Independent investigation: Jenny Foote, Acton (2015)

The Trust must ensure that discharge planning includes the following elements and
develop a system to ensure standards are maintained.
• How legal conditions of discharge are interpreted.
• Provide a complete discharge summary and care plan which includes
contingency management prior to discharge.
• Define who is responsible for delivery as well as what interventions are to occur
and when.
• Must include carers, provider service staff and all relevant clinical personnel.

The Trust must ensure that the agreed standardised risk assessment (including HCR-
20) protocols, practice and documentation are monitored to reflect the outcomes from
the Trust’s internal action plan.
The focus of monitoring should be on communicating risk related information,
reviewing of risk assessments and management plans considering additional
information and the development of a risk formulation.

The Trust must ensure that joint working practices with other organisations reflect
developments in practice and protocol arising from this incident and the internal
investigation action plan outcomes.
Specifically, that joint risk assessment and management plans, contingency plans and
agreed protocols for discharge and recall are agreed in each individual case.

The Trust must ensure that staff are appropriately skilled and competent to undertake
the role of Social Supervisor.

The Trust must ensure that it has a robust process for checking that all staff are
appropriately registered with their professional body, and this should include ensuring
that any agency staff employed are appropriately registered.

In partnership with LCH, the commissioners of Collette House should clarify the role
and nature of the Collette House service provision, including the limits of the service,
and clear thresholds for raising and escalation of any concerns.