Recipient

Crystal CareIncludes reports addressed to a minister or senior office-holder acting for this organisation.

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First report 25 Jun 2019•Latest report 25 Jun 2019

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Social-care provider. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

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.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. Addressed to: Managing Director, Crystal Care Ltd.

    Norfolk

    AI-generated summary

    James Owen DELANEY · 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

    James Owen DELANEY was a resident at Sapphire House Care Home and had insulin-controlled diabetes. He refused insulin on 25 and 26 July 2018 and was unwell on 27 July; he was found unresponsive and pronounced dead on 28 July 2018. Concerns included insufficient regular refresher training on policies and inconsistent procedures for contacting a GP when medication was refused.

    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 Crystal Care; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of regular refresher time for staff to review Policies and Procedures

    Wider context from the report

    “1. There are several general Policies and Procedures in place and individual documents relating to service users. Whilst staff are now given ring-fenced time to read and understand those documents on entering the Home, the evidence is that time is not set aside to refresh themselves at regular intervals with regard to this information; ”
    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 Crystal Care; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain a consistent and accessible medication-refusal procedure across Homes

    Wider context from the report

    “2. The Medication Policy covering all medication, all service users at all Homes within the Crystal Care umbrella organisation, provides a GP should be called if medication is not taken for 24 hours. At Sapphire House staff have been sent an email requiring them to call a GP should a service user refuse one dose of medication. This is not a standard procedure across all Homes and could lead to confusion, particularly should staff transfer between Homes and on new staff joining who may not have access to the email. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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