Recipient

Crosscrown Limited

First report 7 Jul 2021•Latest report 7 Jul 2021

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 3
Stated actions: 8

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

8stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Crosscrown Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

7 Jul2021
Warwickshire
Concerns raised3
1. Failure to record resident aggression incidents in care plans
2. Failure of staff to be aware of care plan contents
3. Failure to raise safeguarding alerts with the local authority
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Enhance fortnightly staff-meeting agendas to address infection control, health and safety, and systematic recording of behavioural issues.
  Stated completed
2. Action
  Implement and maintain the CareDocs digital care-planning and recording system across all homes, supported by upgraded Wi-Fi and staff access devices.
  Stated completed
3. Action
  Record challenging behaviour in CareDocs, require ABC forms, conduct daily managerial checks, escalate safeguarding concerns, and analyse referrals through monthly management reporting.
  Stated completed
1. Action
  Provide new staff with supernumerary induction, CareDocs training and a role-dependent buddying period.
  Stated completed
2. Action
  Implement challenging-behaviour, dementia and safeguarding training programmes, with safeguarding included in staff induction.
  Stated completed
AI-generated summary

Dorothy Seekings · 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

Dorothy Seekings, a resident of Clifton Court Nursing Home, was found dead in her room on 8 August 2019 after another resident entered the room; a post-mortem examination showed blunt force injuries, which were probably caused by that resident. Concerns included care plans not recording the other resident’s aggressive incidents towards staff, failure to raise a safeguarding alert, and staff appearing unaware of the care plan contents.

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. The report was sent to Crosscrown Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to record resident aggression incidents in care plans
Wider context from the report
“(1) the care plans for ████████ did not record incidents where ████████ had acted aggressively to staff members including an occasion when a staff member was kicked in the mouth by ████████. (2) the failure to raise a safeguarding alert with the local authority regarding the above incident. (3) The staff did not appear to be aware of the contents of the care plan for ████████ or other resident ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Crosscrown Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure of staff to be aware of care plan contents
Wider context from the report
“(1) the care plans for ████████ did not record incidents where ████████ had acted aggressively to staff members including an occasion when a staff member was kicked in the mouth by ████████. (2) the failure to raise a safeguarding alert with the local authority regarding the above incident. (3) The staff did not appear to be aware of the contents of the care plan for ████████ or other resident ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Crosscrown Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to raise safeguarding alerts with the local authority
Wider context from the report
“(1) the care plans for ████████ did not record incidents where ████████ had acted aggressively to staff members including an occasion when a staff member was kicked in the mouth by ████████. (2) the failure to raise a safeguarding alert with the local authority regarding the above incident. (3) The staff did not appear to be aware of the contents of the care plan for ████████ or other resident ”
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
Enhance fortnightly staff-meeting agendas to address infection control, health and safety, and systematic recording of behavioural issues.

Verbatim wording from the response
“The Operations Team has implemented an enhanced agenda for the fortnightly staff meetings that are held at Clifton Court to include inter alia infection control – Covid, health and safety and accurate and systematic recording of behavioral issues.”

Source location
2021-0230-Response-from-Crosscrown-Ltd_Published
Page 3 · response
Published 9 July 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
Implement and maintain the CareDocs digital care-planning and recording system across all homes, supported by upgraded Wi-Fi and staff access devices.

Verbatim wording from the response
“The two key changes are the acceleration of the implementation of a digital care management software system called CareDocs. This was being gradually introduced into the Homes run by Crosscrown during the Summer of 2019 but the events of August 8th accelerated the implementation of the new system and it is now in place in all Crosscrown Homes including Clifton Court and has been for some time. The digital CareDocs system allows Care Plans to be created that meet the specific requirements of individual service users and it allows the creation of a care plan reflective of the needs and preferences of the individual user.”

Source location
2021-0230-Response-from-Crosscrown-Ltd_Published
Page 1 · response
Published 9 July 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
Record challenging behaviour in CareDocs, require ABC forms, conduct daily managerial checks, escalate safeguarding concerns, and analyse referrals through monthly management reporting.

Verbatim wording from the response
“Under the new scheme such behaviour is recorded on the CareDocs system which prompts the completion of an Antecedent Behaviour Consequences form on the CareDocs system. The Care Home Manager at Clifton Court checks on a daily basis for amongst other things any ABC charts which may have been completed by members of staff. Should any safeguarding issues be recorded then the Manager will contact Adult Social Services and complete that process. The Operations Team are copied into all emails in relation to any safeguarding issues. In the last eighteen months Clifton Court has made eight referrals to the Adult Social Services Team at Warwickshire County Council all of which were closed down without an action by the Council. The issue of safeguarding is also now part of the Monthly Managers Report and is analysed by the Operations Team and evaluated for any patterns or learning issues.”

Source location
2021-0230-Response-from-Crosscrown-Ltd_Published
Page 3 · response
Published 9 July 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
Provide new staff with supernumerary induction, CareDocs training and a role-dependent buddying period.

Verbatim wording from the response
“Clifton Court has purchased a number of tablets to be given to each member of staff for their use and that is the usual device upon which information is recorded. It should be stressed that all nurses and carers have access to CareDocs. When a new member of staff joins the organisation they undergo a two week period of training for which time they are supernumerary and thereafter there is a “buddy” scheme which lasts from between two weeks and three months depending on the requirements of the individual member of staff. During that time the individual undergoes a detailed period of training into the CareDocs system.”

Source location
2021-0230-Response-from-Crosscrown-Ltd_Published
Page 2 · response
Published 9 July 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
Implement challenging-behaviour, dementia and safeguarding training programmes, with safeguarding included in staff induction.

Verbatim wording from the response
“The Operations Team have implemented two relevant programs entitled “Understanding Challenging Behaviour and Dementia Training” and “Safeguarding Training” and the issue of safeguarding is now a part of the induction process at the Crosscrown Homes.”

Source location
2021-0230-Response-from-Crosscrown-Ltd_Published
Page 3 · response
Published 9 July 2021
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised3

Failure to record resident aggression incidents in care plans

Failure of staff to be aware of care plan contents

Failure to raise safeguarding alerts with the local authority

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.5

Actions described in response 5