AS Valga Haigla audit report Brüsselisse

EQUASS ASSURANCE AUDIT REPORT 05.12.2016-0612.2016 Valga Haigla welfare department Tiina Unukainen © 2012 by European Quality for Social Services (EQUASS) All rights reserved. No part of this document may be reproduced in any form or by any means, electronic, mechanical, photocopying and recording or otherwise without the prior written permission of the EQUASS. 2  1. Information of the social service provider Name of the Valga Haigla w elfare department social servi ce provider Address: Valga Haigla AS Peetri 2, Valga 68206 Person Monika Horn responsible (CEO): Contact Monika Horn person: Phone: 766 5270 E-mail: [email protected] [email protected] Web site: http://www.valgahai gla.ee/haigl a/osakonnad/hoolekanne/ Name of Tii na Unukainen Auditor: Dates of 05.12-06.12.2016 audit: Clients: Number of person served: 110 As of (date): 06.12.2016 Staff: Number of Full time staff: 39 Number of Part time staff: 3 3 Services: Care home servi ce for elder l y Round the clock special care for persons w ith multiple disabilit y 4  2. Audit program Date Day 1 ( R ound th e c lo ck spe c ia l c ar e fo r p er so ns w ith 05.12.2016 mult ipl e di s abi li t y) Time Acti vit y 9:00-9.15 Opening meeting 9.15-12.15 Documentation review 12.15-12.45 Lunch 12.45-14.30 Interview with f inancing body 14.30-15.15 Interview with the st aff 15.15-16.00 Site visit (also meeting the clients) 16.00-16.45 Interview with the parents 16.45-17.15 Documentation review, conclusions Dat e Da y 2 ( C a re ho me se r v ic e fo r e ld er l y) T ime Ac t iv ) it y 08 : 30- 1 0 .0 0 Documentation review 10 . 00- 1 1. 0 0 Interview with the st aff 11 . 00- 1 1. 4 5 Interview with the clients 11 . 45- 1 2. 3 0 Interview with the Valga Cit y administrat ion off icer 12 . 30- 1 3. 0 0 Lunch 13 . 00- 1 3. 4 5 Interview with the cooperat ion partners 13 . 45- 1 4. 4 5 Interview with the clients`s cousins 14 . 45- 1 5. 4 5 Interview with the m anagement 15 . 45- 1 6. 1 5 Closing remarks 5 16 . 30- 1 7: 0 0 Closing meeting Detailed feedback on performance 1. The social ser vice provider def ines documents and implements its vision and mission values on ser vice provision. Remark from the auditor: The ser vices of th e social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Str e n gt hs Im pro vem e nt & de v e lo pm ents 6 The social ser vice provider has The Valga Haigla developmental plan def ined its vision, mission and has not conf irmed. Af ter the values in a Valga Haigla conf irming process it is important to development plan. publish the vision, mission and values on the walls and webpages. The main values in Valga Haigla are reliabilit y, prof essionalism, The Valga Haigla welf are department responsibilit y, client/pat ient could consider to manage regular orientation. workgroups to talk about how the vision, mission and values are The employees of Valga Haigla implemented in a every day lif e. demonstrated through inter views that they included to t he Valga Haigla Previous proposals will help the st aff mission, vision and values def ine to understand importance of the process. For example they explained vision, mission an d values. that in the meet ings they discussed about Valga Haigla vision, mission Valga Haigla arengukava ei ole veel and values. kinnitatud. Peale arengukava kinnitam ist on oluline avaldada mission, vision ja väärtused ka Valga Haigla kodulehel ning stendidel. Valga Haigla hoolekandeosakond võiks korraldada regulaarseid töörühmi personal ile arut amaks missiooni, visiooni ja väärtuste rakendumist igapäevaelus. Eelnevate ettepankute rakendam ine aitab personalil paremini mõista missiooni, visiooni ja väärtuste olulisust. 7  2. The social ser vice provider def ines, documents, and implements its qualit y policy by determining long term qualit y goals, and its commitment to cont inuous improvement. Rem ark f rom th e au d it or : The services of the social ser vice providers meet this criter ia of the EQUASS Assurance certif ication program Str e n gt hs Im pro vem e nt & de v e lo pm ents Valga Haigla has def ined its qualit y The Valga Haigla qualit y strategy is strategy in a Valga Haigla mainly based on provision of medical development plan. ser vices. We have aging societ y so the client oriented social ser vic es The main goal ( which aff ects direct ly will become mo re important in the Valga Haigla welf are department) is f uture. Valga Haigla could consider to ensure qualit y of the medical, to pay more attent ion to the social nursing and social services. ser vices. For example to specif y developments in social ser vices in The employees of Valga Haigla qualit y strateg y. demonstrated through inter views that they included to the qualit y strateg y Valga Haigla kvaliteedistrateegia process. keskendub peamiselt tervish oiuteenuste pakkumisele. Meil on vananev ühiskond, mis tähendab, et kliendikesksed sotsiaalteenused muutuvad aina olulisemat eks. Tuginedes eelnevale võiks Valga Haigla täpsustada näiteks kvaliteedistrateegia s sotsiaalteenuste arengut. 8  3. Persons ser v ed, family members and ser vice user organisations are able to give f eedback on their individual and collective experience of programmes and ser vices. Rem ark f rom th e au d it or : The services of the social ser vice providers meet this criter ia of the EQUASS Assurance certif ication program Str e n gt hs Im pro vem e nt & de v e lo pm ents Valga Haigla has developed diff erent The ser vice provider could f ormulate methods to ask and receive f eedback the f eedback syst em in a staff f rom persons ser ved and staff . handbook. The system helps to collect the f eedback regular y. On the webpage is a link to give the f eedback. Teenuse osut aja võiks dokument eerida tagasisidesüste emi. The ser vice provider also organizes Süsteem loob eeldused selleks, et satisf action questionnaires f or staff , tagasisidet kogutaks regulaarselt ja clients and stakeholders. läbimõeldult. The service provider could organize information days to the cooperation partners once a year. It helps to collect the feedback and also plan the next year activities. Teenuse osutaja võiks organiseerida nö teabepäeva tagasiside küsimiseks ja uue aasta tegevuste planeerimiseks koostööpartneritele. 9  4. T h e s oc i a l s er v ic e pr o v i d er inf o rm s al l s tak e ho l de rs a b ou t t h e of f er ed pro gr am m es a n d s er v i c es a v ai l a bl e . Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The service provider has published the ser vices descr ipt ions on the webpage and on the wall. The service provider has also document ed the ser vices descr iptions in a staff handbook. The detail ed inf ormation about the organizat ion is also published on the webpage. Through the meetings the staff is involved to the services provision process. The process is descr ibed in a staff handbook. During the inter views was conf irmed that the stakeholders are awar e of the ser vice provision. 10  5. T he s oc i a l s er v ic e pr o v i der m an ag em en t es t a bl is h es a nd d oc um ents an an n ua l p l a nn i n g an d r e v ie w pr oc es s . Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The ser vice pr ovider has f ormulated a document “ Quidance on the preparat ion of the annual plan ”. Based on that document the annual plan is prepared. T here is regulated who are included to the planning process, what kind of inf ormation is used to prepar e the annual plan and who is the main supervisor. 11  6. T he p l a n i nc lu d es :  an n ua l o u tc om es / tar ge ts  th e ac ti v i t ies t o b e u n der t ak en i n ac h ie v i n g th e a nn u a l tar g ets  m onit or i ng of th e p er f orm anc e of t he o rg a n is a t io n i n m eet i ng it s an n ua l t ar ge ts  tim e- s c al es a n d pr oc e dur es f or r e v i e w a n d r e v is i o n. Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents 12 Valga Haigla social welf are The annual is now reviewed once a department has documented the year. The Valga Haigla social welf are annual plan f or the year 2016. department could r eview the annual plan at least t wice a year. It helps to The plan includes: change the activit ies when it is needed. 1)schedule; Valga Haigla hoolekande osakonna 2)main goals; aastaplaani vaadat akse hetkel üle 3)activit ies; kord aastas. Teenuse osutaja võiks kaaluda süsteemi muutmist. 4)planned results; Aastaplaani võiks üle vaadata vähemalt kaks kor da aastas - see 5)real results; aitab vajadusel tegevusi muuta, kui 6) super visors selgub, et eesmärgid ei ole saavutat avad vms . The activities are planned based on strategic goals which are 1. the staff is working based on annual plan; 2. qualit y of the ser vices; 3. the staff is trained and motivated; 4. the documentation is based on based on regulations; 5. the social welf are department is working based on budget. The annual plan is approved by the management. 13  7. T h e s oc i a l s er v ic e p r o v i der d em ons tr at es org a n is a t io n ’s s uc c es s i n s at is f yi n g th e n e eds a nd ex p ec t a ti o ns of t h e s oc i et y. Rem ark f rom th e au d it or : Th e s erv ic es of t he s o c i al s er v ic e pr ov i ders me e t th is c r it er ia of t h e EQ U A S S As s ura nc e c er ti f ic a t io n pr ogr a m Str e n gt hs Im pro vem e nt & de v e lo pm ents Valga Haigla is a member of competence center “ Hõbem ajandus ”. The centre was f ounded in september 2016. The main purpose of the centre is to develope the service provision processes, inf ormati on technolog y and environment al solutions f or the social ser vices. 14  8. T h e s oc i al s er v ic e pr o v i d er dem o ns tr at es or ga n is at i on ’s s oc i a l res p o ns ib i l it y thr o ug h ac t i vi t ies c on t r i bu t in g t o th e s oc i et y. Rem ark f rom th e au d it or : Th e s erv ic es of t he s o c i al s er v ic e pr ov i ders me e t th is c r it er ia of t h e EQ U A S S As s ura nc e c er ti f ic a t io n pr ogr a m Str e n gt hs Im pro vem e nt & de v e lo pm ents Valga Haigla social welf are department cooperates while providing the services wit h other organizat ions . For example local school and kindergarten are perf orming to the clients (especially when it is christmas t ime). There are also str ong cooper ation with the church. Valga Haigla social welf are department is also training base f or social work students etc. 15  9. T h e s oc i a l s er v ic e pr o v i d er h as a s t af f rec r ui tm ent a nd r e te n ti o n p o l ic y th at pr om otes t he s e lec t io n of q ua l if i e d pe rs o n ne l b as e d o n r eq u ir ed k no wle d ge , s k i l ls a n d c om pet e nc es . Rem ark f rom th e au d it or : Th e s erv ic es of t he s o c i al s er v ic e pr ov i ders me e t th is c r it er ia of t h e EQ U A S S As s ura nc e c er ti f ic a t io n pr ogr a m Str e n gt hs Im pro vem e nt & de v e lo pm ents Valga Haigla has documented its staff recruitment and retention policy The service provider has also document ed a procedure f or the new specialist ( while starting working in Valga Haigla) and t he procedure f or the specialist who is leaving the job in Valga Haigla. In a job descriptions are def ined the staff skills, knowledge and compentence. 16  10 . T h e s oc i al s e r vi c e pr o vi d er o per a tes i n c om pl i a nc e wi th m anda t or y na t io n a l le g is l at i on , pr o v id i ng a p pr opr i at e w ork in g c o nd i t io ns , a d e qu a te a n d agr e e d s t af f le v el a n d s t af f rat io , a n d a p p rop ri a te r e war d in g f or s taf f an d v o lu nt e er s . Rem ark f rom th e au d it or : Th e s erv ic es of t he s o c i al s er v ic e pr ov i ders me e t th is c r it er ia of t h e EQ U A S S As s ura nc e c er ti f ic a t io n pr ogr a m Str e n gt hs Im pro vem e nt & de v e lo pm ents The working condit ions are evaluated and necessar y action plans ar e drawn up and amendments are made. Valga Haig la has documented “ The staff recognit ion pr ocedur e ”. In that document are def ined mechanisms rewarding the staff . The staff was aware of the document. 17  11. The social ser vice trains all staff based on a plan f or leaning and development and evaluates the eff ectiveness of the training. Rem ark f rom th e au d it or : Th e s erv ic es of t he s o c i al s er v ic e pr ov i ders me e t th is c r it er ia of t h e EQ U A S S As s ura nc e c er ti f ic a t io n pr ogr a m Str e n gt hs Im pro vem e nt & de v e lo pm ents The social ser vice provider has def ined the docum ent “Organi zing the trainings in Valga Haigla ”. In that document is an overview how the trainings are organized in Valga Haigla. Ever y department has also own training plan. The social welf are department ha s def ined training plan in an annual plan . Af ter the training t he staff have to evaluate the training eff ecti veness. 18  12 . T he s oc ia l s er vic e pr o v i de r a pp l i es re q u ir em ents f or c om pet e n c e i n t h e i de nt if ie d r o l es a nd f u nc t i ons of s t af f a nd e v a lu at es t hem o n a n nu a l b as is . Rem ark f rom th e au d it or : Th e s erv ic es of t he s o c i al s er v ic e pr ov i ders me e t th is c r it er ia of t h e EQ U A S S As s ura nc e c er ti f ic a t io n pr ogr a m Str e n gt hs Im pro vem e nt & de v e lo pm ents The competence r equirements f or employees are described in their job descr iptions (prof iles). Valga Haigla has def ined the document “The quide of the developmental int er views”. During the developmental inter views the staff competence has been evaluated. Valga Haigla social welf are department staff is also wr it ing down ever y day activit ies in a department diar y. 19  13 . T he s oc i a l s er v ic e pr o v id er r ec o g n is e s th e s taf f as a r es ourc e f or f ee db ac k on or ga n is at i on a l perf orm anc e , s er v ic e d e ve l o pm ent an d s taf f de v e l opm en t Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The involvem ent of staff in the planning and evaluation of services is descr ibed in var ious procedures of Valga Haigla (staff policy, st aff handbook). Valga Haigla also organizes regular f eedback questionna ires to staff . There are also regular department meetings and the staff has to change to give f eedback. During the individual planning the staff has also change to give the f eedback. Based on staff f eedback etc the ser vice pro vider f ormulates the training plan f or the staff . The training plan is included to the annual plan. 20  14. The social ser vice provider has mechanisms in place to enhance satisf action and mot ivat ion of staff Rem ark f rom th e au d it or : Th e s erv ic es of t he s o c i al s er v ic e pr ov i ders me e t th is c r it er ia of t h e EQ U A S S As s ura nc e c er ti f ic a t io n pr ogr a m Str e n gt hs Im pro vem e nt & de v e lo pm ents Valga Haigla also organizes regular feedback questionnaires to staff. During the interviews the staff approved that they have change to give the feedback to the service provider. Valga Haigla has formulated the staff motivation policy. During the interviews the staff approved that the service provider organizes events etc to motivate them (for example christma s party, spring party). 21  15 . T h e s oc i a l s e r vi c e p ro v i de r as s ur es th e r i gh ts of p ers o ns s e r ve d ou t l in e d in a Ch ar ter of R ig h ts wh ic h is bas e d on t he E U C har t er of Fu nd am en ta l Ri g hts , t he E ur op e an C on v e nt i on f o r t he Pr ot ec t io n of Hum an Ri g hts a n d Fu n dam e nt a l Fre e dom s of the Cou nc i l of E uro p e an d o th er i nt er n a ti o n al h um an r i gh ts c on v e nt i ons , es p ec ia l l y t h os e e l ab or at ed u nd er th e U ni t ed N at i o ns . Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents 22 The ser vice pr ovider has def ined t he The service provider could organize rights and duties of persons ser ved regular f or example regular work in a “Code of ethics” and in a groups f or the staff about clients document called “ Home rules”. The rights and duties based on ever y day “Home rules” are also on t he wall of situat ions. It helps the staff to the Valga Haigla. understand the based on ethics in ever y day sit uation. Those working The procedure “ Code of ethics ” is groups help the staff to understand part of the “Staff handbook”. the real meaning of rights and duties of persons ser ved. The staff was aware of the “ Staff handbook”. Teenuse osustaja võiks regulaarselt organiseerida töörühmasid personalile klientide õigustest ja kohustustest. See aitab personalil mõista klientide õiguste ja kohustuste tähendust igapäevast es situatsioonides. The service provider should update the “Home rules”. For example ther e is a sentence- the long term departure ( over 24 hours) are permitted with the approval of social worker. It could be more client centered- f or example when the client (support person w ishes) wishes to leave over 24 hours then please to notif y the social worker. The clients ar e not there based on court order. Teenuse osutaja võiks üle vaadata kehtiva kodukorra. Kodukorras on näiteks järgnev lause - Pikaajaline lahkumine (üle 24h) on lubatud kooskõlastatult osakonna sotsiaaltöötajaga. Selle kokkuleppe võis sõnastada järgnevalt: kui klient (kliendi tugiisik) 23  16 . T h e s oc i a l s er v ic e pr o v i d er inf orm s th e pers o n s er ve d a bo ut h is / h er ri gh ts a nd d ut i es es pe c i al l y t o eq u a l tre atm e nt o n gr ou n ds of a g e, d is a b i li t y, ge n de r , r ac e , r e l ig i o n or be l i ef an d s ex u al or ie nt a ti o n b ef or e rec e i vi n g t he s er v ic es . Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am 24  Str e n gt hs Im pro vem e nt & de v e lo pm ents The ser vice pr ovider has def ined t he Some of the clients are multiple rights and duties of persons ser ved disabled and need alternat ive in a “Code of ethics” and in a communication. The service provider document called “ Home rules”). The could organize to staff trainings “Home rules” are also on t he wall of about alter native communication. It the Valga Haigla. helps to reduce the client`s behavioural problem s. The clients demonstrated their knowledge of the rights and duties Mõned kliendid on liitpuudega ja through the inter views. vajavad alternatiivset kommunikatsiooni. Teenuse osutaja võiks personali organiseerida vastavasisulisi koolitusi. Alternatiivse kommunikatsiooni kasutam ine aitab vähendada klient ide käitum ispr obleeme . 17 . T he s oc i a l s er v i c e pr o v id er h as ac c es s ib l e c om pl a i nt m ana g em ent s ys tem wh ic h r e gis t e r s f ee d bac k o n perf orm anc e f rom pers o n s s er v ed , purc h as er s an d o th er r e le v a nt s t ak eh o ld ers . Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents 25 The social ser vice provider has def ined procedure f or handling complaints. The procedure regulates who is the supervisor of the complaints and how the com plaints are proceeded. The ser vice provider encodes the complaints based on contents of the complaint. There is also an opportunit y to give f eedback using the homepage link. 18 . T h e s oc i a l s er v ic e pr o vi d er res p ec ts t he f u nd am en ta l r ig h t t o s e lf - de t er m in at i on of t h e per s o n s er ve d . T he y f ree l y de te rm ine t he ir po l i t ic a l s ta tus an d f r ee l y p ur s ue t h e ir ec on om ic , s oc i al an d c u lt ur a l d e ve l o pm ent . Rem ark f rom th e au d it or : <T h e s er v ic es of t he s oc ia l s er v ic e pr o v id ers m eet t h is c r i ter i a of t he EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am > 26  Str e n gt hs Im pro vem e nt & de v e lo pm ents Valga Haigla social welf are The service provider could develop department prepares to the client s the procedure f or prepar ing the individual act ion plan or individual clients/relat ives et c individual plans. nursing plan (based on clients At moment the service provider needs). involves the clients/relat ives etc to the individual planning process Most of the individual plans ar e rather f ormally (though that process signed by the client or relat ives. respects the f undamental r ight to self determination). The def ined Most of the elder ly service clients procedure helps to involve the conf irmed that the staff ask their clients to the individual planning opinion about the service activities. more systematically. Teenuse osutaja võiks välja töötada protseduuri individuaalsete plaanide koostam iseks. Hetkel on kliendid/klientide lähedased sellesse protsessi kaasatud pigem formaalselt. Selgelt määratletud protseduur aitab kaasa süst eemsele lähenem isele inidividuaalsete plaanide koostam isel ning see läbi aitab kaasa ka klientide enesemääramisele. 19 . T he s oc i a l s er v ic e pr o v i der f ac i l i ta t es th e pers o n s er v e d in c ho os i ng an d h a v in g ac c es s t o ad v oc at es a nd / or s u pp ort i ng pers o ns . Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am 27  Str e n gt hs Im pro vem e nt & de v e lo pm ents W hen the client needs ad vocates and/or supporting per son the ser vice provider helps thr ough individual planning. There are also meetings protocols showing how the ser vice provider helps to f ind supporting person to the client. 20 . T h e s oc ia l s er v ic e pr o v i d er def in es a n d doc um en ts its p o l ic y o n et h ic s th at r es p ec ts a nd as s ur es th e d i gn i t y of th e p ers o ns s er v e d, pro tec ts th em f rom un du e r is k an d pr om otes s oc i a l j us t ic e 28 Rem ark f rom th e au d it or : The services of the social ser vice providers meet this criter ia of the EQUASS Assurance certif ication program Str e n gt hs Im pro vem e nt & de v e lo pm ents The ser vice pr ovider has def ined t he The document called “The staff rights and duties of persons ser ved handbook” is new. So it is ver y in a “Code of ethics ”. The ethical important that the social ser vice aspects were part of the “The staff provider syst ematically introduces to handbook”. the staff the handbook. During the inter views I f ound out that Dokument “Töötajat e käsiraamat ” on the staff was aware of the handbook. suhteliselt uus ja seetõttu on oluline , et teenuse osuataja seda töötajatele regulaarselt tutvust aks. 21 . T he s oc ia l s e r vic e pr o v id er op er at es m ec han is m s wh ic h pr e ve n t th e ph ys ic a l, m ent a l a nd f i na nc i al ab us e of u s ers . Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am 29  Str e n gt hs Im pro vem e nt & de v e lo pm ents The social ser vice provider has def ined a document called “ Code of ethics” ( which includes mechanisms how to prevent clients physical and f inancial mechanism s prevent ing the clients abuse). During the inter views I f ound out that the staff is aware of the document. Valga Haigla social welf are department has def ined the document called “ The procedure of using the bank cards”. The staff was aware of the document. 22 . T he s oc i a l s er v i c e pr o v id er pr o v i des s erv ic es i n a s af e s ys tem of work i n g wit h in a s af e e n v iro nm en t t o e n s ure th e ph ys ic a l s e c ur it y of pers o ns s er v ed , t he ir f am il i es a nd c ar e tak ers . 30 Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The working condit ions are evaluated (risk assessments are carried out b y prof essional outside experts ) and necessar y act ion plans are drawn up and amendments are made. Valga Haigla also organizes internal trainings about saf e envir onment to the staff . 23 . T h e s oc i a l s er v ic e pr o vi d er d ef i nes , doc um ents , m on it ors a nd e va l u at es a s e t of pr inc i p les , v a l ues a nd pr oc e d ur es t ha t go v er n b e ha v i o ur i n s er v ic e de l i v er y c o nt a in i n g as p ec ts of c o nf i d en ti a l it y, ac c u rac y, pr i v ac y an d i nt egr i t y. 31 Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The social ser vice provider has Valga Haigla social welf are def ined a document called “ Code of department could organize regular ethics” ( which includes mechanisms work groups to the staff based on how to prevent clients physical and “Code of ethics ” using the real f inancial mechanism s prevent ing the unethical situat ions . It helps the staff clients abuse). to understand the “ Code of ethics ” in real lif e. During the inter views I f ound out that the staff is aware of the document. Valga Haigla võiks korraldada töörühmi eetikakoodeksi rakendamiseks (näiteks kasutades ebaeetilisi juht umeid analüüsiks tuginedes eet ikakoodeksile. 24 . T h e s oc i a l s er v ic e pr o vi d er d ef i nes , doc um ents , m on it ors a nd e va l u at es proc e d ur es f or as s ur i n g c o nf i d en t ia l it y of d at a re g ard i n g t he pe rs o ns s er v e d an d t he s er v ic e pr o v i d ed t o t hem . 32 Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The procedures f or assuring conf ident ialit y of data have been def ined and documented. The procedur es ar e evaluated at meetings. 33  25 . T h e s oc ia l s er v i c e pr o v i d er def in es th e r o les a n d r es po ns ib i l it i es , au t hor i ti es a nd t he i nt er r e la t io n of a l l p ers o n n el wh o m a na g e, d es ig n, de l i v er , s up p or t a n d e v a lu at e t he s er v ic e pr o v is i o n to pers o n s er v ed . Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The roles and responsibilit ies ar e def ined in job descr ipt ions and work contracts. General r oles responsibilit ies ar e def ined also on hom epage. The service provider has def ined also general client work f unctions on the homepage. 34  26 . T h e s oc i a l s er v ic e pr o vi d er work s i n p art ners h i p wi th o th er or g an is at i o ns i n th e pr o v is io n of s er v ic es . Rem ark f rom th e au d it or : The services of the social ser vice providers meet this criter ia of the EQUASS Assurance certif ication program Str e n gt hs Im pro vem e nt & de v e lo pm ents The partnership wit h other organisat ions is very developed in Valga Haigla social welf are department. There is strong cooperat ion with local special school. There are regular Chr istmas events etc. The local elderly org anisation also is visiting Valga Haigla social welf are department. There is also regular communication bet ween the Valga Haigla and f inancial body. Valga Haigla is a member of competence center “ Hõbemajandus ”. Together with other organisat ions are planned the ser vices developments. 35  27 . T h e s oc i a l s er vic e p r o v i de r work s i n p art n ers h i p wi t h p ers o ns s e r ve d, purc h as er s an d o th er s tak e ho l de rs i n th e d e v e lo pm en t of s er v ic es . Rem ark f rom th e au d it or : The services of the social ser vice providers meet this criter ia of the EQUASS Assurance certif ication program Str e n gt hs Im pro vem e nt & de v e lo pm ents The social ser vice provider involves The service provider could involve the clients and their relat ives to the more the f inancial body to the ser vice provision through individual ser vice provision –f or example planning process. organizing the inf ormation days or so on. It helps to develop the ser vice. There is also regular communication bet ween the ser vice provider and Teenuse osut aja võiks r ohkem f inancial body. kaasata r ahast ajat teenuse arendam isse. Näiteks korraldades nn teabepäevi ja selle r aames uuriks ka väljaspool igapäevast suht lust rahastaja soove teenuse arendam iseks. 36  28 . The s oc i a l s er v ic e p ro v i de r inc l ud e s p ers o ns s er v ed as ac t i v e par t ic ip a nts in p la n n in g a nd h a ve s et u p ap pra is a l m ade up of on - go i n g of an o n- go i ng s tr uc t ur e d d i a lo g u e pr oc es s in th e m an ag em en t of t h e s er v ic e , i nc l u d in g th e d ef i ni t io n of th e n ee ds , t h e d ef i n it i on of t h e s er vic es , as we l l as of t h e e v al u at i on of q u al i t y. Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The service provider prepares the The service provider could change individual plans to the clients. The the individual plan form and organize clients/relat ives/support persons are the meetings to prepar ing the included to the pr ocess. individual plan . There could be an opportunit y to show the The individual plan is evaluat ed at clients/relat ives wishes. It will help least once a year. to include the clients to the process. Teenuse osutaja võiks muut a indidviduaalse tegevusplaani vormi ja organiseer ida nö koosolekuid tegevusplaani koostam iseks (kaasatud võiksid olla ka klient ide lähedased ja teised olulised isikud). See aitab kaasata kliente teenuse osutamise protsessi. 37  29 . T he s oc i al s er v ic e pr o v id er i ns t it u tes an a nn u a l e v a l ua t io n of par t ic ip a ti o n of per s o n s s er v e d bo t h o n i nd i v i du a l a nd / or gr ou p b as i s . Rem ark f rom th e au d it or : The services of the social ser vice providers meet this criter ia of the EQUASS Assurance certif ication program Str e n gt hs Im pro vem e nt & de v e lo pm ents The social ser vice provider is document ing the individual plans to clients. The individual plans are signed by the clients or relat ives. The individual plans results ar e evaluated at least once a year. 38  30 . T h e s oc i a l s er v ic e pr o vi d er o pe ra tes s pec if ic i ns tr um ents f o r us ers t o im pr o v e t he ir pe r s o n a l em po werm e nt a n d pers o na l s it u at i on a nd . t ha t of th e ir c om m un it y Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t i o n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The ser vice provider helps to improve the clients personal empowerment through individual planning. During the inter views I f ound out that there are many very good results. For example some clients are more active, and independent. Few clients started to hold she spoon. Some clients started to walk. 39  31 . T he s oc i a l s e r v ic e pr o v id er o p er a tes s pec if ic m ec h a n is m s f or es t a bl is h in g a n em po w er in g e n v iro nm en t. Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The service provider has off ers the physical exercises to the clients and there is a special room f or that. There is also a senses development room f or clients. The service provider has also document ed the training plan ( which is part of the annual plan). Based on that plan the staff is trained. 40  32 . T he s oc i al s er v ic e pr o v i der s e lec ts pr ogr am m es wh ic h are bas e d o n a ne e ds as s es s m ent at th e l oc at i on wh ic h i s m os t c o n ve n i en t f o r th e p ers on s er ve d , f am i l y a nd c a r e tak er s Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents Valga Haigla social welf are department organizes regular f eedback questionnaires and also examines through that clients needs. The social ser vice provider is prepar ing the analysis what ar e the potent ial clients needs. Valga Haigla is located in Valga cit y which is the centre of the Valga count y. 41  33 . T he s oc i a l s er v i c e pr o v id er of f ers p rog ram m es c ons is te n t wit h t h e i de nt if ie d n ee ds of i ts c us t om ers an d o bj ec t i v es f or t h e pr ogr am m e. Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The service provider organizes regular feedback questionnaire to clients and cooperation partners. There is also regular communication between financial body and Valga Haigla social service department. End of the year the service provider documents the summary of the year. 42  34 . T he s oc i a l s er v ic e pr o v i der o per at es in d i v i du a l pr oc es s es t h at are dr i ve n b y th e n e eds of t he p e r s on s er ve d . Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The service provider evaluates the clients individual needs through the individual planning process. Some clients personal needs are evaluated also through rehabilitation process. 43  35 . T h e s oc i al s e r vic e pr o v id er d oc um ents t he p l a nn i n g of s er v ic e s b as e d o n th e id e nt if ic a ti o n of in d i vi d ua l n ee ds an d ex pec t at i ons of p ers ons s er ve d i n an I n d i vi d ua l P la n. Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The service provider organizes feedback questionnaires to the clients. Generally through individual plan activities the clients expectations and needs are marked in an individual plan. Mainly the individual plans are signed by the clients or relatives etc. 44  36 . T he s oc i al s er v ic e pr o v i d er i d e nt if i es , d oc um en ts , a nd m a in t ai ns t he k e y s er v ic e d e l i ver y pr oc es s es t o th e p ers o ns s er v ed in l i n e wi th its vis i o n, m is s io n s ta t em ent a n d q u al i t y p ol ic y. Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The service provider has defined The service delivery processes the general service delivery could be more accurate. Only processes on the homep age (for general aspects are defined in a care home service for elderly and processes. It will help the staff round the clock special care for (mainly the new specialists) to persons with multiple disability). understand the processes and generally increases the quality. The service provider evaluates the processes through the evaluation. Teenuse osutamise protsessid võiksid olla täpsemad (määratleda - kes, mida ja millal teeb). See aitab töötajatel (peamiselt uutel töötajatel) mõista teenuse osutamise protsesse. Seeläbi on võimalik tõsta teenuse osutamise kvaliteeti. 45  37 . T h e s oc i a l s er v ic e pr o v id er r e vi e ws th is d e l i ver y p roc es s a n d m ain t ai ns c on tr ol o ver t h e d el i v e r y of th e s er v ic e. Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The service provider plans The service provider could define regularly internal audits. The the internal auditing process. It planned internal audits are helps to plan the internal audits documented in an excel table. more systematically. The service provider had also Teenuse osutaja võiks defineerida documented Equass test audits siseauditite protsessi – see aitab reports. siseauditeid planeerida ja läbi viia süstemaatilisemalt . 46  38 . T he s oc i a l s er v ic e pr o v id er e ns ur es th at the pers o n s er v ed c a n ac c es s a c on t in u um of s er v ic e s th at s p a n f rom ea rl y i n ter v e nt i o n to s u pp or t a nd res p o n d t o c h a ng i n g r eq u ir em ents o v er t im e . Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The service provider organizes feedback questionnaires for clients and their relatives. Mainly based on feedback questionnaires and annual plan results the service provider plans next year goals and activities. The annual plan results are discussed in a general meetings. 47  39 . T he s oc ia l s er v ic e pr o v i d er d e ve l o ps a s eam l es s c o nt i n uum of s er v ic es a nd red uc es b ar r ier s i n a m ult i - d is c i p li n ar y or m u lt i - ag e nc y s et t in g . Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The service provider documents every year the summary of the year activities The summary is based on the year activities. The clients individual plan is prepared by the rehabilitation plan and the evaluations of the specialists. 48  40 . T h e s oc i a l s er v ic e pr o vi d er o pe ra tes s er v ic es f rom a h o l is t i c a p pro ac h bas e d o n t he ne e ds a nd ex p ec ta t io ns of t h e p ers o n s er ve d wit h th e a im of im pro v i ng t h e qu a l it y of lif e f or t h e pe rs o n s er ve d . Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The service provider organizes feedback questionnaires to the clients and their relatives. In an individual planning the persons served needs are documented. The individual plan results are analyzed regularly. 49  41 . T h e s oc i al s er v ic e pr o vi d er i d en t if i es t he ne e de d c om pe te nc es , s k il ls an d s u p por t f or s taf f t o e nh a nc e t h e qu a l it y of lif e f or p ers o n s er v ed . Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The service provider has documented the procedure for “Development interviews”. Based on that procedure the service provider analyses the staff competence. Based on the feedback questionnaires and development interviews the service provider plans the training plan. 50  42 . T h e s oc i a l s er vic e pr o vi d er i de nt if ies i ts bus i n es s r es u l ts a n d pr o vi d es f orm al p er io d ic a n d i nd e pe n de n t re v i e w a nd pr oc e d ures to ac h ie v e t h e tar g et ed r es u l ts . Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The service provider documents Valga Haigla social welfare every year the annual report. In department should continue the that report are analysed also the annual planning process and social welfare department results. based on that plan result s prepare the report. It helps to achieve the Based on that report the results results in a long term perspective . are analysed in a meetings. Valga Haigla hooleka nde osakond The report is confirmed by the peaks jätkama aastaplaanide Valga Haigla council. koostamist ja selle paani tulemustest kähtuvalt koostama aastaaruande. See aitab pikemas perspektiivis eesmärke saavutada. 51  43 . T h e s oc i al s er v ic e pr o vi d er i d en t if i es an d re g is t ers t he ou t c om es a n d be n ef i ts f or p er s o n s er ve d of th e rec e i v e s er v ic es on in d i v i du a l a nd c o ll ec ti v e b as is . Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The service provider has documented the annual year planning process and Valga Haigla social welfare department annual plan. The clients individual plans results are evaluated at least once a year . 52  44 . T he s oc i a l s er v ic e pr o v id er e v a l ua tes its bus i n es s res ul ts i n or der to de t er m in e b es t va l u e f or purc h as ers an d f u nd ers ( „b es t v a lu e ‟ c a n a ls o be ex pr es s e d i n r e la t io n to t h e i nc re as ed qu a l i t y of lif e of f ere d t o th e p ers o n be i n g s er v ed) . Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The service provider asks regular feedback from the financial body (through regular communication). The persons served life quality is evaluated based on individual plan. 53  45 . T h e s oc i a l s er v i c e pr o v i d er e va l ua t e s th e i nd i v i d ua l a nd c o l lec t i ve s at is f ac t io n of pe r s o n s s er ve d an d ot h er s tak e ho l de rs b y i nt er n a l a n d/ or ex t er na l e v a l ua t io n. Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The service provider has analysed based on feedback questionnaires the clients and their relatives satisfaction. The financial body satisfaction is analysed based on regular communications. 54  46 . T he s oc i a l s e r v ic e pr o v id er p ro v i des ac c es s i b le an d e as il y un d er s t a nd a b le r ec or ds on o utc om e, i nc l ud i n g p ers o na l p erc e pt i on a n d ac h i e v em ents Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The social service provider analyses the results of the annual plan in an annual meeting. The individual plan is also agreed with the clients and their relatives . 55  47 . T h e s oc i a l s er v ic e pr o v i d er ac t i v el y d is s em in at es org a n is a t io n perf orm anc e am ong its s t af f , s er v ic e us er s an d ex t ern a l s tak e ho l de rs . Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The service provider has regular communication with the financial body and organizes meetings with the staff. There are regular event with the clients (for example birthdays, christmas parties and so on). The service provider also organizes development conversations with the staff and through of that the staff has a change to give feedback. 56  48 . T h e s oc ia l s er v i c e pr o v i d er has a s ta n dar d pr oc e d ur e f o r c o nt i nu o us im pro v em ent on t h e b as is of a n im pr o vem en t c yc l e. Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The ser vice pr ovider has def ined t he annual planning process and that process has applied through the Equass applying. The service provider has also document ed the annual plan. 57  49 The s oc i a l s er v i c e pr o v i der i d en t if i e s perf orm anc e i n d ic at ors f or m eas ur in g t he r es u l ts of t h e im pro v em ent ac ti o ns . Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The service provider has defined the individual plan form. There is a field- planned results and there the service provider documents the performance indicators. The indicators are based on following themes: 6. the staff is working based on annual plan; 7. qualit y of the ser vices; 8. the staff is trained and motivated; 9. the documentat ion is based on based on regulations; 10 . the social welf are department is working based on budget. 58  50 . T h e s er v ic e p r o v i der in tr od uc es an d m an a ges in n o va t i ve wa ys of work i ng th at ha v e b ee n i d en t if i ed bas e d on t h e n ee ds of s tak e ho l d ers . Rem ark f rom th e au d it or : T he s er v ic es of t he s o c i al s er v ic e pr o v i ders m eet th is c r it er ia of t h e EQ U A S S As s ura nc e c er tif ic a t io n pr ogr am Str e n gt hs Im pro vem e nt & de v e lo pm ents The service provider has developed the senses room to the clients. It is very good that the service provider has recruited the activity therapists to the clients (for the elderly service). It will help to activate the clients. The innovative projects are measured in an individual plan or in an annual plan . 59 3. Agreed additional development / improvements T he ap p l ic a n t d ec id ed on t he f o l l o wi ng im pro v em ent ac t i on s an d/ or ad d it i o na l d e v e lo pm e n t f or t h e pe ri o d of t wo ye ars : Sho rt d es c ri ptio n of the a cti on s ( in clud ing SM ART ob je ctiv es ) 1 Devel op feedback system. Feedback system can be part of the staff handbook. Feedback syst em could regulate how the feedback is collected systematicall y from financial body, clients , staff and other important persons/organizati ons and how the feedback has been anal ysed. Luua tagasi sidesüsteem. Mõelda läbi, kuidas süsteemselt tagasisidet koguda rahastaj atelt, klientidelt, lähedastelt jt ja kuidas tagasidet analüüsida. 2 Develop internal auditing s ystem. Internal auditing system can be part of the staff handbook. Luua siseauditi süsteem. See võib olla üks osa töötajate käsiraamatust. 3 Develop the individual planning process. There could be follow ing aspects: w ho is staring the process, w ho are included, how and w hen the results are evaluated. Dokumenteerida individuaalsete plaanid e koostamise protsess. Töökorras võiks volla kirjeldatud näiteks järgmised punktid: kes algatab individuaalsete plaanide koostamise, keda kaasatakse, kes ja kuidas tulemusi hindab. 60 4 Train the staff about alternative communication. Koolitada personali alternatiivse kommunikatsiooni alal. 5 Ensure client oriented approach and for example introduce to the staff and clien ts their rights/duties and code of ethics . Tagada kliendikeskne lähenemine ja tutvustada klientide/läheda stele nende õiguseid ja kohustusi teenusel. 6 Update the service provision processes . Uuendada ja täiendada teenuse osutamise protsesse. Ensure that the activity report (based on annual plan) is published (for example on the homepage) 7 and sent to financial body, cooperation partners etc. Tagada, et tegevusaruannet tutvustatakse kõigile olulistele osapooltele (rahastajad, koostööpartnerid, kliendid jt). 61  5. Closing remarks Valga Haig la is locat ed in the north part of Estonia: in Valga count y, in a cit y called Valga. In Valga city ar e living about 13 426 persons. Valga Haigla is provising also medical ser vices. In Estonia Valga Haigla is general hospidal. It means that available must be the main m edical ser vices. Valga Haigla is implementing Equass qualit y system to the social ser vices (home ser vice f or elderly, round the clock special care for persons with multiple disabilit y). Valga Haigla social welf are department has started the annual planning based on developm ental plan and analyses. It is ver y important that Valga Haigla continue s implement ing the system. The elder ly ser vice ( home ser vice f or elderly) staff was ver y motivated and pleased with their work. The multiple disabilit y (round the clock special car e f or persons with multiple disabilit y) appr oved t he client s well- being is ver y important. It is important that the service provider (manager) guarantee s training s to the staff (f or example trainings about alt ernative communicat ion). The ser vice pr ovider has def ined main service provision processes. The next step would be to accurate these processes. The detail im provements ar e presented in a report . It is ver y impressive that Valga Haigla has good cooperat ion with other social partners. Now the ser vice pr ovider is also a member of the organizat ion Hõbemajandus. Cooper ation is ver y developed f ield in Valga Haigla. The elderly ser vice is well designed. The clients conf irmed that they are happy and satisf ied with the ser vice. The servic e provider should think more how to develop the round the clock special care ser vice f or persons with multiple disabilit y. The main keyword should be client cent ered approach. Ver y important is to include the relatives/f inancial body to the process and not only f ormally. In conclusion I can say that Valga Haigla social welf are depart ment meets on the first level Equass criterias. 62 Valga Haigla asub Valgamaal Valga linnas. Valga linnas elab orienteeruvalt 13 426 isikut. Valga Haigla pakub lisaks sotsiaalteenu stele ka tervishoiut eenuseid. Valga Haigla kuulub Eestis üldhaiglate hulka ja peab tagama nö esmaste tervishoiuteenuste kättesaadavuse. Valga Haigla rakedab Equass kvaliteedisüsteemi peam iselt sotsiaalteenustele ( eakate hoolekandele ja erihooldusteenusele sügava liitpuuega isikutele). Equass kvaliteedisüsteemi rakendamisel on Valga Haigla alustanud ka aastase paneer imise protsessiga. Siinkohal on väga oluline, et Valga Haigla jätkaks selle süsteemi rakendamist. Valga Hailga on üldsõnaliselt def ineer inud pe amised teenuse osutamise protsessid. Järgmine etapp võiks olla nende protsesside täpsustam ine j a täiendamine. Väga muljeltavaldav oli tut vuda, kuidas Valga Haigla teeb koostööd teist e sotsiaalpartner itega. Võib kinnitada, et koostöö on Valga Haigla hoolek ande osakonnas kõrgel tasemel. Eakate hoolekande teenuse osut amine on Valga Haiglas hästi läbi mõeldud ja toimiv. Kliendid kinnitasid, et nad on teenusega rahul ning personal on viisakas ja sõbralik. Erihooldust eenuse pakkumine süg ava liitpuudega isikutele vaj ab veel arendam ist. Peam ine märksõna siinkohal võiks olla kliendikeskne lähenemine. Väga oluline on, et mitte ainult f ormaalselt ei oleks lähedased/kliendid jt kaasatud teenuse osut amise protsessi. Kokkuvõt valt kinnitan, et Valga Haigla hoolekande osa kond on täitnud Equass kriteeriumid esmasel tasemel. T artu , 3 1. 12 . 20 1 6 63 T ii na U n uk ai n en 64 EQUASS ASSURANCE APPLICATION ADDITIONAL INFORMATION 1. Short information about the organisation in the nati ve language AS Valga Haigla üldeesmärgiks on olla nii patsiendile, kliendile kui koostööpartner ile usaldusväärne, innovaatiline ja hooliv arst i - ja õendusabi ning hoolekande keskus. Pakkuda kõigile abivajajatele häid võimalusi meditsiini ja sotsiaalteenuste kättesaamiseks ning oma potentsiaali arendam iseks. Meie eesmärki toetavad pikaajalised traditsioonid ja töötajat e kogemused. 2. Short information about the organisation in English (acti vities, clients, etc.) AS Valga Haigla’s social welf are depart ment belongs together with AS Valga Haigla since 01.01. 2012. We off er general nursing home ser vice f or 90 clients and since 03.03.2014 we also off er specia l welf are ser vice f or 20 deeply disabled person. 3. Name of the organisation as you w ould w ant it to appear on the EQU ASS Assurance certificate AS Valga Haigla 4. Name of services / departments of the organi sation i n the scope of the application as you w ould w ant it to appear on the EQU ASS Assurance certificate : Hoolekande osakond 5. Organisation’s logo Information to be published on EQUASS website: Name of the organi sation : AS Valga Haigla Post address: Peetri 2, Valga 68206 Director: Marek Seer Contact person: Monika Horn Email: inf [email protected] Web: http:// www. valgahaigla.ee 1 EQUASS ASSURANCE ASUTUSE KÜLASTUSE ETTEVALMISTAMISE VORM Asutuse külastus: 05.12-06.12.2016 Valga Haigla Tiina Unukainen © 2012 by European Quality for Social Services (EQUASS) Kõik õigused kaitstud. Antud dokumendi elemente ei tohi paljundada, kopeerida ega muul elektroonilisel moel salvestada ilma EQUASS kirjaliku loata.  Asutuse külastuse ettevalmistamise küsimused EQ U AS S As s ur a nc e t ao t lus v or m i le j a a nt ud l is ai nf orm ats i oo n i l e p õh i n ed es pa l um e te i l e tt e va lm is t us ek s v as t at a j är g ne v at e l e s e l gi t us t n õ ud v at e l e k üs i m us tel e : Üldised teemad (max. 10 küsimust) 1. P al u n k irj e ld a ge , m is on t ei e as u tus e s u ur im ad v ä lj ak u ts e d l ä h im a vi i e a as t a j ook s u s e os es t e en us t e os ut am is e ga ? 2. P a lu n s e l g it ag e t u l e v ik u s eis uk oh as t , m i l lis t el e k va l if ik a ts i o o n in õ ue te l e p e ak s pers o n al v as t am a? 3. M id a t e m uu d ak s it e üh is k o nn as , et k li e nt i d e õ ig us ed ol ek s i d p are m ini k ai ts t u d? 4. M id a t e ie j a ok s t äh e nd a b m õ is t e t e en us t e t u lem us l ik k us ? 5. P a lu n s e l g it ag e , k u i das t e t ee t e k oos t öö d k oguk on n ag a ? 6. P a lu n n im eta g e k o l m k õig e o l ul is em at a s j a, m i da p e at e te e n us t e os ut am is e l k õig e o l ul is em ak s . 7. 8. 9. 10 . Version 1.0 2  1. Kvaliteedi põhimõtetele ja EQ U ASS Assurance kriteeriumitele vastavuse küsimused / teemad: Te en us e s a aj a d Kv al i te e d i ju ht J uh t/ dir ek tor Huv i gr up i d P ers o n a l Juht im in e 1. P a lu n s el g it a ge , k u id as vä lj e nd u v ad x x x te i e as ut us e v äär t us e d i g ap ä e vas es e l us . 2. S e lg i ta g e, m i l l in e on teie as u tus e x x aas t a p la n eer im is e pr ots es s ? 3. P a lu n k irj el d a ge , k uid as on t e il v õ im al ik an d a ta g as i s i de t V a lg a Ha i g l a x tö öt aj at e le ? 4. 5. P er so na l 1. P a lu n s e l g it a ge , k as ja k ui das x ar ves t at ak s e t e i e k o ol i tus s o o vi d eg a ? 2. P a lu n s el g it a ge , k ui das o n t ei l v õ im al ik x an d a ta g as is i d et om a j uh i l e? 3. K as te i e t ag as is i des t l äh t u va l t on m uuda t us i t eh t ud as ut us es ? K u i j a h, s i is x pa l u n s e lg i ta g e. 4. M id a te p e at e o l ul is ek s pers on a l i x x ar e n d am is e l? 5 Version 1.0 3  Õ igu se d 1. Pa l u n s e l gi t ag e , k ui das te i e s o o v id e j a x et te p an ek ut e ga a r ves t at ak s e? 2. Pa l un s e lg i ta g e, m ill is e id m eetm e id x x k as ut at e k l i en t id e õ i gu s te t a gam is ek s ? 3. P a lu n s el g it a ge , k ui das o n t ei l v õ im al ik ta g as is i d et a n da V a l ga H a ig l a x tö öt aj at e le ? 4. P a lu n t oo g e v õim a l us e l n ä it e id , m i da o le te t ee n us e os ut am is e l m uut nu d pe a l e x x k aeb us e (k ae bus te ) m ene t lem is t ? 5. E et i k a 1. P a lu n t o og e n ä it e i d, k ui d as o n t e ie as u t us es rak e nd un u d ee t i lis e d x x x põ h im õtt e d 2. K u i k ee g i o n r ik k unu d t ei e as ut us es ee t i lis i põ h im õtt e i d, s i is m il l is e d x x x ta g aj är j ed s el l e l o n? 3. K u id as s e lg i ta t e v a ba ta h tl ik e le x x as u t us es k eh ti v a i d e et i l is i põ h im õtt e id ? 4. M i ll is e i d m eet od e i d te om a as ut us es k as ut at e t a g am ak s k lie n ti d e x x x is ik ua ndm et e k ai ts e ? 5. Koo st öö suh t ed 1. P a l un s e l g it a ge , k ui d as te e te k oos t öö d r ah as taj a te ja t e is t e x x s ots i aa l p art n eri t eg a 2. M id a te o l et e s aa v u ta n ud t ä nu x x k oos t öö l e? Version 1.0 4  3. P a lu n s e lg i ta g e, m i l lis e i d x k oos t öö v orm e te n ä et e V a lg a H a ig l a ga tu l e v ik us ? 4. 5. O s al em in e 1. P a lu n s e lg i ta g e, k as te ie k ä es t x k üs it ak s e, m i da t e s o o v it e ? 2. P a lu n t o og e nä i te i d, k ui d as t e ie x et te p an ek ut e ga o n ar v es t at u d? 3. K u id as te i l e tu t v us t at ak s e te i e x i nd i v i du a a ls e t te g e vus p la a ni ? 4. P a lu n t o og e n ä it e id x x m är k im is v äärs e tes t k li en d it ö ö tu l em us tes t? 5. P a lu n s e l gi t ag e, m ida t ei e j a ok s x x tä h en d ab m õis te jõ us t am i n e ? Is ik uk e sk su s 1. P a lu n s e l g it a ge te ie as u t us e x x x i nd i v i du a a ls e te te g e vus p la a n id e /h o ol d us p l a an i de k oos t am is e pr ots es s i 2. P a lu n s e l g it ag e , m il le g a p ea b x x k ind l as t i ar v es t am a i nd i v i du a a ls e te p la a ni d e k o os t am is e l ? 3. P a lu n s el g it a ge , k uid as te t e et e x x k oos t öö d k lie n ti d e l äh e das te / ees tk os tj at e ga ? 4. K u id as t e t e et e k in d lak s ra has taj at e x x j t hu v ir ü hm ade vaj a du s ed ? 5. Version 1.0 5  Lai ah a ar de li su s 1. P a lu n k irj e l da g e, m i l l is e i d t ak is t us i o n x x es in e nu d t ee n us t e os u tam is e l ? 2. P a lu n k irj e l da g e te ie as u tus es x x k as ut at a va t e l uk v a li te e di m õõ tm is e m etoo d ik at ? 3. P a lu n k irj e ld a ge , m ida te o le t e x s aa n ud om a e l us m uu t a t än u V a lg a Ha i g la p ers o na l i b a i le ? 4. P a lu n t oo g e n ä it e id , m il lis e i d x x m uuda t us i te ol e te te i n ud te e n us e os u t am is e l s is e a ud it i tu l em us t es t l äh tu v a lt ? 5. T ulemu st el e 1. P a lu n a ndk e ü l e va ad e om a as u tus e x x ori en t e e rit u s s aa v u tus tes t. 2. P a lu n s el g it a ge , m il l is ei d m uu da t us i te x x o le te as ut us es läbi v i in u d t ug i n ed es r ah u l o luk üs im us t ik e t u l em us te l e? 3. P a lu n s e l g it a ge , k as ja k ui das on x V al g a H a i g la te i l e om a te g e v us es t ü le v a ad et an d nu d ? 4. M i ll is e i d te g e vus i teg i te ee lm is el x aas t al k oos t ö öt aj a te g a? 5. Pi dev a r eng 1. P a lu n t o og e n ä it e i d om a as ut us es x x l äb i v i id u d in n o v ats i o on i pr oj ek t id es t ja s e lg i ta g e, m ik s j us t ne e d pr oj ek ti d o n i nn o v ats i oo n i proj ek ti d Version 1.0 6  2. P a lu n an dk e ü l e v aa d e, m i l lis e i d x x k va li t ee d i i nd ik a at or ei d o le t e s e a dn u d, et m õõt a om a te g e vus t e tu l em us i . 3. 4. 5. Version 1.0 7  2. Nõutav dokumentat sioon EQ U AS S As s ur anc e ta ot l us es s e m ärg i tu d i nf o le j a lis a de l e p õh i n ed es pa l um e v aa t lus ek s e tt e v a lm is ta d a j är g n e v d ok um ent ats i oo n : 1. AS Valga Haigla arengustrateegia 2017 - 2019 2. Töötaja käsiraamat 3. Aastaplaani koostamise juhend 4. Klientide rahulolu - uuring Rahastajate rahulolu -uuring Personali rahuolu -uuring 5. Aastaplaan 6. AS Valga Haigla per sonalipoliit ika Version 1.0 8  7. Individuaalne hooldusplaan, i ndividuaalne tegevusplaan 8. AS Valga Haigla tegevusaruanne 9. AS Valga Haigla hoolekande osakonna kaebuste ja ettepanekute lahendamise kord 10 . 11 . 12 . 13 . 14 . 15 . Version 1.0 9  3. Personali, teenuse saajate ja teiste oluliste huvi gruppide intervjueerimine EQ U AS S As s ur anc e t ao t lus es an tu d v as t us te l e j a t õ en d it e l e p õh i ne d es p a lum e k orral d ad a i n ter vj u ud j är gm is te in im es t eg a (f unk ts io o n j a k es t v us ) : Juhtkond Kestvus 1.J u ha tus 35 2. K v a li t ee d i s p ets i a lis t 35 3. 4. 5. 6. Personal Kestvus 1. Ho o l dus p er s o n a l 35 2. Er i ho o l ek an de t ee n us t p ak k uv 35 pers o n al 3. 4. 5. 6. Version 1.0 10  Teenuse saajad Kestvus 1. Ü ld h oo l dus e k li e nd i d 30 2. Er i ho o l ek an de k l ie n d id 30 3. 4. 5. 6. Teised huvigrupid Kestvus 1. Ra h as t aj a S K A 35 2. Ra h as t aj a k oh a l ik o m ava l its us 35 3. Er i ho o l ek an de k lie n ti de 35 l äh e das e d/ ees tk os tj ad 4. Ü ld h oo l dus e k li e nt i d e l äh e das e d 35 5. K oos t öö p ar t n er ( p ar t ner i d) 35 6. 4. Asutuse kül astuse ajakava formaat As ut us e k ül as tus pe ak s o l em a k orra l da t ud v as t a v al t j är gn e v at e le j uh is te l e: a. As ut us e k ül as tus pe ak s o l em a k av a nd a tu d k ah e l e tö ö pä e v a le ( = 1 6 tu n d i) b. Dok um en ta ts io o ni g a t ut v um in e p e ak s olem a p l an e er it ud es im es e 3 h s is s e k ülas tus e es im es e l p ä e va l . Version 1.0 11  c . P äe v ak a vas pe ak s ol em a s ag ed as ed pa us i d (1 5 – 3 0 m inu t it) , et a u d ii t or s aak s in d ik aa to r i t e tõ e nd e i d ü le va a d at a j a k orr as t ad a . d. In ter vj u ud j uh tk on n a, per s o na l i j a t e is te g a ( vä l is ed hu v i gr up i d/ par tn er i d) pe ak s k es tm a m ax 30 - 5 0 m in ü h e in ter vj uu k oh t a . I n ter vj u u d t ee n us e s aaj at e ga pe ak s id ol em a k orra l da t u d gr u p ii n ter vj u ud e na ( m ax 5- i n im es t k orr ag a) e. J uh i g a/ d ir ek tor ig a i n ter vj uu p e ak s ol em a p la n ee ri t ud as ut us e k ülas t us e te is e le p ä e va l e ( s o o v it a va l t p ea l e lõ u na l) . f. Lõ p l ik as ut us e k ül as t us e pr ogr am m peak s o lem a t ao t lej a j a au d i it or i va h e l k ok k u le p it u d j a s a ad e tu d EQ U A S S k o ha l ik ul e es in d aj a l e . Asutuse külastuse ajakava kuup ä ev P äev 1 Ae g T egev us ( l üh ik e k irj e l dus ) 9: 0 0- 9 .1 5 A v ak oos o lek - p r o ts es s i t ut v us t us 9. 1 5- 1 2. 1 5 Dok um en ta ts io o ni g a t ut v um in e 12 . 15- 1 2. 4 5 Lõ u na In ter vj u u er ih o o lek a nd e k l i en t id e ga ( 15 m in k ok k uvõ te te 12 . 45- 1 4. 3 0 te g em is ek s ) In ter vj u u p er s o n al i g a ( er ih o o lek a nn e) - 1 0 m i n k ok k uvõ te t e 14 . 30- 1 5. 1 5 te g em is ek s In ter vj u u r a has taj a ga ( er ih o o lek a nn e) - 1 0 m i n k ok k uvõ te t e 15 . 15- 1 6. 0 0 te g em is ek s 16 . 00- 1 6. 4 5 In ter vj u u l äh e das e ga ( er ih o o lek a nn e) - 1 0 m i n k ok k uvõ te t e te g em is ek s 16 . 45- 1 7. 1 5 Dok um en ti d eg a t ut v u m ine, pä e v as t k ok k uv õ te te t e gem i ne Version 1.0 12  kuup ä ev P äev 2 Ae g T egev us ( l üh ik e k irj e l dus ) 9: 0 0- 10 . 00 Dok um en ti d eg a t ut v u m ine 10 . 00- 1 1. 0 0 In ter vj u u h oo l dus t ee n us e pers o na l i ga - 10 m i n k ok k uvõ te te te g em is ek s 11 . 00- 1 1. 4 5 In ter vj u u h oo l dus t ee n us e k l ie nt i d eg a - 1 5 m i n k ok k uvõ te t e te g em is ek s 11 . 45- 1 2. 3 0 In ter vj u u r a has taj a ga ( ü ld h oo l dus ) - 1 0 m in k o k k uvõ t et e te g em is ek s 12 . 30- 1 3. 0 0 Lõ u na 13 . 00- 1 3. 4 5 In ter vj u u k o os t öö p art n er it eg a 13 . 45- 1 4. 4 5 In ter vj u u l äh e das e ga ( ü ld h oo l dus ) - 1 0 m in k ok k uvõ te te te g em is ek s 14 . 45- 1 5. 4 5 In ter vj u u j uh tk on n ag a (ü ldj u ht, k v a li t ee d ij u ht ) 15 . 45- 1 6. 1 5 K ok k uvõt e te t e gem i ne 16 . 15- 1 7: 0 0 Lõ p uk oos o lek Version 1.0 13 Saatja: Maarika Aro Saatmisaeg: 2. jaanuar 2017. a. 10:39 Adressaat: 'guusbeek'; 'Marie Dubost' Koopia: Keiu Talve Teema: AS Valga Haigla audit report Manused: 2016_12_31_EQ-ASS_AUD_Audit Report_valga_haigla.docx; Additional Information Form_Valga Haigla.doc; Asutuse auditi külastuse ettevalmistuse vorm _valga_haigla.docx; EQUASS Assurance taotlusvorm_Valga Haigla (2).xlsx Dear Marie, Dear Guus, Attached you’ll find an audit report and other documents of AS Valga Haigla EE2016-027. Please let Keiu to know in case there are some comments about the report. Best regards, Maarika Aro Sotsiaalteenuste kvaliteedi keskus Arendusspetsialist Astangu Kutserehabilitatsiooni Keskus tel +372 687 7223 mob +372 521 3563 [email protected] Astangu 27 Tallinn 13519 www.astangu.ee Liitu Astangu uudiskirjaga