both
the cord and call 999.

7. There was no procedure for what should happen in an emergency situation (in this
instance the catering staff member who found Mr Evans located a carer instead of calling
999 themselves).

Since this tragic incident Hibiscus have, with the assistance of their consultants, Delphi, and in
conjunction with the CQC, implemented a formal procedure and provided training to its staff on the
steps to take in an emergency situation. This procedure is now in written form reflected in risk
assessments and forms part of Hibiscus’ new improvement plan. This is attached.

8. Staff did not know who else was on duty at any given time

As stated previously, Hibiscus is not a residential/nursing facility and therefore there is no 24-hour
care setting in place. All of the tenants live autonomously, making their own choices and permission
is hot required for them to go about any aspects of their daily lives, akin to someone who lives
independently in a house.

That said, Hibiscus does ensure that there is a member of staff on site at all times as staff are
required to sign in and out of the building. The premises also has a concierge facility from 10.00pm
to 6.00am every night, 52 weeks of the year. The concierge undertakes walks arounds the site and is
alerted if the Care Link cord has been pulled. .

Carers have allocated tenants who they provide care for individually. This is an additional service
funded privately by the tenants, or the Local Authority and forms part of their domiciliary care
package with specific start and end times. Carers are often on site from 5.00am to assist their service
users, leaving to attend to their next service user as soon as their care provision has finished with
that tenant and not returning until the afternoon or the evening, if so required.

None of these carers are called in for assistance with eating/feeding. If any of tenants struggled with
this particular aspect of their daily living, it is likely they would not be able to live independently and
would require a higher level of care. As such Hibiscus would not be able to accommodate them as
tenants.

Hibiscus also operates a day centre from the premises from Tuesdays to Thursdays which has
allocated day centre workers in attendance and so there is always a member of staff present at the
site when this is in operation.

Hibiscus employs a weekday and a weekend kitchen member of staff. The kitchen staff are not
required to have health and social care qualifications given the specific nature of the kitchen role,
however incidentally the weekend kitchen member of staff does hold a Level 2 qualification in
Health and Social Care.

9. There was no proper procedure in place for staff to report concerns about residents

Communication between staff and tenants prior to Mr Evans death was spoken and therefore much
relied upon verbal communication. Tenants will have their own files which contain their risk
assessments and general details, such as medication, next of kin details etc. A copy of this is kept
both in their flat and in the general office on site.

Hibiscus has since implemented a new IT system called “Birdie”. This is accessible on computers and
staff members’ phones, and it is used to log any observations and concerns about particular tenants.
The Manager has access to all resident files on Birdie. The carers who have specific service users will
only have access to their service user’s details in order to maintain data protection. Where a tenant
requires a different carer (whether due to change of carer, holiday cover etc), the manager will allow
the carer access to that resident's file on Birdie.

If an incident occurs this is logged on Birdie and on the resident’s file and the manager is informed.
Staff are aware that all concerns and notes should be logged and reported.

10. No further risk assessments were being conducted if a resident returned to Hibiscus House
after a hospital admission to ensure the facility could still meet the needs of the resident.
(Coroner was told staff relied on a discharge summary and/or the GP).

«

Hibiscus is fully aware that the needs of its tenants can change whether through the natural ageing
process or via incidents or hospital admissions. Risk assessments are always undertaken by the
Acting Care Manager on first arrival into the accommodation.

Hibiscus has ensured that new procedures are in place for a reassessment should a tenant attend
hospital and subsequently be discharged home. Faye Cadogan advised the Coroner at the inquest
that where a tenant had attended hospital previously, the discharge letter was relied upon to inform
the staff of any changes in that tenant’s needs.

Since the inquest one tenant has had to attend hospital. Upon discharge and following an
assessment at the hospital, it was determined that they required a higher level of care which
Hibiscus was not able to accommodate. Sadly, whilst that tenant did not want to move away from
Hibiscus, it was not in their best interest to remain there as the level of support offered could not
accommodate their needs.

Should a tenant return home after a hospital admission, Hibiscus will continue to place reliance on
the discharge summary as it is one of the most informative ways to understand and reassess their
needs (if any) upon return from hospital. Historically it has always been the case that a tenant
requires a change in medication only. Going forward the discharge summary will continue to be
reviewed, the tenant will be risk assessed by the Care Manager and will continually be observed by
their carer, with any outcomes logged both in their file and on Birdie. If applicable, a decision will be
made as to whether Hibiscus remains the most suitable place for them.

Largely Hibiscus are moving away from a paper-based system and in conjunction with Delphi are
looking to move all logs and tenant associated paperwork to an electronic system.

11. Post inquest, the Coroner noted the CQC inspection report for Hibiscus House Domiciliary
Care Agency dated July 2019 which rated the facility as “Requiring improvement”. The
Coroner is concerned to establish whether the service provider put forward an action plan
following the CQC inspection setting out what they would do to improve the standards of
quality and safety and whether the CQC monitored any progress towards said plan.

Following the CQC inspection of July 2019, Hibiscus took no immediate action. That said, the Care
Manager left shortly after this inspection and Hibiscus was left with insufficient senior members of
staff to implement or effect any change.

The current Chief Officer a :: been in post since 3 March 2020 and upon joining
Hibiscus drew up an Action Plan for the three areas of improvement which were identified by the
CQC. Training had been put in place to address specific issues, however could not be undertaken for
a significant length of time due to covid restrictions. At this point work had already been undertaken
to redesign care plans and upgrade systems which held vital information, but there was difficulty in
implementing this. There was no monitoring of, or involvement by the CQC in this regard.

Since the July 2019 inspection there has been a further CQC inspection. feedback has been provided
and action plans have been shared with the CQC but Hibiscus are yet to receive an updated report or
rating from the CQC.

“

Hibiscus are grateful to the Coroner for raising her concerns and providing the opportunity to
respond. Hibiscus will ensure that all of the measures put in place to improve our systems and staff
training are continually observed and audited to ensure that they remain suitable and safe for the
tenants, staff and site. Hibiscus extends its condolences to the family of Mr Evans, who shall be
missed very much at Hibiscus.

For and on behalf of Hibiscus Housing Association

Sensitivity: PROTECT 

Ms J Lees  
Black Country Coroner 

Dear Ms Lees 

Your reference:  9040812 

21 October 2022 

Thank you for sharing the attached Regulation 28 Report where it invited the Local 
Authority to urgently review Hibiscus House.   Upon its receipt, an urgent meeting was 
arranged, and a plan of action agreed.   

An unannounced monitoring visit to the service was undertaken by the Quality Assurance 
Team.   The Council was not assured that the service was operating safely, therefore a 
recommendation  to  suspend  the  service  from  any  new  business  was  proposed  and 
agreed.   An improvement plan has been implemented and agreed with the provider. A 
meeting will be held in due course to review this plan.   

The plan includes a review of staff training to ensure all staff have completed mandatory 
and/or  relevant  training.  This  includes  assurances  that  staff  have  the  right  skills  and 
competences to react appropriately in an emergency situation.  

The suspension of new business by City of Wolverhampton Council will remain until the 
Council is satisfied that the service is performing at the required standard and the 
people using the service are safe.  

Reviews are being undertaken of the people who are funded by the Council either 
directly or by Direct Payments.  One person has been relocated to a more appropriate 
setting.    

We  have  liaised  with  the  Care  Quality  Commission  (CQC)  prior  to  and  following  their 
inspection of the service, and we will continue to do so.    

CQC  raised  a  safeguarding  referral  about  the  service  outlining  care  quality  concerns, 
there are being addressed via the improvement plan with ongoing monitoring.  Concerns 
were also raised about a person who they felt was being deprived of his liberty, as advised 
above, this person has now moved.  

City of Wolverhampton Council 
Civic Centre, St. Peter's Square  
Wolverhampton WV1 1SH. 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
  
 
 
 
 
 Sensitivity: PROTECT 

For information, the City of Wolverhampton Council had not been made aware of this 
incident prior to receiving this report and we are addressing this with the relevant 
agencies.  

Mr Charles Evans was reviewed by a social worker in January 2022 where he was 
reported to be happy and content living at Hibiscus House.  His needs were being met 
and he wished to remain.    

If you require further detail, please do not hesitate to contact me.   

Kind regards 

Deputy Director Adult Services