Steps2Recovery
Action Taken
Steps2Recovery has implemented several measures including clarity in communication, improved referrals, reconsideration policies, leadership experience, policy reviews, staff training, and enhancements to its case management system. (AI summary)
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Lexham House 4TH January 2025 28 St Charles Square LONDON W10 6EE To: Mr Nick Armstrong KC, Assistant Coroner to the West Sussex, Brighton & Hove Coroner’s Service. Response to the Regulation 28 Report following the Inquest into the Death of Kirsten Hocking Steps2Recovery (S2R) acknowledges the findings and conclusions outlined in the Coroner’s report regarding the sad death of Kirsten Hocking and the concerns raised and herein responds to the concern directed to S2R. We would like again to send our condolences to Kirsten’s family. We remain committed to learning from these events and ensuring that every possible action is taken to address the issues raised. Our organization is dedicated to improving our processes, strengthening communication, and refining our approach to supporting vulnerable individuals in need of rehabilitation. The concern raised was as follows:- “S2R started providing this kind of specialist accommodation because there was such a pressing need for more of it. They are to be welcomed for having done so. However, like many small organisations which have grown, it appears that their systems have not always grown with them. Work is already being done, but there remains a continuing risk. Placement offers and the conditions and expectations which attach to them are too unclear. The recording of decisions around offers, withdrawal, and reconsideration, also needs to be better, not just to ensure that decisions are recorded, but also to ensure that decision making is properly structured and takes all relevant matters into account. Withdrawing accommodation offers without first speaking to the requesting organisation (in this case staff at the prison) also gives rise to risks. As this case shows, these are critically important decisions, and great care is required.” In response to this, we have reviewed the findings in detail and have implemented the following measures to address the concern raised and more:
1. Clarity in Communication with Potential Admissions o All potential admissions are informed during the assessment process that they are required to remain fully abstinent from drugs and alcohol. Additionally, it will now include clearer parameters relating to issues such as, but not limited to; self-harm, suicide, prescribed medication, criminality, mobility and physical health. Any changes in these circumstances may lead to a re-evaluation of their application by a
multidisciplinary team, which may include third-party input and may result in the withdrawal of their offer. This information will always be provided in writing in clear and unambiguous terms, as well as communicated verbally. We have implemented a new ‘Offer/Acceptance’ document that details the offer, on which any conditions placed on our offers will be clearly communicated in written form and sent to the main point of contact and where appropriate cc’d to other involved parties. This single document can then be accessed by other involved parties and eliminates any confusion as to what is required to fulfil a successful placement. As part of the review of our case management system ‘Lamplight’, this form will be available on clients’ individual files.
2. Obligations of Referring Services o Referring services, such as Probation Services, HMP Services and substance misuse commissioning agents, will now be explicitly informed during the assessment stage that they must notify S2R, in a timely manner, of any changes in the circumstances of prospective clients. This includes, but not limited to, updates related to mental health, physical health, self-harm, suicide risk, drug or alcohol use, or any other significant issue. We will, whenever possible, recommend to referring services that alternative placements should be considered as a precaution, in case conditions change and the place offered by us is at risk.
3. Documentation of Communication & Decision Making. o To provide further robustness and transparency all communications, discussions, and decisions, with regards to the prospective client, will be recorded on Lamplight, and regularly audited by our new senior management team. This ensures robust documentation and accountability of decision making.
4. Pre-Arrival Updates from Referring Services o In addition to our normal application process, and to ensure preparedness, S2R will contact the referring service two weeks prior to the client’s arrival to confirm there have been no changes in circumstances. If circumstances have changed, which may lead to the withdrawal of the offer, the referring service will be contacted and have input into the final decision before it is made.
5. Leadership Experience. We have appointed new executive team members, with a new Head of Therapy and CEO to further develop the delivery of our services. We have
also expanded our board of Trustees to include someone with extensive experience in clinical management.
6. Policy and Procedure Review o S2R has engaged an external consultant to conduct a comprehensive review of all policies and procedures, including but not limited to: Referrals Assessment and Admissions Self-Harm and Suicide Risk Planned and Unplanned Discharges o The reviewed policies will now incorporate all the aforementioned processes and actions, ensuring a robust framework moving forward.
7. Staff Training o S2R provides mandatory continuous training to ensure all staff are fully trained on the updated processes, recording of decision-making, policies and procedures.
8. Enhancements to Case Management System o S2R has undertaken a thorough review of its case management system, Lamplight, and is collaborating with Lamplight to ensure the system operates at its most efficient and effective configuration. o Comprehensive further staff training on the Lamplight system will then be provided to ensure its optimal use and accuracy in documentation. We remain committed to continuous improvement and to providing the highest level of care and support for the individuals we serve. We continue to take all necessary steps to minimise risk and ensure a more robust service to the vulnerable individuals who rely on Steps2recovery.
1. Clarity in Communication with Potential Admissions o All potential admissions are informed during the assessment process that they are required to remain fully abstinent from drugs and alcohol. Additionally, it will now include clearer parameters relating to issues such as, but not limited to; self-harm, suicide, prescribed medication, criminality, mobility and physical health. Any changes in these circumstances may lead to a re-evaluation of their application by a
multidisciplinary team, which may include third-party input and may result in the withdrawal of their offer. This information will always be provided in writing in clear and unambiguous terms, as well as communicated verbally. We have implemented a new ‘Offer/Acceptance’ document that details the offer, on which any conditions placed on our offers will be clearly communicated in written form and sent to the main point of contact and where appropriate cc’d to other involved parties. This single document can then be accessed by other involved parties and eliminates any confusion as to what is required to fulfil a successful placement. As part of the review of our case management system ‘Lamplight’, this form will be available on clients’ individual files.
2. Obligations of Referring Services o Referring services, such as Probation Services, HMP Services and substance misuse commissioning agents, will now be explicitly informed during the assessment stage that they must notify S2R, in a timely manner, of any changes in the circumstances of prospective clients. This includes, but not limited to, updates related to mental health, physical health, self-harm, suicide risk, drug or alcohol use, or any other significant issue. We will, whenever possible, recommend to referring services that alternative placements should be considered as a precaution, in case conditions change and the place offered by us is at risk.
3. Documentation of Communication & Decision Making. o To provide further robustness and transparency all communications, discussions, and decisions, with regards to the prospective client, will be recorded on Lamplight, and regularly audited by our new senior management team. This ensures robust documentation and accountability of decision making.
4. Pre-Arrival Updates from Referring Services o In addition to our normal application process, and to ensure preparedness, S2R will contact the referring service two weeks prior to the client’s arrival to confirm there have been no changes in circumstances. If circumstances have changed, which may lead to the withdrawal of the offer, the referring service will be contacted and have input into the final decision before it is made.
5. Leadership Experience. We have appointed new executive team members, with a new Head of Therapy and CEO to further develop the delivery of our services. We have
also expanded our board of Trustees to include someone with extensive experience in clinical management.
6. Policy and Procedure Review o S2R has engaged an external consultant to conduct a comprehensive review of all policies and procedures, including but not limited to: Referrals Assessment and Admissions Self-Harm and Suicide Risk Planned and Unplanned Discharges o The reviewed policies will now incorporate all the aforementioned processes and actions, ensuring a robust framework moving forward.
7. Staff Training o S2R provides mandatory continuous training to ensure all staff are fully trained on the updated processes, recording of decision-making, policies and procedures.
8. Enhancements to Case Management System o S2R has undertaken a thorough review of its case management system, Lamplight, and is collaborating with Lamplight to ensure the system operates at its most efficient and effective configuration. o Comprehensive further staff training on the Lamplight system will then be provided to ensure its optimal use and accuracy in documentation. We remain committed to continuous improvement and to providing the highest level of care and support for the individuals we serve. We continue to take all necessary steps to minimise risk and ensure a more robust service to the vulnerable individuals who rely on Steps2recovery.