Crosscrown Ltd
Action Taken
AI-generated response summary
• Crosscrown Ltd implemented a digital care management software system, CareDocs, across all homes, enabling staff to record daily notes, conduct care assessments, and access resident care plans. • An Operations Team was established to oversee compliance and governance, which implemented new training programs on challenging behaviour and safeguarding. • New processes were introduced for recording challenging behaviour on the CareDocs system, prompting Antecedent Behaviour Consequences forms, and for managers to review these daily and initiate safeguarding referrals.
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RESPONSE TO CORONER’S REQUEST FOR REGULATION 28 REPORT TO PREVENT FUTURE DEATHS FOLLOWING THE INQUEST INTO THE DEATH OF DOROTHY SEEKINGS CONCLUDED ON THE 7TH JULY 2021 BY A NARRATIVE VERDICT MATTERS OF CONCERN The matters of concern raised by the Coroner are as follows: (i) 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 . (ii) The failure to raise a safeguarding alert with the Local Authority regarding the above incident. (iii) The staff did not appear to be aware of the contents of the care plan for or other residents. Crosscrown Limited owns a number of Residential & Nursing Care Homes in Warwickshire, Dorset and Wiltshire and offer a range of services from residential and nursing care through to dementia and respite care. Following the tragic events of the 8th August 2019 the organisation has implemented a number of changes which are now in place and which hopefully address the concerns which have been raised. 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.
The CareDocs system is stored on a cloud portal package and mobile devices which are connected to the internet allow detailed daily notes to be recorded, care assessments to take place and for all staff to review resident information. Clifton Court have found the system intuitive and easy to use by all staff regardless of their level of computer literacy. The evidence based features of the system allow Clifton Court to demonstrate a safe, caring and responsive environment and allows compliance to be monitored. It allows for the creation of a digital care plan, digital care assessments, daily notes to be updated and charts and body maps to all be recorded and in one place. The staff can have easy access to profiles and most importantly the digital care document itself through desk top computers, laptops, tablets and even mobile phones. 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.
The introduction of the system was dependent on upgrading the Wi-fi capability throughout the Homes which ensures that the electronic care plan records can be utilised and read and updated throughout Clifton Court.
The second significant change made by Crosscrown Limited was the appointment of a Quality Assurance & Compliance Manager in August 2019 which led to the creation of an Operations Team developed throughout 2020 and fully implemented by December 2020. This team is responsible for compliance and governance across the Crosscrown Homes including of course Clifton Court. The team contains three members who are responsible for Quality Assurance and Compliance together with matters of governance, human resources and learning and development. The Operations Team are supported and guided by an
independent external consultant called The Care Excellence Partnership. The lead at that organisation is an experienced former national lead and inspector of services for the CQC.
The Operations Team have overseen the implementation of the CareDocs scheme and implemented a number of new processes which deal with issues of training and good practice.
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.
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.
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.
The Operations Team has implemented backing up the issue of safeguarding by issuing each and every member of staff with a small pocket sized laminated safeguarding document to remind the staff of safeguarding issues.
The CareDocs system is stored on a cloud portal package and mobile devices which are connected to the internet allow detailed daily notes to be recorded, care assessments to take place and for all staff to review resident information. Clifton Court have found the system intuitive and easy to use by all staff regardless of their level of computer literacy. The evidence based features of the system allow Clifton Court to demonstrate a safe, caring and responsive environment and allows compliance to be monitored. It allows for the creation of a digital care plan, digital care assessments, daily notes to be updated and charts and body maps to all be recorded and in one place. The staff can have easy access to profiles and most importantly the digital care document itself through desk top computers, laptops, tablets and even mobile phones. 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.
The introduction of the system was dependent on upgrading the Wi-fi capability throughout the Homes which ensures that the electronic care plan records can be utilised and read and updated throughout Clifton Court.
The second significant change made by Crosscrown Limited was the appointment of a Quality Assurance & Compliance Manager in August 2019 which led to the creation of an Operations Team developed throughout 2020 and fully implemented by December 2020. This team is responsible for compliance and governance across the Crosscrown Homes including of course Clifton Court. The team contains three members who are responsible for Quality Assurance and Compliance together with matters of governance, human resources and learning and development. The Operations Team are supported and guided by an
independent external consultant called The Care Excellence Partnership. The lead at that organisation is an experienced former national lead and inspector of services for the CQC.
The Operations Team have overseen the implementation of the CareDocs scheme and implemented a number of new processes which deal with issues of training and good practice.
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.
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.
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.
The Operations Team has implemented backing up the issue of safeguarding by issuing each and every member of staff with a small pocket sized laminated safeguarding document to remind the staff of safeguarding issues.