Recurring concern

Unreliable CQC monitoring and escalation of provider safety risks

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First reported 13 Apr 2021•Latest report 25 Aug 2022

Definition

What this concern includes

Includes CQC processes for monitoring provider action plans and engagement, maintaining an accurate regulatory risk profile, triggering earlier reinspection or further regulatory action, and following up whether required quality and safety improvements are implemented.

Not included

Excludes the underlying care deficiencies or provider safety risks where no failure in CQC monitoring, risk escalation or action-plan oversight is identified.
Excludes generic organisational monitoring, audit or governance failures not explicitly concerning CQC regulatory oversight of provider safety.
Excludes failures in the initial conduct or evidence appraisal of a CQC inspection unless they directly concern monitoring provider action plans, non-engagement or escalation of regulatory risk.
Excludes regulatory oversight by bodies other than CQC unless the assertion explicitly concerns the same CQC provider-monitoring process.

Reports: 2
Individual concerns: 2
Date range: 2021–2022
Stated actions: 5

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission2

Health and Safety Executive1

Hibiscus House Domiciliary Care Agency1

Hibiscus Housing Association Limited1

South West Yorkshire Partnership Teaching NHS Foundation Trust1

Stars Social Support Limited1

Wolverhampton City Council1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

25 Aug2022
Black Country
Concerns raised1
1. Failure to monitor progress towards the quality and safety action plan
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Monitor the service and determine whether further action is required in response to identified risks.
  Stated by Care Quality CommissionStated in progress
2. Action
  Follow internal enforcement processes to take appropriate regulatory action and monitor progress against the provider’s action plan.
  Stated by Care Quality CommissionStated in progress
3. Action
  Implement and monitor an improvement plan addressing care quality and service safety concerns.
  Stated by Wolverhampton City CouncilStated completed
Respondent positions 1
1. Position
  The CQC did not inspect Hibiscus DCA during the pandemic because of changing priorities.
  Stated by Care Quality CommissionUnable to act
AI-generated summary

Charles Evans · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Charles Evans, a resident at Hibiscus House, choked on food in the communal dining room on 29 May 2022, suffered cardiac arrest and severe hypoxic brain injury, and died in hospital the following day. The concerns included inadequate CPR and first-aid provision, absence of a defibrillator and emergency communication arrangements, insufficient staffing and emergency procedures in the dining room, and weaknesses in risk assessment and reporting processes.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to monitor progress towards the quality and safety action plan
Wider context from the report
“During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House. 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 & Social care which does not include any training in first aid; 2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death); 3. There was no Registered First Aider at the premises; 4. There was no defibrillator on site; 5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements; 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; 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; 8. Staff did not know who else was on duty at any given time; 9. There was no proper procedure in place for staff to report concerns about residents; 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); 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. ”
Source location
Charles Evans · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Monitor the service and determine whether further action is required in response to identified risks.

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

Source location
Response from Care Quality Commission
Page 3 · response
Published 4 November 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Follow internal enforcement processes to take appropriate regulatory action and monitor progress against the provider’s action plan.

Verbatim wording from the response
“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.”

Source location
Response from Care Quality Commission
Page 3 · response
Published 4 November 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement and monitor an improvement plan addressing care quality and service safety concerns.

Verbatim wording from the response
“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.”

Source location
Response from Wolverhampton City Council
Page 1 · response
Published 4 November 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The CQC did not inspect Hibiscus DCA during the pandemic because of changing priorities.

Verbatim wording from the response
“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.”

Source location
Response from Care Quality Commission
Page 3 · response
Published 4 November 2022
Open published response
13 Apr2021
South Yorkshire (Western)
Concerns raised1
1. Failure to escalate regulatory risk in response to provider non-engagement and lack of an action plan
This report raised 20 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Implement a monitoring system that analyses service intelligence and generates prioritisation scores to identify services most at risk.
  Stated by Care Quality CommissionStated completed
2. Action
  Continue monitoring, inspecting and regulating the provider with service-user safety as the priority.
  Stated by Care Quality CommissionStated in progress
Respondent positions 3
1. Position
  Earlier reinspection was not undertaken during the pandemic because inspections required an extreme risk threshold and assessed risks did not meet it.
  Stated by Care Quality CommissionUnable to act
1. Position
  No action plan was requested for the Warning Notice because enforcement policy did not require one; the remaining breach posed no serious risk.
  Stated by Care Quality CommissionExisting arrangements considered sufficient
2. Position
  A decision to cease operating prevents provision of a detailed response to the indicated corrective actions.
  Stated by Stars Social Support LimitedUnable to act
AI-generated summary

Anthony Wilkinson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Anthony Wilkinson died on 4 April 2018 after choking, with the inquest concluding that he was unlawfully killed as a result of foreign body obstruction of the airway. The report identifies concerns about the failure to incorporate Speech and Language Therapy advice on diet and supervision into care plans, risk assessments and staff communications, alongside wider concerns about care-provider governance and regulatory oversight.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to escalate regulatory risk in response to provider non-engagement and lack of an action plan
Wider context from the report
“(14)CQC too readily accepted the lack of an action plan from the provider and did not use this lack of engagement from the provider to increase the risk profile for this provider. Had they done so an earlier re inspection may have been triggered or further regulatory action. This failure may have exposed other service users to unnecessary risk of harm as a result of an inaccurate risk picture being provided by the CQC. ”
Source location
Anthony Wilkinson · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement a monitoring system that analyses service intelligence and generates prioritisation scores to identify services most at risk.

Verbatim wording from the response
“CQC’s approach to monitoring services at the beginning of the pandemic in lieu of changes to routine inspections was reviewed in December 2020 and CQC implemented a monitoring system to improve the approach that had been taken up until that date. This system analyses intelligence we hold about services and”

Source location
2021-0102-Response-from-CQC-Redacted
Page 3 · response
Published 13 April 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue monitoring, inspecting and regulating the provider with service-user safety as the priority.

Verbatim wording from the response
“This ensured during the pandemic, that CQC continued to carry out their regulatory function when there was extreme risk at a service. This was determined on a case by case basis. CQC’s inspection priorities remained under continuous review in line with national priorities, but our monitoring of Stars Social Support as well as their failure to provide a completed action plan in relation to the breach of regulation 19, was not assessed as an ‘extreme’ risk in all of the circumstances. CQC monitored all ASC care providers throughout the pandemic and has implemented several systems to support remote monitoring of services. A decision was taken not to inspect the service at this time and the team considered the providers failure to submit an action plan when reaching this determination.”

Source location
2021-0102-Response-from-CQC-Redacted
Page 3 · response
Published 13 April 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Earlier reinspection was not undertaken during the pandemic because inspections required an extreme risk threshold and assessed risks did not meet it.

Verbatim wording from the response
“CQC acknowledged at the Prevention of Future Deaths hearing that the re-inspection of Stars Social Support (completed on 27 August 2020 to 3 September 2020) fell outside of our usual timeframe of re-inspecting a service, rated requires improvement, 12 months from the last inspection publication date. However at that time, the decision not to inspect the service sooner we feel was justified and proportionate. COVID-19 resulted in CQC adapting its inspection priorities during the pandemic to ensure risk and people’s safety were the highest priority. A decision was taken by the CQC that during the pandemic, CQC would take on a more supportive role, as well as not adding to the overall risk and pressures COVID-19 presented to the rest of the health and social care sector. As at May 2020, there needed to be an “extreme” level of risk for CQC to cross the threshold for inspection.”

Source location
2021-0102-Response-from-CQC-Redacted
Page 3 · response
Published 13 April 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
No action plan was requested for the Warning Notice because enforcement policy did not require one; the remaining breach posed no serious risk.

Verbatim wording from the response
“We understand point 14 refers to the re-inspection of Stars Social Support following the February 2019 inspection, where the local team identified two breaches of regulations. Civil enforcement action was taken; a Warning Notice was served against the breach of regulation 17; and a Requirement Notice was served against the breach of regulation 19. As a Warning Notice was served, we did not request an action plan in line with CQC Enforcement Policy. We did, however, request an action plan be submitted to CQC by 29 May 2019 for the”

Source location
2021-0102-Response-from-CQC-Redacted
Page 2 · response
Published 13 April 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
A decision to cease operating prevents provision of a detailed response to the indicated corrective actions.

Verbatim wording from the response
“A decision has been taken by the Registered Manager and Director of Stars Social Support Limited for the organisation to cease to continue. The Registered Manager and Director at Stars Social Support Limited has contacted the Local Authority and the Care Quality Commission to notify them that Stars Social Support Limited will cease to continue.”

Source location
2021-0102-Response-from-Stars-Social-Support-Ltd-Redacted
Page 1 · response
Published 13 April 2021
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to monitor progress towards the quality and safety action plan

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to escalate regulatory risk in response to provider non-engagement and lack of an action plan

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Actions described in response 3

Respondent positions 1

Actions described in response 2

Respondent positions 3