Care Home: Maison Moti

What the care home does well The home cares for a group of people of different ages, abilities, cultural backgrounds and with varying needs. The residents spoken to said they are very happy there and that they enjoy the home. They said that the staff are helpful and kind. The home is well kept, clean, tidy and comfortable. The home`s records are well organised. The staff team coped well in a period without a Registered Manager and outcomes for people living in the home have been well protected, partly because of the resilient and responsive management arrangements and because of the way the team worked together. The home is part of an organisation providing supported living; an organisation committed to service development and improvement in the mental health field. This is demonstrated by the way people using the service and staff are involved in the planning and delivery of the service and by the way in which resources are allocated. What has improved since the last inspection? Since the last inspection, the one requirement, to ensure that the Service User Guide is updated with details of management and staffing arrangements, has been met. Two good practice recommendations have also been actioned: information about the financial arrangements of residents is now better protected and thehome has commissioned training for staff on relationships, sexuality and sexual orientation. What the care home could do better: No requirements were made at this inspection. CARE HOME ADULTS 18-65 Maison Moti 200 Chase Side Southgate London N14 4PH Lead Inspector Margaret Flaws Unannounced Inspection 8 and 9th May 2008 10:30 th Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maison Moti Address 200 Chase Side Southgate London N14 4PH 020 8440 7535 020 8441 7378 oxana@maisonmoti.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Maison Moti Limited Donna Palmer (new manager applying for registration) Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (15), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One specific service user who is over 65 years of age and has mental health needs may be accommodated in the home. This condition will need to be removed at such times as the service user vacates the home. 28th September 2007 Date of last inspection Brief Description of the Service: Maison Moti is registered to provide accommodation and care for fifteen people under the age of sixty five (65) who have a mental disorder (mental health problems). A condition of registration has been approved for a service user who is over the age of 65 to remain at Maison Moti, as long as the home can meet her needs. The home is situated in Southgate, on a residential street, and blends in well with the other local houses. All the amenities of Southgate are short walk away and the home is well situated for bus and underground transport. Maison Moti Ltd operates this care home and 5 supported living projects for people with mental health problems. The organisation also provides floating support/outreach services. The fees are normally £600 to £1,000 for each placement per week, and service users are expected to pay separately for items such as hairdressing and clothes. Following Inspecting for Better Lives the provider must make information available about the service, including inspection reports, to service users and other stakeholders. Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use the service experience good quality outcomes. This key unannounced inspection took place over two days at the service in Southgate. The inspection comprised a tour of the building with two residents, interviews with staff and residents, and the inspection of care, staff and service management records. The new manager was on leave but the Service Manager assisted us on the first day and a covering manager helped on the second day. We made the second visit to inspect the staff records, as the key to the filing cabinet was not available on the first day. We also spoke to the Registered Person and later to the new manager by telephone. A good Annual Quality Assurance Assessment (AQAA) was sent to CSCI before this inspection. It gave specific examples of how the service is working to meet the National Minimum Standards. What the service does well: What has improved since the last inspection? Since the last inspection, the one requirement, to ensure that the Service User Guide is updated with details of management and staffing arrangements, has been met. Two good practice recommendations have also been actioned: information about the financial arrangements of residents is now better protected and the Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 6 home has commissioned training for staff on relationships, sexuality and sexual orientation. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents receive good information about the home before going to live there. Their needs are fully assessed prior to entering the home to ensure that the home is suitable for them. EVIDENCE: We reviewed the Service User Guide, which is clear and informative. Minor changes required at the last inspection have been made (mainly covering changes in management and staffing) as part of a wide ranging review of all documents and information available about the service. The Managing Director, Mr. Mostak Ahmed, who started in September 2007, described the scope of the organisational review. He said, “we are reviewing all processes affecting outcomes for people using the service, right from the initial assessment. We are making fundamental changes to improve the service.” The Service User Guide states that the home is “committed to providing a service that is unique, needs driven and uncompromising in terms of quality”. There is helpful information about the gender and cultural mix of people living in the home and explicit equality and diversity commitments. Maison Moti has Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 9 a useful website for potential residents and referrers. There is detailed information on the home made available before each new admission and trial visits are a standard part of the admission procedure. At the time of the inspection, there were fourteen people living at Maison Moti. Staff said that one person, who was in hospital would probably not be coming back to the home as they needed nursing care. Placements are funded by eight London boroughs. We reviewed the care files of two residents. There have been no new admissions since the last inspection. The files we looked at had comprehensive background about each prospective resident’s needs and detailed assessments undertaken by the home manager and by other professionals. Pre-admission planning meetings had been well documented, potential risks were thoroughly considered and prospective residents were involved in the assessment process. Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ care plans contain good information about their assessed and changing needs, resulting in good outcomes for them. Residents are well supported to make decisions about their own lives. They are enabled to safely take risks that improve their wellbeing. EVIDENCE: We inspected two files of people living in the home. These were well presented, well organised and easy to follow. Each person’s records included a range of professional assessments, including risk assessments and multidisciplinary reviews. Each person had a detailed personal plan, which set out his or her needs, abilities and goals. The risk assessments were sound and well thought out. They were specific to each individual’s mental health needs, life history, their preferred lifestyle and clear about their wellbeing and development. Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 11 The consultation and involvement of residents in developing and reviewing their personal plans and risk assessments was clearly documented. The Service Manager said that one to one sessions with key workers are part of this process. Daily reports were good. They were person centred and conveyed clear information. They were not repetitive and did not use blanket phrases (sometimes seen in other services). People we spoke to said that they felt involved in making decisions about their own lives. There was good evidence that supporting people with taking risks was part of the rehabilitative approach of the home. For example, the home has made good progress in improving outcomes for one person who initially presented some behavioural challenges to staff and other residents. Incident reports were very thorough and precise. Actions as a result of incidents were well linked into the risk assessment and care plan review process. Residents who have histories of addiction are supported with back-up from appropriate services. All people living in the home have their own bank accounts and are supported to manage their own finances. A recommendation from the previous inspection, to keep residents’ key financial information more securely, has been addressed and residents’ confidentiality in this area is now better protected. Staff spoken to were committed to the home’s rehabilitative philosophy and gave good examples of how they work with the residents. They had been trained in the Mental Health Capacity Act and had a good understanding of the Act. One person requires more frequent one to one support to reduce anxiety and the home has been able to accommodate this. A psychologist also provides coaching sessions. Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. 11,12, 13, 15,16, 17 This judgement has been made using available evidence including a visit to this service. People living in the home are supported with a range of personal development opportunities, activities and community involvement options to enhance their lives. Family involvement is encouraged by the home. Their rights and responsibilities are respected. Meals are reasonable but would benefit from a wide choice of culturally appropriate options. EVIDENCE: Individual goal setting and a commitment to residents’ personal development appears central to Maison Moti putting its rehabilitative philosophy into practice. The organisation also runs supported living accommodation and one resident was due to move into this more independent setting in the near future. Another resident has started study at college, which the Service Manager said was a significant achievement for him. One other resident is studying jazz and performs regularly. Other residents do voluntary work. Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 13 There was good evidence of people getting out and about in the local community. During the inspection, residents were observed coming and going, either on their own or accompanied, to and from the local shops, from college and from other activities. One new in house activity is Tai Chi, which everyone said they enjoyed. Other activities include games, music sessions, watching films together, going to the theatre, the cinema and the pub, as well as outings and holidays to the beach. Staff said that while they were without a permanent manager, there had been less time to accompany people out and about. They also said that some residents need considerable prompting to participate in activities and that this regular prompting and developing new ideas with residents was a big part of their job. A recommendation made at the last inspection, that staff receive formal training in supporting residents with their relationships and in supporting people around their sexual orientation, is being followed up. After seeking and failing to find an appropriate or useful course, the service has commissioned its training partner, Pathways, to design a course for them. The proposed course content is sound. Family support arrangements were documented individual files and it was clear that family involvement was encouraged. One resident was away with his family during the inspection. Staff were observed respectfully interacting with the residents, knocking on their bedroom doors before entering and having careful negotiations about household matters, such as smoking in inappropriate areas indoors. Residents participate in the daily running of the home and undertake housekeeping tasks. The home employs a cook. She showed us around the kitchen, which was in very good order. The home has recently installed a new cooker. There were two menu choices at lunch, including a vegetarian option. Menus indicated that choices are available each day. People spoken to said that they could choose what they liked to eat. There were regular documented discussions about the food at the residents’ meetings. In one recent discussion, more culturally appropriate food was requested and the service is beginning to address this. The Service Manager said that the home consults a dietician as needed and has a nutritionalist who provides support. Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home receive personal support in the way they prefer and their dignity is protected. The health needs of people living in the home are considered and well met by the home and other professionals. People living in the home are well protected by the medication policy and procedures. EVIDENCE: The Maison Moti group Clinical Manager, who was appointed around the time of the last inspection, has now left and the position (now Clinical Supervisor) has been readvertised. The Service Manager said that, in the short time the clinical role operated, it proved valuable for one to one support for the residents and the staff. She said that they hoped to fill the position as soon as possible. Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 15 We spoke to three people using the service, all of whom were positive about the support staff gave them. They commented that the staff helped them gain and maintain independence and that staff were attentive to their physical and mental health needs. Three people are supported with personal care and one resident said that the staff were sensitive and kind. There is a prominent noticeboard in the office showing peoples’ healthcare appointments. These appointments were systematically planned and detailed in care plans and files. Staff said that the home liaises closely with the local community mental health team but said there had been some problems with service continuity for the residents since the community team was restructured. Three people go to the Community Mental Health Service offices to receive regular medication by injection. We inspected the medication storage, administration and recording arrangements. These were in good order. The covering manager described how the service holds one week’s supply of medication on site. The pharmacist, who visits the home weekly, makes up the medication into dossett boxes. The medication was appropriately stored in a quiet, light medication room on the first floor of the building. The room is temperature controlled and well ventilated. No one was taking controlled drugs at the time of the inspection. The Medication Administration Records were clearly completed and no gaps or omissions were identified. One person is diabetic and staff said that a recent seminar for staff and residents on the management of diabetes received a good response. There is a good system in place to support one person who self medicates. This includes a regular spot check on compliance with medication undertaken with this person’s permission. A medication risk assessment was in place. Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home are protected by robust complaints and safeguarding adults policies and procedures. EVIDENCE: The complaints procedure is clear and is readily available for the residents. It is displayed in the entrance hall, along with complaints forms for people to fill in. Two minor complaints were recorded and addressed. The residents we spoke to said that they liked living in the home and that they felt safe there. They were clear about what to do if they had a complaint or concern, or if they didn’t feel safe. There are ongoing day to day opportunities for residents to express their opinions and views and this was observed throughout the inspection. There are formal means of expressing concerns, such as regular residents’ meetings, which were well documented with actions for follow-up in place. No safeguarding (adult protection) concerns been raised about or by the home. Part of this inspection involved asking additional questions about safeguarding adults as part of a CSCI survey. Staff spoken to were clear about their responsibility to report concerns and about the process that they would follow if they suspected abuse or were told of an allegation. The home obtained a more up to date version of the local authority’s safeguarding adults policy and procedure during the inspection. Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 17 The Service Manager described how the home adopted a resident’s suggestion for an ‘alerter’s postcard’. These postcards, kept in the entrance area with the complaints forms, are stamped and addressed: the resident only has to fill in their name and contact details to say that they wanted to speak to someone about a concern. Residents spoken to thought it was a very good idea and made them feel safe and confident about reporting concerns. Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is a comfortable, pleasant, clean and well maintained environment for the residents to live in. EVIDENCE: We toured the building with two residents and spoke briefly to one other resident. The building is well set up and resourced. Residents who were at home during the inspection either spent time in the lounge, garden or in their rooms. They were watched television, chatted, played music or read in their rooms. The lounge has a large TV, musical equipment and a computer. The furniture and furnishings are of a good standard. Cable TV is available to people living in the home and three people have this option in their rooms. Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 19 There is a smoking room adjoining the lounge. However, staff explained that after 1 July 2008, when legislation takes full effect, all smoking must be outside. The Service Manager said that a covered space will be created. Six bedrooms are ensuite. There are three additional toilets and two bathrooms. There is a well-equipped utility/laundry room and people generally do their own washing. One resident said that the laundry arrangements work well. Health and safety is generally systematically addressed. Kitchen temperatures are monitored daily and recorded and the dryer filter regularly defluffed. Monthly health and safety inspections are documented. Infection control procedures in the home were good, with clear signage, hand washing facilities, gloves and industrial washing machine available. The home was clean and well maintained on the day of the inspection. Both the cleaner and the Maison Moti group maintenance person were working there at the time. Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home are well protected by the recruitment policies and procedures. Staff are well trained and supported to meet the needs of the people living in the home. EVIDENCE: On the first day of the inspection, the service did not have a key available for the staff records filing cabinet. We completed an additional visit to view these records the following day, when a covering manager assisted. The staffing rota accurately reflected the staffing levels in the home on the inspection days. Staff and residents said that there was sufficient staff on duty to meet the needs of the people living in the home: two staff on duty during the day, during evening hours and overnight. Care staff were supported by a cleaner staff, one cook and a manager, who normally works Monday-Friday. The Service Manager and staff explained a change in the staffing structure: instead of having a Deputy Manager position, staff will apply for and rotate in Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 21 the role of senior care worker. This received a positive response from staff, who said it was an opportunity for their skills to be recognised and developed. This approach appears to be in line with the organisation’s policy of internally recruiting, where possible. Staff spoken to were positive about the workplace culture and said that, despite a period without a permanent manager over the past few months, they felt that disruption had been minimized. The response to a recent team-building day with the new manager was positive. Staff meeting minutes indicated that staff are involved in service planning and that frank discussions are followed up with actions by named persons. The Service Manager said that staffing vacancies were almost filled after a period of staff turnover. New staff are recruited from a variety of backgrounds which contribute to their understanding of the residents’ needs, for example, from nursing and psychology. One resident is involved in the recruitment interviews, following training by the organisation. She said she felt that she knew what to look for in a potential staff member and that she felt valued by Maison Moti as part of the recruitment team. We inspected three staff files. Pre-employment checks had been properly carried out, with appropriate identification, reference and Criminal Records Bureau checks. The staff induction and refresher training covers the Skills for Care programme and core topics. The organisation’s Workforce Development Training Plan (July 2007) takes a strategic approach to the funding and provision of training to staff, identifies training needs and outlines the priorities for the 2008/09 year. There is a wellplanned, rolling staff training programme in place. The staff files contained good evidence of training, including certificates. Courses are provided in mental health awareness, support planning/needs assessment, cultural awareness, nutrition awareness, effective communication, managing risk, promoting independence, health and safety, manual handling, food hygiene, medication, first aid, risk assessment, protection of vulnerable adults (safeguarding), Mental Capacity Act, managing challenging behaviour, infection control, disability awareness. Staff have attended a two day equality and diversity training programme and, when spoken to, had a good understanding of these issues. Managers are trained at higher level in health and safety; in quality assurance and as trainers. Three staff have NVQ qualifications or one is working towards NVQ2. During the inspection, this staff member met with an NVQ assessor to put together his portfolio for NVQ2. Staff supervision records were thorough, with clear issues raised and actions to be addressed. According to staff, supervision is generally held monthly. Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home benefit from sound management and organisational practices in which their needs are central. People living in the home are regularly consulted for their opinions, which are taken seriously. Their health and safety is well protected. EVIDENCE: According to the Maison Moti Managing Director and the Service Manager, the home is now in a process of management consolidation. In the period before and immediately after the last inspection, the home was without a permanent manager. Temporary cover was put in place and an appointment to the manager’s post was made late last year but the candidate did not take up the post. It was then readvertised and a new manager appointed recently. Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 23 The new manager, Donna Palmer, has several years management experience in mental health; holds a Registered Manager’s Award and an NVQ4 in Care and has been a Registered Manager. She has obtained registration documents and is commencing her application. Staff spoken to said that they felt valued by the new manager and were optimistic about service improvement and stability in the future. Good senior management support is provided by the Service Manager, who is very knowledgeable about the needs of the people living in the home. There are good on-call management arrangements, with a clear on-call duty rota in the office. Quality assurance processes are good. There are weekly policy and procedure reviews, with the opportunity for people living in the home and staff to feed into. A survey of people living in the home and others involved in their care and support is undertaken annually. We reviewed the fire records. The London Fire Authority made a positive inspection in August 2007. The home has a fire safety risk assessment. Fire drills are undertaken three monthly. Fire testing was infrequent. We checked this with the Service Manager, who said that the home been advised that alarms and smoke detectors only need to be tested every three months. When we expressed concerns about this, the home immediately took further advice and has now initiated weekly testing. From July 2008, any residents who smoke will be required to do so in a covered area outside. Maintenance records checked were in good order. The home has up to date health and safety certificates. Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 3Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 x Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Maison Moti DS0000010639.V363489.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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