Report evidence summary
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of an emergency response procedure
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of staff training in CPR
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to establish and implement a service-provider action plan for improving quality and safety
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of a proper procedure for staff to report concerns about residents
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.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of reliable emergency communication facilities in the residents’ dining room
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to ensure staff know who else is on duty
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to conduct further risk assessments after a resident’s return from hospital
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Unavailability of a defibrillator on site
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Unavailability of a registered first aider on the premises
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of staff presence in the communal dining room during mealtimes
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.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
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 .
” Open source report
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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
Open published response
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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
Open published response
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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 Require the provider to submit an action plan addressing safety concerns and meet with the provider to discuss it.
Verbatim wording from the response “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 the concerns and held a meeting with the Provider to discuss these following the inspection on 9 September 2022.” Source location Response from Care Quality Commission
Open published response
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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 Review staff training, including mandatory training and emergency-response skills and competences.
Verbatim wording from the response “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.” Source location Response from Wolverhampton City Council
Open published response
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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
Open published response
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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 Provide formal first-aider training to four employees.
Verbatim wording from the response “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.” Source location Response from Hibiscus House
Open published response
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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 Seek quotations for purchasing a permanently located on-site defibrillator.
Verbatim wording from the response “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.” Source location Response from Hibiscus House
Open published response
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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 the Birdie electronic system for recording tenant observations, concerns, incidents and notes.
Verbatim wording from the response “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.” Source location Response from Hibiscus House
Open published response
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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 written emergency procedure, embed it in risk assessments and the improvement plan, and train staff on it.
Verbatim wording from the response “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.” Source location Response from Hibiscus House
Open published response
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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 Draw up an action plan addressing the three improvement areas identified by the CQC.
Verbatim wording from the response “The current Chief Officer ████████ has 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.” Source location Response from Hibiscus House
Open published response
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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 Provide CPR training to all employees and refresh it annually.
Verbatim wording from the response “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.” Source location Response from Hibiscus House
Open published response
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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 Introduce a formal first-aid duty rota after the four employees complete first-aider training.
Verbatim wording from the response “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.” Source location Response from Hibiscus House
Open published response
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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 Reassess tenants returning from hospital, including Care Manager risk assessment, ongoing observation and recording outcomes in tenant files and Birdie.
Verbatim wording from the response “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.” Source location Response from Hibiscus House
Open published response
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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 is not responsible for regulating the quality of Hibiscus House’s accommodation.
Verbatim wording from the response “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.” Source location Response from Care Quality Commission
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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
Open published response
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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 Continuous staff supervision of the communal dining room is not considered necessary because the accommodation is not a nursing or residential care facility.
Verbatim wording from the response “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.” Source location Response from Hibiscus House
Open published response
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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 concern that no emergency alarm was available in the dining room is disputed because a functioning Care Link pull cord was installed there.
Verbatim wording from the response “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.” Source location Response from Hibiscus House
Open published response
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 11 1 Review the provider’s action plans addressing the 2019 governance and staffing breaches.
Stated by Care Quality Commission Stated completedThe respondent said that this action was complete when they made their response on 4 November 2022. View source 2 Publish the inspection report in the public domain.
Stated by Care Quality Commission Stated plannedThe respondent said that this action was planned when they made their response on 4 November 2022. View source 3 Inspect Hibiscus Domiciliary Care Agency against the Safe, Effective and Well-Led key questions.
Stated by Care Quality Commission Stated completedThe respondent said that this action was complete when they made their response on 4 November 2022. View source 4 Continue liaison with the Care Quality Commission before and after service inspection activity.
Stated by Wolverhampton City Council Stated in progressThe respondent said that this action was in progress when they made their response on 4 November 2022. View source 5 Review people funded directly or through Council Direct Payments.
Stated by Wolverhampton City Council Stated in progressThe respondent said that this action was in progress when they made their response on 4 November 2022. View source 6 Hold a meeting to review the improvement plan.
Stated by Wolverhampton City Council Stated plannedThe respondent said that this action was planned when they made their response on 4 November 2022. View source 7 Suspend new business at Hibiscus House until required standards and safety are achieved.
Stated by Wolverhampton City Council Stated completedThe respondent said that this action was complete when they made their response on 4 November 2022. View source 8 Conduct an unannounced monitoring visit to assess whether Hibiscus House is operating safely.
Stated by Wolverhampton City Council Stated completedThe respondent said that this action was complete when they made their response on 4 November 2022. View source 9 Provide workplace first-aid awareness training to all employees and refresh it annually.
Stated by Hibiscus Housing Association Limited Stated completedThe respondent said that this action was complete when they made their response on 4 November 2022. View source 10 Redesign care plans and upgrade systems holding vital information.
Stated by Hibiscus Housing Association Limited Stated in progressThe respondent said that this action was in progress when they made their response on 4 November 2022. View source 11 Continually observe and audit measures introduced to improve systems and staff training for ongoing suitability and safety.
Stated by Hibiscus Housing Association Limited Stated plannedThe respondent said that this action was planned when they made their response on 4 November 2022. View source
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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 Review the provider’s action plans addressing the 2019 governance and staffing breaches.
Verbatim wording from the response “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.” Source location Response from Care Quality Commission
Open published response
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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 Publish the inspection report in the public domain.
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
Open published response
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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 Inspect Hibiscus Domiciliary Care Agency against the Safe, Effective and Well-Led key questions.
Verbatim wording from the response “3. Following the HM Coroners request for CQC to urgently review/revisit Hibiscus House given the concerns raised and previously identified regarding training in CQC’s 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.” Source location Response from Care Quality Commission
Open published response
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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 liaison with the Care Quality Commission before and after service inspection activity.
Verbatim wording from the response “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.” Source location Response from Wolverhampton City Council
Open published response
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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 Review people funded directly or through Council Direct Payments.
Verbatim wording from the response “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.” Source location Response from Wolverhampton City Council
Open published response
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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 Hold a meeting to review the improvement plan.
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
Open published response
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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 Suspend new business at Hibiscus House until required standards and safety are achieved.
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
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 Conduct an unannounced monitoring visit to assess whether Hibiscus House is operating safely.
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
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 Provide workplace first-aid awareness training to all employees and refresh it annually.
Verbatim wording from the response “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.” Source location Response from Hibiscus House
Open published response
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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 Redesign care plans and upgrade systems holding vital information.
Verbatim wording from the response “The current Chief Officer ████████ has 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.” Source location Response from Hibiscus House
Open published response
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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 Continually observe and audit measures introduced to improve systems and staff training for ongoing suitability and safety.
Verbatim wording from the response “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.” Source location Response from Hibiscus House
Open published response
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