Dear Ms Lees

Your reference: 9040812

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.

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

Hibiscus Housing Association Limited 46 Yew Street, Graiseley, Wolverhampton, WV3 ODA mail: 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: 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 wn 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 limitedl 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. 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 in a 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 The The

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. 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 year. It should be noted that there was no carer "on duty" at the time f Mr Evans' incident: As Hibiscus is not a nursing facility there is no requirement to always have a person on at the premises. On the day, Mr Evans' package of care services finished at approximately 7.OOam and there was no further care planned for him that 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: 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: every duty day:

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'$ 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. 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 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 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: pull help:

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 the cord alarm which 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 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 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 not 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.OOpm 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.O0am 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 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 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. using pull they fire duty any day

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 ifa 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' $ 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 and tenant associated paperwork to an electronic system. logs

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 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 in place to address specific issues, however could not be undertaken for 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 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 Dated_= scl4Z03 put they 21

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