Service Delivery Model Template

A summary of our Services

Established since 1993 Maison Moti Limited provides the
Our Service Delivery Model
following range of community based step-down services We operate a 5-stage service delivery model across all
for adults recovering from a mental health condition: our service areas, comprising:

 Residential care
 Shared Housing
 Assessment (An Initial Assessment is
 Supported Housing
conducted following the referral with a more
 Floating Support
comprehensive (Core) Assessment within 4
 Community Outreach
weeks of the service commencing)
We currently have a combined total of 49 units of 24-
hour supported accommodation across our residential,  Support Planning (An outline Support Plan is

shared and supported housing services (One 15-bedded completed from the findings of the Initial

CSCI registered care home, two shared housing units Assessment following referral, with a more

providing 6 placements each and two supported housing comprehensive (Core) Support Plan resulting

units with 16 self contained flats in one and an additional from the Core Assessment, provided within 4

6 in the other). As a further step-down to these services weeks of the service commencing)

we have 14 floating support placements provided over  Key Working (All service users are designated
five properties. In addition we also provide an unlimited a named Key Worker with formal Key Working
number of community outreach arrangements, either as meetings held on at least an 8-weekly cycle)
the final step towards complete independence or as an
 Reporting (Reports setting out progress against
early prevention service.
each of the agreed Core Support Plan areas,
together with other relevant information are
Service Aims provided to involved professionals and others as
All our services strive to achieve the most independent may be agreed on at least an 8-weekly cycle)
life situation possible for our service users. We do this by
ensuring a sustained focus on:  Review (A formal review of the service and the
Core Assessment and Core Support Plan are
 Stabilising and further promoting recovery
carried out on at least an annual basis)
from mental ill- health, &
 Re-establishing the independent living These are the key primary interventions via which all
skills required to enable an unsupported Maison Moti user services are determined, agreed,
life in the community
provided, monitored and reviewed.

1
 About this document
This template document is the tool via which the service Any new information added to the document must be
delivery model is implemented and monitored. dated in the ‘last updated’ box provided at the top of
each Part and also next to the new text that is added.
It is set out in four distinct parts: A paper copy of the SDMT is to be maintained on the
1. Service inquiry individual service user’s files. At all times when
2. Referral information is added, the relevant page/s must be printed
3. Assessment and inserted into the paper file, replacing the old page/s.
4. Service delivery
The SDMT can be made available to all involved
The document provides a single point of reference for
professionals and others such as family and relatives, but
readily obtaining key customer and service user
only with the express consent of the service user.
information, for purposes of tracking progress on service
inquiries, referrals and more crucially on our interventions Part 1 (Service inquiry) is to be completed only by staff
to monitor distance travelled, post service based at Maison Moti’s head office.
commencement.
Part 2 (Referral) is to be completed only by authorised
operational staff. (Relevant sections can also be
completed by the referrer if they choose to provide the
Guidance notes requested information by way of completing the form
rather than over the phone)
Every Maison Moti service user is required to have an up
to date Service Delivery Model Template (SDMT) in place Part 3 (Assessment) – The initial assessment is to be
at all times. completed only by Maison Moti’s Clinical Supervisor
together with an authorised operational senior or middle
The document is to be maintained electronically on the
manager. Part 3 is also to be used for all subsequent
company’s shared server and added to as changes occur
assessments as part of a formal review. These are to be
or at required intervals, without deleting any previous
completed by the designated Key Worker except for the
information.
risk assessment part in section 7 which is to be completed
The SDMT should only be ceased when the service user by the Clinical Supervisor.
moves on to a different service, or unless otherwise
Part 4 (Service delivery) is to be completed by project
authorised by a member of Maison Moti’s senior
staff, usually the designated key worker and the project
management team.
manager. (Changes to the risk assessment and risk
If the service user moves to another service within management plan, including those further to a review,
Maison Moti a new SDMT is to be started. must only be completed by the Clinical Supervisor).

NB: Particular care should be taken to ensure that the referral agency, and in particular the service user, are not asked to
repeat any information that has been provided previously.

Please take time to read the guidance notes that have been provided throughout this document to ensure that it is
completed as intended.

2
Part 1 – Service inquiry
This part is only to be completed in the case of an inquiry about Maison Moti services, including where an inquiry leads to a
referral. In the event of a direct referral at first contact proceed straight to Part 2.
Part 1 can be completed by any member of Maison Moti’s head office staff team. Any queries should be referred to a
member of the senior management team.

Date of first inquiry      

Last updated      

1. Subject information
Name       Date of Birth      
Home address       Current address      
Gender       Type of placement      
Religion       Ethnicity      
Nationality       NHS No      
Marital status       NINO      

Children
Yes No Details
     

Next of kin
Name       Relationship      
Address       Tel      
Mobile       Email      

Immigration issues
Yes No Details
     

Languages spoken      

Interpretation/ translation required

Yes No Details
     

Physical disabilities/ learning difficulties

Yes No Details
     

Mobility issues
Yes No Details
     

Mental health diagnosis:

     
Relevant section of Mental Health Act      
Section upon discharge      

Subject to CPA:
Yes No Details
     

Brief outline of relevant history:

     

2. Inquirer information
Full name       Designation      
Address       Organisation      
Telephone       Fax      
Mobile       Email      

Responsible LA name and address (If different to above)

Name of LA      
Address      

3. Service details
Indicate below the service that is required
Service Group Project X Vacancy details Comments
Residential care Maison Moti            

Shared housing Moti Lodge            

Casa Moti            
Supported Moti Villa            
housing
Chez Moti            
Floating Studio Moti            
support
Other            
Community outreach            
To be decided            
Other            

Anticipated service start date      

Anticipated service outcomes      

4. Outcome
     
5. Follow up action
Document type Service group/ Date despatched Sent to By post By e-mail
Project
Referral procedure                  
Maison Moti Brochure                  
Relevant Service                  
Specification
Relevant Service User                  
Guide

Completed by      
Name of operational staff inquiry sent to      
Date sent      

Further actions required and actions subsequently taken (inc. date and name of person making the note)
     

6. Additional info
Relevant additional information relating to Part 1
     

7. No further action
Where the inquiry is satisfactorily resolved, the contact does not lead to a referral and no further action is required note here
any relevant comments and file away the document together with all related paperwork
     

NFA authorised by       Date of closure      

 Part 2 – Referral
This part is to be completed by Maison Moti operational staff authorised to deal with referrals. All information must be
completed in full. If the required information has already been recorded in Part 1 then it is not necessary to repeat, however
please note the additional information requirements in this part.

Date of first referral contact      

Date/s follow – up referral info provided      
Last updated      

1. Service details
Indicate below the service that is required
Service Project X Vacancy details Comments
Group
Residential Maison Moti            
care
Shared Moti Lodge            
housing
Casa Moti            
Supported Moti Villa            
housing
Chez Moti            
Floating Studio Moti            
support
Other            
Community outreach            
To be decided            
Other            

How did referrer learn about Maison Moti?

     

Anticipated service start date      

If service is not available by this date does the referrer want the service user to be placed on the waiting list?
Yes No Details
     

Anticipated service outcomes      

2. Referrer info
Full name       Designation      
Address       Organisation      
Telephone       Fax      
Mobile       Email      

Care Co-ordinator details (if different from above)

Full name       Address      
Telephone       Fax      
Mobile       Email      
Funding authority details
Authority 1       Authority 2      
Invoicing address       Finance contact      
Telephone       Fax      
Mobile       Email      

3. Supporting documents
Establish which of the following documents have or will be provided. NB: Those underlined are compulsory, without which
the referral may not be accepted.
Document Dated To follow Date provided
Psychiatric Report                  
Psychological Report                  
Risk Assessment                  

OT Assessment Report                  

Discharge Summary                  
CPA Report                  
Care Plan                  
Social Circumstances Report                  
Social Work Report                  
Other (insert details)                  

4. Subject information
Name       Date of Birth      
Home address       Current address      
Gender       Type of placement      
Religion       Ethnicity      
Nationality       NHS No      
Marital status       NINO      

Children
Yes No Details
     

Next of kin
Name       Relationship      
Address       Telephone      
Email       Mobile      

Immigration issues
Yes No Details
     
Languages spoken      

Interpretation/ translation required

Yes No Details
     

Physical disabilities/ learning difficulties

Yes No Details
     

Mobility issues
Yes No Details
     

Mental health diagnosis      

Relevant section of Mental Health Act      

Section upon discharge      

Subject to CPA
Yes No Details
     

Details of current medication and how it is administered

     

Index offence
Yes No Details
     

Forensic history
Yes No Details
     

Known risk behaviours      

Placement history      

Relevant history      

5. Scheduling the assessment meeting

Scheduled date of assessment       Venue      
To be conducted by       Also present will be      
6. Additional info
Relevant additional information relating to Part 2
     
 Part 3 – Assessment
The initial assessment is to be completed by Maison Moti’s Clinical Supervisor together with an authorised senior or middle
manager. This section is also to be used for conducting all subsequent assessments, which are to be completed by the
designated Key Worker, except for section 7 which will be completed by the Clinical Supervisor.
NB: The plan resulting from any changes to the initial assessment (i.e. minor changes during the course of the service as
well as from subsequent assessments as part of a formal review) are to be updated using the Core Support Plan in part 4
(The Outline Support Plan in this part is only to be used to document the plan prior to the service commencing).

All information in this section must be completed in full, unless already recorded in the earlier parts of this document. Before
completing this section please complete any relevant incomplete sections from parts 1 and 2.

Date of assessment Conducted by Others present Last updated (state By

meeting ‘review’ if as part of
a formal review )
                             

Sources of information
1      
2      
3      
4      
5      

1. Current situation
     

2. Medication and treatment

Is subject self medicating?
Yes No

Will s/he be expected to self medicate upon commencing service with Maison Moti?
Yes No Comments
     

Provide details of all medication for all physical and mental health conditions
Medication Dosage Frequency Administered by Comments (inc. side effects, when last
reviewed and date finished)
1                              
2                              
3                              
4                              
5                              
6                              
7                              
8                              
 Medication Dosage Frequency Administered by Comments (inc. side effects, when last
reviewed and date finished)

9                              

10                              

Details of all current mental health treatment and how the subject is responding to the treatment. Also note any follow-up
appointments and whether Maison Moti staff will need to facilitate these.
     

Details of all current physical health treatment and how the subject is responding to the treatment. Also note any follow-
up appointments and whether Maison Moti staff will need to facilitate these.
     

The amount and details of all medication the subject will have available upon commencing service with Maison Moti and
agreement to continue with supply until registered with a local GP and CMHT
(NB: A minimum supply for 4 weeks is required)
     

Plans for change of GP      

registration and CMHT

3. Background
     

4. Professional support network

Details of all professionals involved in providing for the subject’s current treatment, care and support
Designation Name Address Tel Fax E-mail
Care Co-ordinator                              
Care Manager                              
Psychiatrist                              
CPN                              
Social Worker                              
GP                              
CMHT                              
Dentist                              
Optician                              
Dietician                              
Emergency Out of                              
Hours Service
Other (Please                              
specify)

5. Personal relationships
Contact details of all people of significance to the subject (i.e. family, relatives, friends, lovers etc …) and indentify any that
the subject would like involved in his / her care whilst at Maison Moti. (Explain that this will mean that we would share all
information, unless advised not to do so)
Name Relationship Contact details Frequency of contact Consent given info
sharing
                             
                             
                             
                             
                             
                             

State the level of support provided by family and friends and whether they would be prepared to increase the support if
required?
     

State whether the subject would benefit from support to promote contact, if so what this should be and whether the subject
is agreeable to this?
     

6.1 Convictions
Number Offence Convicted Sentence Details
Index offence                        
1.                        
2.                        
3.                        
4.                        
5.                        
6.                        
7.                        

6.2 Other criminal acts

Any relevant information about criminal involvement that did not lead to a conviction, any pending charges, details of bails,
curfews etc…
     

6.3 Conditions imposed by the Ministry of Justice

     

7. Emotional and mental health

NB: This section must be completed by Maison Moti’s Clinical Supervisor

7.1 Current diagnosis

Diagnosis      

Is the subject currently detained under the Mental Health Act?

(If relevant state which section the subject will be under following discharge)
Yes No Details
      

Has the subject ever been detained under the Mental Health Act previously?
Yes No Details
     

7.2 Mental health history

Summary of the subject’s mental health history, including his/ her circumstances and issues leading up to the mental health
problems, the services received, current condition, etc…
     

7.3 Significant life events

Summary of all relevant events leading up to the mental health breakdown and how these continue to impact etc… (Include
any incidents of bereavement, loss and separation).
     

7.4 Self perception and confidence

Provide an outline of the subject’s perception of him/ her self, including self- esteem, his/ her level of confidence in self, how
this impacts on him/ her, in his/her interaction with others, presentation etc…? Also, provide information on the subject’s
ability to make decisions and to assert him/her self.
     

7.5 Insight and awareness

Provide an outline of the subject’s level of insight and awareness of his/ her mental health condition, how this affects him/
her, his/ her ability to manage the impact, etc…?
     

State whether the subject is able to describe his/ her triggers or indicators to relapse and if so is s/he able to ask for support
when this occurs?
     

State whether the subject is able to identify risks (to self, others, from others etc) and if so what is his/ her method for
managing the risks?
     

7.6 Risk behaviours

Refer to the ‘Methodology for determining risk levels’ document to establish whether the risk level is Low, Moderate,
High or Extreme. Where there is no risk state ‘none’ and if a lack of information means that the risk is not known state ‘N/K’.
Details must be provided below for all areas where there is either a historical or current risk.
Risk Historical Current Risk Details
Level

Self –harm
Talk/thoughts of self harm                  
Act with suicidal intent                  
Acts of self harm                  
Other form of self harming                  
behaviour
Other (Please specify)                  
Risk Historical Current Risk Details
Level

Harm to others
To children                  
Sexual assault                  
Violence to family                  
Violence to other service users                  

Violence to professionals                  

Violence to public                  

Exploitation of others                  

Intimidating behaviour                  

Other (Please specify)                  

Self-neglect
Poor hygiene                  

Malnutrition                  

Poor physical health                  

Non-compliance with medication                  

Refusal of services                  

Disengagement from key services                  

Eviction                  

From environment                  

Other (please specify)                  

Harm from Others

Neglect                  
Physical abuse                  
Exploitation                  
Financial abuse                  
Bullying/ harassment                  
Over medication                  
Unlawful restriction                  
(e.g. abduction)
Racial abuse                  
Other (please specify)                  

Other risks
Subject to POVA                  
Substance abuse                  
Alcohol                  
Use of weapon                  
Incident involving the police                  
(e.g. anti-social behaviour)
Accidental harm at home                  
Risk Historical Current Risk Details
Level
Dangerous driving                  
Absconding                  
Arson                  
Isolation                  
Due to lack of exercise                  
Exploitation                  
Damage to property                  
STD’s                  
Others (Please specify)                  

7.7 Relapse indicators

Identify any known behaviours that could indicate a risk of relapse and state the action to be taken in this event
Number Risk indicator/ behaviour Action to be taken in the event of occurrence
1.            

2.            

3.            

4.            

5.            

6.            

7.            

8.            

9.            

10.            

7.8 Summary evaluation of emotional and mental health issues

     

8. Physical health
8.1 General health info
Height Weight Blood pressure
(in centimetres) (in kilos) 120/80 = ideal
120/80 or 140/90 = normal but slightly
higher than it should be
140/90 over a few weeks – consult GP
                 

Does the subject have any physical disabilities or learning difficulties?

Yes No Details
     

Does the subject smoke, drink alcohol or take illicit drugs?

Yes No Details
     
8.2 Medical conditions
All questions answered with a ‘yes’ in this part must be followed up with relevant details.
Condition Y N NK Details
Allergy      
Anaemia      
Angina      
Anorexia Nervosa      
Arthritis      
Asthma      
Autism      
Back pain      
Bulimia Nervosa      
Cancer      
Cataracts      
Chicken Pox      
Chronic Obstructive      
Conjunctivitis      
Constipation      
Coronary Heart Disease      
Diabetes      
Diverticulitis      
Eczema      
Epilepsy      
Erectile Dysfunction      
Fibroids      
Gallstones      
Haemorrhoids      
Hay Fever      
Heart Attack      
Hepatitis A/B/C      
HIV and Aids      
Hypotension      
Hypertension      
High Cholesterol      
Incontinence      
Irritable Bowel      
Syndrome
Kidney Failure      
Kidney Stones      
Laryngitis      
Leukaemia      
Mastitis      
Condition Y N NK Details
Meniere’s Disease      
Meningitis      
Migraine      
MRSA      
Multiple Sclerosis      
Neuralgia      
Obesity      
Osteoarthritis      
Osteoporosis      
Ovarian Cyst      
Pulmonary Disease      
Parkinson’s disease      
Pelvic Inflammatory      
Disease
Pneumonia      
Prostate Disease      
Psoriasis      
Repetitive Strain Injury      
Shingles      
Stroke      
Thyroid problems      
Tinnitus      
Tonsillitis      
Tuberculosis      
Ulcerative Colitis      
Urinary Tract Infection      
Varicose Veins      
Vertigo      
Other (Please specify)      

Date of last medical examination      

Is an annual medical examination due?      

Does the subject have any personal or religious beliefs that may prevent medical treatment?
     

8.3 Healthy living

Describe below the subject’s typical diet, stating what support/ services are necessary, if any?
Diet Advice/ support/ services required?
           

Does the subject have a weight issue?

Yes No Details Advice/ support/ services required?
            

Does the subject take any form of physical exercise?

Yes No Details Advice/ support/ services required?
           

Is the subject sexually active?

Yes No Details
     

Does s/he have an awareness of the need to have safe sex?

Yes No Details Advice/ support/ services required?
           

8.4 Summary evaluation of physical health issues

     

9. Race, Culture & Identity

Note here information relating to the subject’s, race, religion, culture and identity. State whether there are any particular
issues or considerations in this regard, whether s/he practices his/ her faith, if there is any issues of disassociation with race
etc… and if support is required to promote race, culture or identity?
     

Note here whether the subject has any discriminatory attitudes or beliefs, if s/he has acted on these in the past and/ or how
these may have an impact on others and the service to be provided?
     

Which of the following proof of identity documents does the subject have?
Document Location where kept Checked by assessor Comments
Passport                  
Home Office documents                  
Driving License                  
Medical Card                  
Other (Please specify)                  
Other (Please specify)                  

10. Education, training & employment

Provide a brief outline of the subject’s past and present education, training and employment (inc. voluntary work). Also
establish his/ her future plans, identifying any obstacles to achieving these.
     

11. Finance
Is the subject currently in any form of employment?
Yes No Details (inc. income)
     
Is the subject receiving any DWP benefits? (If not state whether they would be eligible?)
Type of benefit Amount Comments
Income Support            
Job Seekers Allowance            
Incapacity Benefit            
Disability Living Allowance            
Sever Disablement Allowance            
Council Tax Benefit            
Housing Benefit            
Community Care Grant            
Other (please specify)            

Does the subject have any outstanding financial claims or settlements (i.e. from the CICB, insurance providers etc…)?
Yes No Details (inc the estimated amount)
     

Does the subject have any savings or assets?

Yes No Details (including amount)
     

Does the subject have any other means of income?

Yes No Details (including amount)
     

Does the subject have any debts?

Yes No Details (including amount)
     

Is s/he able to manage his/ her money?

     

Confirm that the subject will have sufficient monies available to them for their basic needs upon the Maison Moti service
starting? (NB: Any applications for benefits / changes will usually take at least 4-6 weeks)
     

12. Daily routine, recreation and leisure

Provide an outline of the subject’s typical daily routine and details of his/ her hobbies and interests etc…?
     

13. Presentation and social awareness

Note here any issues relating to the subject’s appearance, personal hygiene, presentation, confidence level, intuitiveness,
awareness of others, the environment etc…
     
14. Interpersonal skills
Note here your evaluation of the subject’s ability to listen, comprehend, and express him / herself through verbal
communication, on his her diplomacy, sensitivity etc…
     

15. Relationships and social support networks

Record here details of the subject’s social and support networks, i.e. family, relatives, friends, involvement with community
and social groups, professionals, lovers etc… State his/ her ability in general to engage in positive relationships.
     

16. Independent living skills

Establish the subject’s ability in the following areas. If fully competent check box Y, otherwise check box 1 to indicate little to
no ability therefore high level of support required, box 2 to indicate some level of ability therefore medium level of support
required and box 3 to indicate good level of ability therefore low level of support required.
NB: All tasks identified as 1, 2 or 3 should be supported with information in the details box.
Task Y 1 2 3 Details
Fill in forms      
Write letters      
Make official tel.      
calls
Budget      
Pay bills      
Manage debt      
Bank account      
Save      
Plan menu      
Food shopping      
Cook      
Clean      
Laundry      
Personal care needs      
Self medicate      
Use public transport      
Access emergency      
services
Access health care      
services
Access professionals      
for current services
Social support      
network

16.1 Evaluation of subject’s independent living skills

Note here your evaluation of the subject’s independent living skills and the level of support that will be required to help
him/her to either achieve complete independent living or the next level of supported living
     
17. Additional Information
Note here the subject’s feelings about the referral for a service with Maison Moti, whether s/he is prepared to engage with
services that would be provided and his/ her feelings about further move on to more independent services.
     

Note here information on any relevant meetings/ hearings, such as discharge, CPA parole or other professional meetings that
are scheduled and state whether it would be of benefit for a Maison Moti representative to attend.
     

Other additional information relevant to Part 3.

NB: Where applicable cross reference any information to the relevant section
     

18. Summary of overall findings from the assessment

Provide here a summary of the overall findings from the initial assessment, identify any gaps in information and state how
these are to be addressed.
     

19. Eligibility and suitability

Is the subject deemed to be eligible for the service s/he has been referred for?
Yes No Details
     

Is the subject deemed to be suitable for the service s/he has been referred for?
Yes No Details
     

If a service is not to be offered set out here the reasons for this, giving consideration to whether an alternative Maison Moti
service could be offered otherwise sign post to appropriate external services.
     

Decision authorised by Managing Director?

Yes No Comments Date
           

If decision not to provide a service has been authorised please state below the date decision notified to the referrer and to
the subject and file this document away together with other relevant papers. Inform the referrer and subject of the appeals
process (which is set out in the Referral Procedure).
     

Info on appeals against decision not to offer a service

Date of appeal Appellant name and contact details Grounds for appeals
                 

Action taken following appeal      

Outcome of appeal      

NB: If service is to be provided proceed with completing the rest of the SDMT.

20. Support Plan (Outline)

Ensure that all areas identified in the initial assessment are set out under the relevant heading and a plan for how each area
is to be addressed clearly stated, including a plan to manage all areas of risk.
Identified Plan By whom By when Time estimate
area of need/ (per week)
risk
Medication &                        
treatment
                             
                             
Professional                        
support
network
                             
                             
Personal                        
relationships
                             
                             
Forensic                        
                             
                             
Emotional &                        
mental health
                             
                             
Managing                        
Risk
                             
                             
Physical                        
health
                             
                             
Race, culture                        
& identity
                             
                             
Education,                        
training &
employment
                             
                             
Finance                        
                             
Identified Plan By whom By when Time estimate
area of need/ (per week)
risk

                             

Daily routine,                        
recreation &
leisure
                             
                             
Presentation                        
& social
awareness
                             
                             
Interpersonal                        
skills
                             
                             
Relationships                        
& social
support
networks
                             
                             
Independent                        
living skills
                             
                             
Other                        
                             
                             
Total      

Note here the action to be taken in the event of an emergency or crisis.

     

Identify here the overall approach and communication style that would best facilitate the subject’s engagement and
progress, noting anything that should not be done as it may irritate or aggravate the subject.
     

Date support plan completed      

Date authorised by Maison Moti’s Managing Director      
Date SDMT sent to the relevant Maison Moti project      
Date sent to referrer      
Date the Individual Service Agreement (ISA) sent to referrer and      
copy for prospective service user

Name & contact details of      

project
Service type       Proposed service start date      

Trial period/Visits       Service charge      

Period of time estimated at       Proposed frequency of key      

proposed service working meetings
Reviews to be undertaken at       monthly intervals

Other instructions to project

     
 Note to referrer
The completed information in Part 3 above represents the findings from our Initial Assessment, which together with any
other information that may have been provided has been used to formulate the Outline Support Plan in section 20 above.

Please be advised that a more comprehensive assessment will be completed upon the service being commenced and this will
form the basis of a Core Support Plan (Part 4). This will be sent to you for your approval within 4 weeks of the service start
date. Once the Core Support Plan has been agreed you will then be sent regular reports (on at least an 8-weekly cycle)
providing a summary of the progress against each of the support plan objectives.

Please use the comments box below to give us your feedback.

In particular what we would like to know from you is:

1. If relevant, the grounds for appealing our decision?

2. Whether there any inaccuracies in the information provided?
3. If there is any further information we should know of?
4. Whether you are agreeable to the proposed support plan?
5. The date that you would like the service to commence from?

Please note that the service can only be agreed once you have signed and returned the Individual Service Agreement, which
formally confirms your agreement to our terms and conditions and a service start date has been agreed.

We look forward to receiving your comments

     

Once you have completed your comments please email the document (in its entirety) to the relevant member of staff at
Maison Moti (first name followed by @maisonmoti.co.uk). If you have any queries please call our head office on 020
83666464.
 The remainder of this form is for internal use only
Details of all subsequent contact leading up to the funding
and service start date being agreed.
     

Date service agreed      

Date of notification to finance team      
NB: Info to finance to inc. copy of ISA which must include service user name, service start date, service charge and funding authority
invoicing contact details
 Part 4 – Service delivery
This part covers Core Assessment, Core Support Plan, Key Working, Reporting, Monitoring and Review.
It is to be commenced immediately after the service has started and kept up to date by the allocated key worker, and
overseen by the relevant project manager.

Available medication
List below all medicine that the service user has in his/ her possession and establish whether further supplies will be
necessary within the first 4 weeks of service commencing.
Medicine Quantity Further supplies required
1                  
2                  
3                  
4                  
5                  
6                  
7                  
8                  

Attach photo of Service User Description of service user (to inc. height, weight, hair, eyes, distinguishing features, birth marks etc…)
here      

Date this Part (4) commenced       By      

Last updated       By      

Service overview information

Date of service start       Date finance team notified      
Project name and address       Service group      
Project Manager       Key Worker      
Trial Period       Date of Key Worker allocation      
Frequency of key work meetings       Date of Review      

Service user charges

Date tenancy agreement issued       Rent charge per week      
Date HB application submitted       Date of decision on HB claim &      
amount agreed
Amount of shortfall (if any) to be       Date notification sent to finance      
paid by SU team
Weekly contribution towards      
utilities
NB: All payments by service users must be set up on a direct debit arrangement using our direct debit mandate form.

1. Core Assessment
This section, Core Assessment and the Core Support Plan in section 2 below must be completed and sent to the Care co-
ordinator within 4 weeks of the service start date.
The Core assessment is a more detailed assessment of each of the areas forming the Initial Assessment (in Part 3). Its
purpose is to establish that the identified needs and risks have been assessed comprehensively and at the right level. Refer
to the guidance notes in the Initial Assessment section for each of the related areas and also to the further guidance
provided under each area in this part. The assessment should be broken down into manageable chunks and conducted over
a 4 week period. NB: Only new or additional information should be added under each of the areas below, unless otherwise
stated, i.e. medication which must be recorded in full again. In all other areas where there is no additional information or
needs to those already stated in the initial assessment then this should be stated.
Take time to explain the purpose of the assessment to the service user and obtain his/ her views and wishes, as well as any
personal outcomes they would like to achieve with regard to each area.

1.1 Medication & Treatment

This section must provide a complete and up to date account of all medication and treatment (for all physical and mental
health conditions) relating to the service user. Therefore, all relevant info in Part 3, section 2 must be repeated.
Is service user self medicating?
Yes No

Provide details of all medication for all physical and mental health conditions
Medication Dosage Frequency Administered by Comments (inc. side effects, when
last reviewed and date finished)
1                              
2                              
3                              
4                              
5                              
6                              
7                              
8                              
9                              
10                              

Details of all current mental health treatment and how the service user is responding to the treatment. Also note any
follow-up appointments and whether these will need to be facilitated by staff.
     

Details of all current physical health treatment and how the service user is responding to the treatment. Also note any
follow-up appointments and whether these will need to be facilitated by staff.
     

Plans for change of GP registration and CMHT

     

1.2 Background
     

1.3 Personal relationships

Record here any additional contacts to those in Part 3, section 5 and provide details of the relationship with each person
named in Part 5, how significant each contact is for the service user and also if support is needed to promote contact?
Additionally, state whether the service user would benefit from assistance to develop other relationships?
     
1.4 Forensic
     

1.5 Emotional and mental health

1.5.1 Current diagnosis
     

1.5.2 Mental health history

     

1.5.3 Significant life events

Record here in detail how any events referred to in Part 3, section 7.3 continue to have an impact on the service user and
whether support / services are required in this regard? Also establish whether there is any additional relevant information?
     

1.5.4 Self perception and confidence

If the service user has a negative self image and/ or low self confidence explore the reasons behind this and record them
here, stating also what s/he feels could be done to improve in these areas.
     

1.5. 5 Insight and awareness

After further exploration record here the service user’s own understanding of his/ her mental health condition, the cause, the
triggers, the relapse indicators and how s/he feels the condition could be stabilised and further improved. Also, describe the
coping mechanisms the service user has adapted and whether further strategies could be developed. (Advice and guidance
should be sought from our Clinical Supervisor as appropriate)
     

1.5.6 Risk behaviours

Changes suspected in this area must be notified to Maison Moti’s Clinical Supervisor who will reassess and record findings
here.
     

1.5.7 Relapse indicators

Changes suspected in this area be must be notified to Maison Moti’s Clinical Supervisor who will reassess. And record
findings here.
     

1.6 Physical health

1.6.1 General health info
     

1.6.2 Medical conditions

Condition Details
           

1.6.3 Healthy living

     

1.7 Culture, Race & Identity

Following further exploration record here relevant info about any racial, cultural, religious, spiritual and other beliefs and any
customs and practices that the service user wants to observe, including any related dietary requirements, etc…
     
Record here details of where any of the proof of identification documents referred to in Part 3, section 9 are located. If any
were not seen at time of Initial Assessment ask to see them and record your observations. If not available are they still
located at the same place as stated and can the service user access them if required?
     
1.8 Education, training & employment
Record here any interests that the service user could realistically pursue that could enhance his/ her employment
opportunities. For example would s/he be interested in volunteering or any educational or vocational courses, does s/he have
an up to date CV, could s/he benefit from training on interview skills etc…?
     

1.9 Finance
Check that all information in Part 3, section 11 is correct and still relevant and note any changes or additional information
here.
     

1.10 Daily routine, recreation and leisure

Explore further with the service user his/ her interests and how these could be incorporated into his/ her activities and
routine at Maison Moti. Note any additional information here.
     

1.11 Presentation and social awareness

Referring to the guidance in Part 3, section 13 explore further any issues in this regard and note any additional information
here.
     

1.12 Interpersonal skills

Referring to the guidance in Part 3, section 14 explore further any issues in this regard and note any additional information
here.
     

1.13 Relationships and social support networks

Explore further the nature and significance of relationships with the stated contacts in part 3, section 15 and note relevant
information below. Consider how any relationships with significant others could be formed or further improved.
     

1.14 Independent living skills

Refer to Maison Moti’s ‘Comprehensive Independent Living Skills Assessment’ document and ensure that each of the
stated areas is covered as part of this core assessment. Record here all areas the service user is assessed as requiring
support in.
     

1.15 Additional Information

Record here any additional relevant information, cross referencing where appropriate to earlier sections.
     

1.16 Summary of overall findings of this assessment

Record here a summary of the additional needs identified as part of the Core Assessment
     

1.17 Service user views

Record here the wishes and feelings of the service user, or other comments. Note any areas of disagreement.
     
Service user signature      

Date signed      

2. Core Support Plan

Record under the relevant area below all needs/ risks identified from the Initial, Core and all Subsequent
Assessments and how these are to be managed. Particular attention should be given to stabilising and improving
mental health, activities to promote social needs such as daily routines, recreation & leisure, social presentation &
awareness, relationships and social support networks, education, training & employment and independent living skills.
Identified Plan By whom By when Time estimate
area of need/ (per week)
risk
Medication &                        
treatment
                             
                             
Professional                        
support
network
                             
                             
Personal                        
relationships
                             
                             
Forensic                        
                             
                             
Emotional &                        
mental health
                             
                             
Managing                        
Risk
                             
                             
Physical                        
health
                             
                             
Race, culture                        
& identity
                             
                             
Education,                        
training &
employment
                             
Identified Plan By whom By when Time estimate
area of need/ (per week)
risk
                             
Finance                        
                             
                             
Daily routine,                        
recreation &
leisure
                             
                             
Presentation                        
& social
awareness
                             
                             
Interpersonal                        
skills
                             
                             
Relationships                        
& social
support
networks
                             
                             
Independent                        
living skills
                             
                             
Other                        
                             
                             
Total      

Note here the action to be taken in the event of an emergency or crisis.

(Repeat the information contained under this section from the Outline Support Plan in Part 3 section 20 and add other
relevant information).
     

Note here the overall approach and communication style that would best facilitate the service user’s engagement and
progress, noting anything that should not be done as it may irritate or aggravate the service user.
(Repeat the information contained under this section from the Outline Support Plan in Part 3 section 20 and add other
relevant information).
     
Record here any comments by the service user (inc. any areas of disagreement)
     

Service user signature

Date signed      

Date support plan Date authorised by Date sent to Care Co- Others sent to (state Date copy given to
completed project manager ordinator name and date sent) service user
                             

Date authorised by Care Co-ordinator

     

Record here any comments by the Care Co-ordinator

     

3. Key working and Reporting

Date of key work meeting Date report sent To whom Comments
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
4. Monitoring and Review
NB: The formal review of a service user’s case (see top of Part 4 for period within which a review is to take place) is to
include a full review of the information contained in the Initial and Core Assessments sections of this document. The
changes identified as part of a subsequent assessment are to be recorded in the assessment section in Part 3 whilst
the plan is to be recorded in the Core Support Plan section in Part 4.
Type of review Date By Comments Change of support Date changes to
plan required? plan made
CPA                              
Placement                              
Case audit                              
Supervision                              
Other                              
(Please specify)
Other                              
(Please specify)

Date document ceased      

Reason (Inc. details of move-on placement/ accommodation and service outcomes)

     

Authorised by