SA Lõuna-Läänemaa Tervishoiu ja Sotsiaalhoolekande Keskus audit raport Brüsselisse

EQUASS ASSURANCE ASUTUSE KÜLASTUSE ETTEVALMISTAMISE VORM Asutuse külastus: 19.-20.12.2016 SA Lõuna-Läänemaa Tervishoiu ja Sotsiaalhoolekande Keskus Audiitor: Mariliis Männik-Sepp © 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 1. Miks alustasite EQUASSi rakendamisega ja mida on kvaliteedi süsteemi rakendamisega saavutatud? 2. Mida olete teinud teenuste kvaliteedi tagamiseks ja tõstmiseks oma asutuses? 3. Kuidas o n kvaliteedisüsteemi rakendamine m õjutanud asutuse juhtimist ja perso nalijuhtimist? Millised muutused on toimunud? 4. Kirjeldage oma asutuse põhiprotsesse: planeerimise protsessi, kestva arengu protses si (PDCA tsükli) ja teenuste o s utamise protsessi rakendamist oma asutuses. 5. Millised on asutuse huvigrupid? 6. Kellega ja millist koostööd teete ning millist lisaväärtust se eläbi olete saavutanud? 7. Kuidas kaasate teenuse saajaid, personali ja muid huvigruppe teenuste arendamisse? 8. Milliste ko gukonnpõhiste tegevustega olete seotud olnud ja kuidas ühiskonnale lisaväärtust pakkunud? 9. Milliseid parendusprojekte/ innovatsiooniprojekte olete ellu viinud? 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 Huv i gr up i d P er s o n a l J uh a ta j a Juht im in e 1. Missioon, visioon ja kvaliteedistandard 1.1. Kuidas olete jõudnud asutuse visiooni, missiooni ja väärtusteni? 1.2. Millised on asutuse kvaliteedi al ased x eesmärgid? 1.3. Millised on asutuse pi kaaj alised eesmärgid ? 1.4. Kuidas o n tagatud järj epidev areng (PDCA tsükli toimimine)? 2. Kommuni katsi oon 2.1. Kuidas o n teenuse saajate l võimalus anda tagasisidet teenus e kohta? x x 2.2. Kuidas asutus informeerib pakutavatest teenustest huv igruppe? 3. Aastaplaani koostami ne x 3.1. Kirjeldage aastase pl aneerimise j a ülevaatamise/ hi ndamise protsessi 4. Panus ühiskonda 4.1. Tooge näitei d tegevuste kohta, mis on suunatud ühiskonna vajaduste rahuldamiseks? x 4.2. Milliste kogukonnapõhiste tegevustega asutus tegeleb (näitamaks üles sotsiaalset vastutust) ? P er so na l 1. Personali juhtimi ne 1.1 Kirjeldage personali värbamis- ja ametis hoi dmise protsessi x x 1.2 Kirjeldage asutuse võrdsuse j a diskrimineerimise vastasuse põhimõtteid. 2. Personali kvalifikatsioon j a arendamine x x Version 1.0 3  2.1 Kuidas toimub arenguvajaduse väljaselgitamine ning koolitus - ja arengukava koostamine ja töötajate arendamine ? 2.2 Kuidas o n korraldatud otseselt teenust osutava personali j älgimine ? 2.3 Milliseid meetmeid kasutatakse töötajate tunnustamiseks ? 2.4 Kuidas o n tagatud nõuetekohased töötingimused? 3. Personali kaasami ne 3.1 Millised on töötajate kaasamise põhimõtted (asutuse tegevuste täiustamisse, teenuste x x arendamisse ja personali arendamisse)? 3.2 Millised on perso nali rahulolu tagamise ja motiveerimise põhimõ tted? Õ igu se d 1. Õigused j a kohustused 1.1 Kirjeldage teenuse saajate õigusei d ja kohustusi ning klienti de teavitamist nende õigustest ja x x kohustustest. 2. Kirjeldage kaebustega tegelemise süsteemi . 3. Enesemääramisõigus 3.1 Kuidas näidatakse üles poolehoi du teenuse saaj a enes emääratlus e osas ? 3.1.1 Kuidas asutus hindab oma sellekohast tegevust? x x x 4. Kuidas asutus toetab teenuse saajat eestkostja (eestkõnel eja) ja/või tugiisiku leidmisel? 4.1.1 Kuidas asutus hindab oma sellekohast tegevust? E eti k a 1. Eetika põhimõtted 1.1 Millised on asutuses kehtivad eetilised põhi mõtted, väärtus hinnangud j a tegevused, millest lähtutakse teenuse osutamisel? 1.2 Milliseid tegevusi tehakse teenuse saaja füüsilise, vaimse ja majandusliku ärakasutamise x x x ennetamiseks ? 1.3 Mida on asutuses tehtud töökeskkonna tur valisuse kindlustamiseks ning teenuse saajatele turvalise keskkonna ja füüsilise turvalisuse tagamiseks? 1.4 Kuidas o n tagatud andmete konfidentsiaalsus ? Version 1.0 4  1.5 Kuidas teenuse saajad oma andmetel e ligi pääsevad? 2. Rollid ja vastutus 2.1 Kuidas ja on määratletud teenuse juhtimise, disaini, osutamise, toetamise ja hindamisega tegeleva x x perso nali rollid ja vastutused , volitused ning omavahelised s uhted ? 2.2 Kuidas neist rollidest teavitatakse? Koo stöö - suht ed 1. Partnerid teenus e osutamisel 1.1 Milliste organis atsioonidega teeb asutus ko ostööd? (sh sotsiaalpartnerid, rahastajad, teenuse saajate organisatsioonid, teenuse saajad) Tooge näi teid toimivast koostööst. 1.2 Kuidas ja millist koostööd teeb asutus teenuste x x arendamisel ? 1.3 Kuidas selgitatakse väl ja väliste huvigruppide vajadus ed? 1.4 Kuidas asutus hindab koostööst tulenevat lisaväärtust ? O s al em in e x x x 1. Teenuse s aaj ate kaasamine 1.1 Kuidas kaasatakse teenuse saajaid vaj aduste väljaselgitamisse, teenuse planeerimisse, hindamisse ja arendamisse ? 1.2 Kuidas koos kõlastatakse osalemine (protsessid, meetmed) teenuse saajatega? x x 2. Teenuse s aaj ate j õustamine 2.1 Milliseid võttei d/ meetodeid kasutatakse teenuse saajate j õustamiseks ? Tooge näiteid, milliseid tulemusi on saav utatud erinevate jõustamise meetodite läbi? 2.2 Tooge näiteid, mida on asutus teinud, et luua jõustavat keskkonda ? Is ik u - x x x x ke s ks us 1. Kliendi vajaduste välj aselgitami ne 1.1 Kuidas teete kindlaks teenuse saajate praeg used ja lähituleviku vajadused ? 1.2 Kuidas teete kindlaks huvigruppide (sh rahastajad, sotsiaalpartnerid) vaj adused? 1.3 Kas asute teenuse saajale, tema pereliikmetele ja hooldajatele kõige sobivamas kohas ? Version 1.0 5  1.4 Kuidas teete kindlaks, et osutatud teenused (tulemused) vastavad seatud eesmärkidele ja teenuse saajate vajadustele? x 2. Individuaal ne planeer imine 2.1 Kuidas selgitatakse välja teenuse saajate individuaalsed vaj adused ja ootused ? Lai ah a ar d x x el is us 1. Teenuse osutamise protsess 1.1 Kirjeldage teenuse osutamise protsessi. 1.2 Kuidas teenuse osutamise protsessi vaadatakse üle /analüüsitakse siseauditite käigus? x x 2. Katkematu teenuse osutami ne 2.1 Kuidas o n tagatud teenuse osutamise järjepidevus (sh katkematus, sujuv üleminek, multidistsiplinaarne lähenemine, asutuste vaheline koostöö)? 2.2 Kuidas hinnatakse ja arvestatakse teenuse saajate muutuvaid vajadusi ? 2.3 Kuidas reageeritakse takistustele teenuste osutamisel / nendele juurepääsul ning neist raporteeritakse? x x 3. Ter viklik lähenemi ne 3.1 Kuidas o n määratletud ja mõõdetakse teenuse saajate elukvaliteeti ? 3.2 Kuidas raporteeritakse elukvaliteedi hindamise tulemustest? T ulemu st e x x le 1. Tulemuste mõõtmine ori en te e rit 1.1 Kuidas mõõdetaks e asutuse tegevuseesmärkide us saavutamist ? 1.2 Kas tulemusi auditeeri b sõltumatu väline üksus? 1.3 Kuidas hinnatakse individuaalsete tegevuspl aanide täitmist / eesmärkide saavutamist (sh lisaväärtus)? 1.4 Kuidas hinnatakse kollektiivsel tasemel teenuste tulemusi / eesmärkide täit mist (sh lisaväärtus)? x x 2. Tulemuste hi ndamine 2.1 Kuidas selgitatakse välja parim väärtus (seoses teenuste osutamisega) teenuse rahastajatele? 2.2 Kuidas hinnatakse teenuse saajate rahul olu ? Version 1.0 6  2.3 Kuidas hinnatakse teiste huvigruppide rahul olu ? x x x 3. Tulemuste raporteeri mine 3.1 Kuidas avaldataks e asutuse tegevusar uanded huvigruppidele? 3.2 Kas aruanded on kättesaadavad ja lihtsasti arus aadavad ning sisaldavad personaalseid hinnanguid j a saav utusi ? Pi dev x ar en g 1. Kestva arengu ts ükkel 1.1 Tooge näiteid parendustegevustest , nende eesmärkidest ja tulemustest. x 2. Innovatsi oon 2.1 Tooge näiteid innovaatilistest töömeetoditest . 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. K v al i te e d ir a am at 2. T ege v us p la a n, a as t a n e 3. O s ak on d ad e a as t as ed t eg e v us ar u a nd e d 4. P ers o n a li p o l ii t ik a 5. Ar en g u ves t lus e d, k ok k u võ t e 6. K oo l it us p la a n, k ok k uv õt e 7. Am et ij u h en d id 8. Ris k i a na l üüs i d ( am et ik oh a põ h is ed) 9. K od u õe n dus l u gu 10 . T ege v us p la a ni k oos ta m is e j u h en d 11 . T ege v us p la a n ( er ih o o l ek an ne ) 12 . Ho o ld us p la a n ( ü ld h o ol dus ) 13 . K l ie nt i d e is ik l ik ud k a v ad 14 . Pr i v aa ts us p o li i t ik a Version 1.0 7  15 . Is ik u an dm et e k a its e or ga n is ats i oo n i l is e d j a t eh n i l is e d a b in õ ud 16 . Fü üs i l is e, v aim s e j a m aj a n dus l ik u är ak as ut a m i s e e n n et am is e k or d 17 . S is e h i nd am is e lä b i v i i m is e k or d 18 . Maj a nd us aas t a ar ua n n e, t e ge v us aru a nn e , au d ii t ori h in n an g 19 . P ers o n a li r ah u l ol uk üs i tl us 20 . K olm a nd at e os a po o lt e j a h u v ig ru p pi d e r a hu l o luk üs it l us 21 . K oos o l ek ute pr o tok o l l i d 3. Personali, teenuse saajate ja tei ste 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 uh a taj a 60 m in ut i t Personal Kestvus 1. T ööt aj a d: Ö ö pä e v ar in g ne G ru pi i nt er vj uu ( 3 - 4 i ni m es t) 4 5 m i nu t it ho o l dus te e nus : h oo l dus j u ht ja ho o l daj ad 2. T ööt aj a d: e r i h oo l ek an d e j uh t, G ru pi i nt er vj uu ( 3 - 4 i ni m es t) 4 5 m i nu t it te g e vus j uh e nd aj ad Teenuse saajad Kestvus 1. T een us e s a aj a d ( ö öp ä e var i n gn e G ru pi i nt er vj uu ( 3 - 4 i ni m es t) 3 0 m i nu t it ho o l dus te e nus ) 2. T een us e s a aj a d ( er i ho o lek a nn e) G ru pi i nt er vj uu ( 3 - 4 i ni m es t) 3 0 m i nu t it Teised huvigrupid Kestvus 1. Hu v i gr u p p id e es i nd aj a d G ru pi i nt er vj uu ( 2- 3 i ni m es t) 4 5 m i nu t it (k oos t öö p ar t n er id , r a h as t aj a) Version 1.0 8  Asutuse külastuse ajakava 19 . 12 .2 0 16 P äev 1 Ae g T egev us 9. 0 0- 1 2. 0 0 A v ak oos o lek , tö ö d ok u m enti d e ga 12 . 00- 1 3. 0 0 Lõ u na p aus 13 . 00- 1 3. 4 5 Int erv j uu pe r son al ig a 13 . 45- 1 4. 0 0 T öö dok um en t id e ga 14 . 00- 1 4. 3 0 Int erv j uu t e enu s e s a aj a t eg a 14 . 30- 1 5. 0 0 T öö dok um en t id e ga 15 . 00- 1 5. 4 5 Int erv j uu ko ost ööp a r tne ri t eg a 15 . 45- 1 7. 0 0 T öö dok um en t id e ga 20 . 12 .2 0 16 P äev 2 Ae g T egev us 9. 0 0- 1 0. 0 0 T öö dok um en t id e ga 10 . 00- 1 0. 4 5 Int erv j uu pe r son al ig a 10 . 45- 1 0. 0 0 T öö dok um en t id e ga 10 . 00- 1 0. 3 0 Int erv j uu t e enu s e s a aj a t eg a 10 . 30- 1 1. 0 0 T öö dok um en t id e ga 11 . 00- 1 2. 0 0 Int erv j uu juh at aj ag a 12 . 00- 1 3. 0 0 Lõ u na p aus 13 . 00- 1 5. 0 0 T öö dok um en t id e ga 15 . 00- 1 6. 0 0 Lõ p uk oos o lek Version 1.0 9 EQUASS ASSURANCE AUDIT REPORT Site visit: 19.-20.12.2016 SA Lõuna-Läänemaa Tervishoiu ja Sotsiaalhoolekande Keskus Auditor: Mariliis Männik-Sepp © 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.  1. Information of the social service provider Name of the social Lõuna- Läänemaa Tervishoiu - ja service provider sotsiaalhoolekande Keskus (hereinfafter foundat ion) Address: Tallinna mnt 37, Lihula, Läänemaa Post box: N/A Person responsible : Vanda Birnbaum Contact person: Ilona Kastepõld Phone: 47 78 700, 53 49 0026 Fax: - E-mail: lihulater [email protected] Web site: www. lihulat er vis. eu Name of Auditor: Mar iliis Männik -Sepp Dates of audit: 19.-20.12. 2016 Clients: 87 Staff: 24 as of 28. 11.2016 Services: 1. general social welf are 2. special care:  ever yday lif e support service  employm ent support ser vice  supported living ser vice  24 hour special care service 3. domestic nurser y ser vice 2  2. Audit program 19.12.2016 Day 1 Time Acti vit y 9:45-12:00 Opening meeting, documentation review 12:00-13:00 Lunch break 13:30-14:15 Interview w ith personnel: general soci al w elfare : Mer ike Pärnpuu, Heli Mets, Raili Küttmann, Erika Ige 14:15-14:30 Documentation review, up -dat ing f iles 14:30-15:00 Interview w ith persons served: general social w elfare : Sulev Liiv, Aivar Antonen , Ur ve-Benita Vederik , Marta Saareleht 15:00-15:45 Interview w ith cooperation partners: Varje Ojala-Toos, Mayor of Lihula Municipalit y Government , member of the board Kaidi Antsi, Lihula Count y social specialist, Ireen Kangro, Hanila Count y social adviser, Külli Raudsik, f amily doctor, member of the boar d , Kersti Lõhmus, head of social department in Lääne Count y Gover nment 15:45-19:45 Documentation review, up -dat ing f iles 3  20.12.2016 Day 2 Time Acti vit y 9:00-10:00 Documentation review, up -dat ing f iles 10:00-10:45 Interview w ith personnel : special care: Gersti Roots, Elle Uustalu, Ülle- Marju Kalbre, Ilona Kastepõld 10:45-11:00 Documentation review, up -dat ing f iles 11:00- 11:30 Interview w ith person s served: special care : Sir let Papor Aivi Teidla, Inger Rudsit , Aivar Antonen 11:30-12:00 Documentation review, up -dat ing f iles 12:00-13:00 Lunch break 13:00-14:00 Interview w ith member of the board: Vanda Birnbaum 14:00-15:00 Documentation review, closing meeting 4  3. Detailed feedback on performance 1. The social servi ce provider defines documents and implements its visi on and mission values on servi ce provision. Remark from the auditor: The ser vices of the social ser v ice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The mission, vision and values of The values on the home page and Foundation are stated in the strategic plan and in the personnel development plan and on the policy do not overlap, make t he website www. lihulat ervis.e u. necessar y changes. The employees of Foundat ion Kodulehel ja areng ukavas esitatud demonstrated through inter views väärtused ei üht i personalipoliit ikas that they ar e aware of the tooduga. Teha vajalikud korrektuurid. organizat ion’s mission, vision and values and they implement them on ser vice provision. 2. The social servi ce provider defines, documents, and implements its qualit y policy by determining long term qualit y goal s, and its commitment to continuous improvement. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The qualit y standard , long -term The charter of the organizat ion is 15 goals and commitment to continuous years old and theref ore is not up to improvement are stated in the date, renew the charter. development plan and in the annual activit y plan. The documentat ion system is in the process of being developed. It would It appeared f rom the inter views that be helpf ul, if all documents would be the staff of Foundation is given numbers and there would be knowledgeable of the qualit y links made between r elated 5 standard and long term goals of the documents inside those documents. organizat ion. Asutuse põhikiri on 15. aasta vanune The staff is devoted to deliver qualit y ning seega on aegunud. Uuendada ser vices and the manager to pursue põhikirja. f or continuous improvem ent. Asutuse dokumentat siooni süsteem on väljatöötamisel. Kasulik oleks anda igale dokumendile number ning lisada dokument ide sisse viit ed seotud dokumentidele. 3. Persons served, famil y members and servi ce user organisations are able to give feedback on their individual and c ollecti ve experience of programmes and services. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Foundation uses different met hods to ask and receive f eedback f rom persons ser ved, staff and stakeholders. Feedback is asked systematicall y f rom var ious stakeholder groups. The var ious ways f or gaining f eedback include f .e meetings, roundtables, perf ormance reviews, satisf action sur veys, periodic reports, inter views, etc. 6  4. The social service provider i nforms all stakeholders about the offered programmes and services avai lable. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQU ASS Assurance certif ication program Strengths Improvem ent & developments Foundation inf orms its stakeholders As an opportunit y f or the f uture, about its ser vices using mostly the more attention and conscious act ions home page www.luhulater vis.eu . should be targeted to satisf ying the needs and expectations of the local The home page of Foundation is communit y and the wider societ y. modestly inf ormative giving basic inf ormation about t he organization Tuleviku võimaluseks oleks enama and the ser vice it offers. tähelepanu ja teadliku tegevuse Inf orming staff and involving staff is suunam ine kohaliku kogukonna ja ka descr ibed in the staff policy of the laiemalt ühiskonna vajaduste ja organizat ion. Inf orming is done ootuste rahuldamisele. mainly through meetings, (in)f ormal communication and trainings. Partners are inf ormed by e -mail, telephone and web page. There has been a brochure made introducing the service of Foundation. Inf ormation about coming events in available f .e on the inf ormation boards in the buildings. The stakeholders are awa re of the ser vices of Foundation, which was ver if ied implemented through inter views wit h persons ser ved, staff and partners. 7  5. The social service provider management esta blishes and documents an annual planning and review process. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The annual plann ing and review Inf ormation has to be included to the process is integrated into the annual planning process about the management process of the inf ormation that is disclosed in the organizat ion. annual report, to ensur e the integrit y of inf ormation. There exists annual planning process descr iption. The process is regular ly Aastane planeerim ise protseduur reviewed. peaks sisaldama inf ot selle kohta, missugune inf ormatsioon lisatakse There is a development plan and aastaaruandesse, et tagada inf o annual act ion plan, which are terviklikkus. reviewed regular ly. The annual plan is kept up -to-date and the current state of the implementation of the plan is depicted in a separate column . 6. The plan includes:  annual outcomes / targets  the acti vities to be under taken in achieving the annual targets  monitoring of the performance of the organisation in meeting its annual targets time-scales and procedures for revi ew and revi sion. Remark from the auditor: The ser vices of the social ser vice pr oviders does not meet this cr iterion of the EQUASS Assurance certif icat ion program Strengths Improvem ent & developments The annual planning process of The annual plan of the f oundation f or Foundation has a cyclic char acter. 2016 does not include detailed inf ormation about the main ser vices Aligning the annual activit ies with 8 the vision and the development plan delivered as well as expected is understandab le, when studying the outcomes and measures. Also documentat ion of the organizat ion. perf ormance measures are missing that would make it possible to The annual plan is approved by the measure expected outcomes and manager of Foundation. eff iciency. Asutuse 2016. aasta tegevuskava ei sisalda inf ormatsiooni peam iste osutatavate teenust e ja oodatavate tulemuste kohta. Saamut i p uudub inf ormatsioon t ulemus mõõdikute kohta, mis võimaldkas mõõta oodatavaid tulemusi ja tulemuslikkust. 7. The social servi ce provider demonstrates organisation’s success in satisf ying the needs and expectations of the societ y. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Foundation is moderately active, As an opportunit y f or the f uture, when it comes to satisf ying the more attention and conscious act ions needs and expectations of the should be targeted to satisf ying the societ y and demonstrating social needs and expectations of the local responsibilit y. communit y and the wider societ y. The inhabitants of the local Tuleviku võimaluseks oleks enama communit y may use the washing tähelepanu ja teadliku tegevuse machine and the shower of suunam isele kohaliku kogukonna ja Foundation. ka laiemalt ühiskonna vajaduste ja ootuste rahuldamisele. 9  8. The social service provider dem onstrates organisati on’s social responsibilit y t hrough acti vities contri buting to the societ y. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Foundation has demonstrated social responsibilit y through diff erent activities contributing to the communit y and also to wider societ y. Examples may allowing local people to join the vents organized in Foundation (f .e concerts) and also off ering internship opportunit ies to students. 9. The social servi ce provider has a staff recruitment and retention policy that promot es the selection of qualified personnel based on required know ledge, skills and compet ences. Remark from the auditor: The ser vices of the social ser vice pr oviders does not meet this cr iterion of the EQUASS Assurance certif icat ion program Strengths Improvem ent & developments The staff recruitment and retent ion Personnel policy / job descriptions policy is descr ibed in the p ersonnel do not include detailed inf ormation policy. The principles f or equalit y concerning the required knowledge, and non-discr imination ar e part of skills and competences of employees the same policy. All employees have of diff erent positions . individual job descr iptions . The staff policy lacks leaving The exper ience and prof essional principles, which shoul d also be know- how of the staff of Foundat ion developed. In the work rules only ensures the qualit y and consistenc y date to give advance notice ar e 10 of the services. mentioned. Foundation has devoted and Personalipoliitika st / competent staff, which is highly ametijuhenditest puudub detailne valued by the persons served . inf ormatsioon erinevatelt ametikohtadelt oodatavate It appeared f rom the inter views wit h teadmiste, oskuste j a kompetentside the staff that they are aware of their nõuete kohta. roles, r ights and dut ies. It also cam e Personalipo liitikast puudub amet ist out that the employees and lahkumise osa, mida tuleks lisada. caretakers like their jobs and are Töökorralduse reeglites on märgitud devoted to deliver ing high qualit y vaid etteteatam ise tähtajad, kuid ser vice. puudub protseduur iline kirjeldus. 10. The social service provider operates in compli ance w ith mandator y national legislati on, providing appropriate w orking conditions, adequate and agreed staff level and staff ratio, and appropriate rew arding for staff and vol unteers. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Ass urance certif ication program Strengths Improvem ent & developments The documentation of Foundation Cont inuous eff ort should be put to meets legal requir ements and is f inding volunteers, trainees and reviewed to do this. other alternat ives / additions to staff (f.e during vacat ions, if help is most The work conditions are assessed needed). regularly and adapt ed to the needs of the staff . The working condit ions Järjepidevat tähelepanu tuleks are discussed during perf ormance pöörata vabataht like, praktikantide ja reviews of the employees and teiste alternatiivide leidmiseks necessar y changes are made. täienduseks olemasolevale personalile (näiteks puhkuste ajaks, Risk analysis of the working mil enim abi vajatakse). conditions is carried out regularly. Feedback is asked f rom employees. 11 The principles f or showing recognit ion to employees is part of the working rules . Employees ar e given bonuses, joint events f or employees are organized , important personal events are celebrated etc. 11. The social service provider trains all staff based on a plan for leaning and development and evaluates the effecti veness of the training. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Staff development and training needs A written summar y and analysis are assessed annually and are about the evaluat ion of the training descr ibed in the training plan, which activities is m issing and should be in part on the annual activit y plan . made and recor ded. The evaluation may be presented in the annual The staff of Foundation is trained report- based on their prof essional needs and e xpectat ions. The needs are An over view of the trainings planned discussed during annual and passed should be created to get perf ormance reviews. a syst ematic over view of the training activities f orm the organizat ion’s The employees showed appreciat ion perspect ive. concerning the trainin gs received. Planeer itud ja läbitud koo litustest Feedback on trainings is collected tuleks teha koond(tabel), et omada after each training and the value and süsteemset ülevaaadet the success of the training is koolitustegevuse kohta asutuse evaluated per iodically. vaates. Hinnangu võib esitada nt aastaaruandes. The overall eff ectiveness of the training s is evaluated based on the Kirjalik kokkuvõte ja analüüs annual training plan and the koolitustegevuse ef ektiivsuse f eedback gained f rom the hindamise kohta tuleb koostada ja 12 employees. säilitada. 12. The social servi ce provi der applies requirements for competence in the identified roles and functions of staff and evaluates them on annual basis. Remark from the auditor: The ser vices of the social ser vice pr oviders does not meet this cr iterion of the E QUASS Assurance certif icat ion program Strengths Improvem ent & developments The competence r equirements f or The competences of personnel that employees ar e descr ibed in gener al help to rise the life qualit y of the in the personnel policy. persons ser ved have to be more clearly descr ibed. There are r egular meetings and regular perf ormance reviews wit h Töötajate kompetentsid, mis on staff . Daily perf orma nce is discussed seotud teenuse saaj ate eluk valiteedi over the regular meetings. Dur ing tõstmisega, peavad olema selgemalt the reviews the results of the work kirjeldatud. done are analyzed and the objectives f or the f ollowing period are agreed upon. 13. The social servi ce provi der recognizes the staff as a resource for feedback on organizational perf ormance, service development and staff development Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The involvement of staff in t he planning and evaluation of services is described in the personnel policy. Feedback on perf ormance is given 13 and asked continuously. Foundat ion recognizes staff as a usef ul tool f or gaining inf ormation. There are regular staff meetings , perf ormance reviews, sat isf action surveys, etc. The managers are always willing to listen act ively, what the employees have to say. 14. The social service provi der has mechanisms in place to enhance satisfaction and motivation of staff Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Staff perf ormance evaluat ions and There could be regular super vision employees’ sur veys are the main off ered to staff to help to deal with tools used to gain f eedback on emotional stress (f rom work). employees’ satisf action and motivat ion. Töötajatele võiks võimaldada regulaarset super visioon i, et aidata Mechanisms to provide satisf action neil toime tulla (tööst tingitud) and mot ivat ion ar e descr ibed in the emotsionaalse stressiga. working rules . Staff are involved and they are asked and given f eedback regular ly. Special events f or showing recognit ion to staff are organized, as Foundation values highly its personnel. There are trainings organized and also meetings to share exper iences. 14  15. The social servi ce provi der assures the rights of persons served outlined in a Chart er of Rights w hich is based on the EU Charter of Fundamental Rights , the European Convention f or the Protection of Human Rights and Fundamental Freedoms of the Council of Europe and other int ernati onal human ri ghts conventions, especiall y those elaborat ed under the United Nations. Remark from the auditor: The ser vices of the social ser vice pr ovide rs meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments All the documents of Foundation ar e based on the legislat ion of Estonia. Foundation has developed the rights and duties of persons ser ved, which conf orm to international human rights convent ions. Foundation is devoted to the protection of the rights of persons ser ved and the promotion of equal opportunit ies, equal treatment, f reedom of choice, self -determinat ion and equal participat ion. The staff demonstrated their knowledge of the rights and dut ies through the inter views. 16. The soci al service provider informs the person served about his/her rights and duties especiall y to equal treatment on grounds of age, disabilit y, gender, race, religion or belief and sexual orientation before recei ving the services. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program 15  Strengths Improvem ent & developments The rights and duties are introduced to persons ser ved by staff . They ar e part of the service deliver y contract. The service provision is regulated b y the ser vice contract and the there are rules of the house f or ever y ser vice. The rights and dut ies are discussed f rom time to time with the persons ser ved. Equal treatment of customers is an under lying principle in the principles of service provision. The clients demonstrated their knowledge of the rights and dut ies through the inter views. 17. The social service provi der has accessibl e complai nt management s ystem w hich registers feedback on performance from persons served, purchasers and other relevant stakeholders. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Foundation has a procedure f or handling complaints. There are var ious ways of complaining - oral complaint is most common, but there are also wr itten complaints. 16 If was verif ied dur ing the interviews that the persons served and other relevant stakeholder s were awar e of the ways of submitting complaints . The complaints are dealt wit h and answered. The complaint management system proves to be transparent. 18. The social service prov ider respects the fundamental right to self-determination of the person served. They freel y det ermine their political status and freel y pursue their economic, soci al and cultural development. Remark from the auditor: The ser vices of the social ser vice pr o viders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Foundation recognizes and supports It does not come out f rom the the right of persons served to the procedures ver y clearly, how the polit ical, economic, social and social ser vice provider evaluates its cultural self -determination. activit y in respecting the f undamental r ight to self - This is one of the f undamental rights determination of the person s ser ved, of service recipients. Support f or it would be advisable to add this self -determination is shown through activit y in the qualit y manual. the individual planning process and by the implementation of Kriteerium the on täidetud, kuid individual plan. tagamaks iga -aastane enesemääratlusest lugupidamise The code of ethics of Foundation alane hindamistegevus, on ref lects on how self -determination is soovitatav see tegevus lisada Foundation is understood. kvaliteedi käsiraamatusse. Feedback is collected though clients’ sur veys and per iodic meetings . It became evident through the 17 inter views that the staff supported the right to self -determinat ions of clients and that the persons ser ved were handled wit h respect. 19. The social service provi der facilitates the person served in choosing and having acc ess to advocates and/or supporting persons. Remark from the auditor: The ser vices of the social ser vice pr oviders does meet this crit erion of the EQUASS Assurance certif icat ion program Strengths Improvem ent & developments Foundation off ers support to the persons ser ved and stand s f or their rights. Feedback f rom person ser ved and the f amily members is gained through satisf action sur veys . The perf ormance in f acilitating persons ser ved in having access to advocates and/or supporting persons is assessed dur ing self -evaluations. 20. The social service provi der defines and documents its policy on ethics that respects and assures the dignit y of the persons served, protects them from undue risk and promotes soci al justice Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments In their work the employees of Foundation and caretakers f ollow the 18 principles set in the code of ethics of the organization. The members of staff showed awareness about the related ethic principles. The ethical principles respect and assure the dignit y of the persons ser ved, pr otect them f rom undue risk and promote social justice. 21. The social service provid er operat es mechanisms w hich prevent the physi cal, mental and financial abuse of users. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & deve lopments It is the dut y of the staff to ensure As it did not com e out f rom the that the persons served are procedures ver y clearly, how the protected f r om physical and mental ser vice provider evaluates the violence including taking advantage eff ectiveness of its policy to prevent of them in any way. physical, mental and f inancia l abuse of persons ser ve d, it should be Procedures f or abuse pr event ion descr ibed in mor e detail in the self - have been. assessment procedure. Members of staff showed awareness Kuivõrd protseduur idest ei tulnud about the re lated principles and selgelt välja, kuidas asutuses procedures. hinnatakse oma käitumist teenuse saajate f üüsilise, vaimse ja Foundation evaluates its prevent ion majandusliku ärakasutamise activities regularly. ennetamisel, siis tuleks seda detaisemalt kirjeldada organisatsiooni sisehindam ise korras. 19  22. The social servi ce provi der provides services in a safe system of w orking w ithin a safe environment to ensure the physical securit y of persons served, their fa milies and caretakers. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Foundation provides services in a The improvement actions derived saf e system of workin g wit hin a saf e f rom the risk assessment should be environment. Risk assessments have included in the annual plans. been conducted and related action s planned. The assessments are As new locations ar e planned, they carried out annually. The necessar y have to undergo risk ass essments amendments are made after that. while starting to use them. There exist all necessar y health and The territory is surrounded by a saf ety procedur es of the f ence, the gate of which should be organizat ion. closed f or the sake of the persons ser ved. The physical securit y of persons ser ved and employees has been Riskide hindamisest tulenevad ensured through these activit ies. parendustegevused tuleks lisada aastasesse tegevuskavasse. Kuivõrd plaanis on laiendada tegevust t eist esse k ohtadesse, tuleb tagada nendes kohtades riskide hindamise läbiviimine nende kasutuselevõtmisel. Kuivõrd keskuse hoovi ümbr itseb aed, oleks soovitatav see kinni hoida teenuse saajate turvalisuse tagamiseks. 20  23. The social ser vice provider defines, documents, monitors and evaluat es a set of principles, values and procedures that govern behavi our in servi ce deli ver y containing aspects of confidentialit y, accuracy, pri vacy and integrit y. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The principles, values and procedures in ser vice deliver y are descr ibed mainly in the personnel policy, working rules, c ode of ethics, rules of the house, descr ipt ions of the ser vices and. The values ar e depicted in the development plan. All of the documentat ion has been developed in cooperation with the staff of the organizat ion. It was demonstrated through the inter views of staff that they ar e aware of the values and procedures that govern behavior in the ser vice deliver y process and the et hical principles related to their work. 24. The social service provider defines, documents, monitors and evaluat es procedures for a ssuring confidentialit y of data regardi ng the persons served and the service provided to them. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments 21 The procedures f or assuring conf ident ialit y of data have been def ined and documented in the data privacy policy. The related pr ocedur es and principles are over viewed regularl y with personnel and with persons ser ved. 25. The social service provider defines the roles and responsibilities, authorities and the interrelation of all personnel w ho manage, desi gn, deli ver, support and evaluate the service provision to person served. Remark from the auditor: The ser vices of the social ser vice p r oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The role of the management is The job description of the manager wr itten in the statues of the needs to be developed. organizat ion. The roles of the employees involved in the provision Välj a tuleb t öötada asutuse juhataja of services a re def ined and ametijuhend. descr ibed in their j ob descriptions . The provision of the service is descr ibed in the rules of procedures of the service and rules of the house of diff erent services. Contact inf ormation is available also on the web page of Foundation and relevant inf ormation has been communicated to t he clients and other stakeholders . 22  26. The social service provi der w orks in partnership w ith other organisations in the provision of servi ces. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Foundation works closely with its It might be usef ul to describe its main cooperat ion partners. It does internal and ext er nal partnership cooper ation wit h local communit y relat ions in the f orm of a table. Also government and municipalit y a graphic depict ion of the var ious government, educat ional stakeholders of the organization establishments, health inst itutions, could be dr awn. etc. There are several good cooper ation partner s abroad (f .e in This helps the organizat ion to Finland). systematically t hink through, with whom and why it cooperates and Names of the main cooperat ion what are the mutual poi nts of partners are listed on the home interests and objecti ves, also to page. evaluate mor e systematically the added value of partnership s. Foundation values and relies on its partners. Võib osut uda kasulikuks kirjeldada oma sisemised ja välised huvigrupid The value of the cooperation is tabeli vorm is. Samuti võib nt evaluated in various f orms – at joonistada graaf ilise esituse oma meetings, through satisf action parnerit est. sur veys, etc. See aitab asutusel süsteemsemalt läbi mõelda, kellega ja miks koostööd tehakse ning millised on vastastikused huvipunktid ja eesmärgid, samuti hinnata süsteemsemalt koostööst saaavat lisandväärtus t. 23  27. The social service provider w orks in partnership w ith p ersons served, purchasers and other stakeholders in the development of services. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & development s The persons ser ved, co -operat ion partners, f inancing bodies and other stakeholders are involved in t he development of services of Foundation thr ough meetings and satisf action sur veys. Foundation evaluat es the mutual cooper ation and their partners' satisf action and f eedback. The cooperat ion partners value Foundation’ f lexibilit y, individual solutions, prof essionalism, development -orientation and good communication. 28. The social service provi der includes persons served as acti ve partici pants in planning and have set up appraisal made up of on-going structured dialogue process in the management of the service, including the definition of the needs, the defini tion of the services, as w ell as of the evaluation of qualit y. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The ser vice recipients have been 24 inf ormed about their participation possibilit ies. The clients are involved in the assessment of individual needs and evaluat ion of results. They have the right to complain and right to view their personal f iles . The criterion was ver if ied sat isf ied also through exploring client work documentat ion and through inter views with staf f and clients. 29. The social service provi der institutes an annual evaluation of partici pation of persons served bot h on indi vidual and/or group basis. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQ UASS Assurance certif ication program Strengths Improvem ent & developments The measures, activities and polic y To ensure that t he policy and f or client participat ion ar e agreed procedures f or involvement ar e with the persons ser ved. This is reviewed annually and documented constant ly rem inded to them during f .e in the m inutes of meetings, this the ser vice deliver y period . should be laid down in wr iting . Tagamaks, et kaasamise põhimõtted ja protseduur id vaadatakse iga - aastaselt ja ülevaatus dokumenteeritakse, tuleks see kirjalikus vormis sät estada . 30. The social service provi der operates specific instruments f or users to improve their personal empow er ment and personal situation and that of their communit y. 25 Remark from the auditor: The ser vices of the s ocial ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Empowerment of the persons ser ved is an integral part of ser vice deliver y. Empowerment r elated activit ies ar e descr ibed in t he individual plans and were evidenced in services’ deliver y processes and also came out f rom the inter views with staff and persons ser ved. The client work is aimed at support ing the clients and improving the qualit y of lif e their lives. The tangible results of empowerment ar e depicted in the individual plans of the persons ser ved. The criterion was ver if ied sat isf ied through exploring client work documentat ion and through inter views with staff and clients. 31. The social service provi der operates specif ic mechanisms for establishing an empow ering environment. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Empowerment of perso ns ser ved is an int egral part of service deliver y. The employees ar e trained about 26 empowerment and the subject is discussed dur ing organizat ion’s meetings. 32. The social servi ce provider sel ects programmes w hich are based on a needs assessment at the location w hich is most convenient for the person served, famil y and care takers Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & development s Foundation has an over view of t he needs of the persons ser ved . This is gained through assistance plans and individual plans. There is a wait ing list held by the Municipalit y Gover nment of Lihula of the potent ial persons served. The buildings of the Foundation ar e located in the center of Lihula and are well accessible . There is also a nice garden. 33. The social service provider offers programmes consistent w ith the identified needs of its customers and objecti ves for the programme. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The needs and expectations of the f unding bodies are communicated to the Foundat ion through meetings and 27 other ver bal and wr itten communications. Related minut es and correspondence is maintained. Stakeholders’ sat isf action s ur vey was carried out lately, which also ref lected t he f ulf illment of expectat ions and goals. The needs and f eedback of diff erent stakeholders (social partners) have been discussed during meetings and during daily cooper ation (though e - mails, telephone) . Also sur veys have been conducted to understand satisf action and success rates of ser vices. The success and results of the exist ing ser vices have been determined and is descr ibed in the activit y report of the organizat ion . Long-term strategic goals are descr ibed in the development plan of Foundation. 34. The social service provi der operates indi vidual processes that are dri ve n by the needs of the person served. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The f ocus in ser vice provision in on individual planning. Individual plan s ar e drawn up f or persons ser ved, depending on the 28 nature of the service. F.e Equal methodolog y and WASA methodolog y are used. 35. The social service provider documents the planni ng of services based on the ident ific ation of indi vi dual needs and expectations of persons served in an Indi vidual Plan. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developm ents The clients’ individual needs and The individual planning process expectat ions are wr itten down in the (including the f ormation of the plan) individual plans. and the inclusion of persons ser ved should be better described in the The individual plans involve all the ser vice deliver y processes. inf ormation set by the criter ion and are agreed by the persons ser ved Teenuse saajate individuaalse (signed), which was ver if ied by planeer imise protsess (sh plaani examples of client do cumentation koostamine) ning nende kaasamine seen during the site visit. tuleks selgemalt kirjeldada teenuse osutamise kordades. Interviews were conducted with persons ser ved that ver if ied that the clients were knowledgeable of their objectives and relat ed activit ies. The individual plans wer e agreed with the customers. The eff ectiveness of th e ser vice deliver y on the collective level is measured through satisf action sur veys and f eedback questionnaires. 29  36. The social service provider identif ies, documents, and maintains the ke y servi ce deli very processes to the persons served in line w ith its vision, mission statement and quali t y policy. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The services provided by Foundat ion are descr ibed on the home page of There exist various documents that the organization, also key ser vice descr ibe the diff erent aspects of the deliver y procedures have been deliver y processes of key ser vices. It document ed. would be advisable to draw up one concrete document t hat would cover The service deliver y proces ses are the whole process of one concrete in line with Foundation ’s vision, ser vice. mission and qualit y principles. Põhiprotsesse (põhiteenuseid ) kirjeldavaid dokumente on mitmeid erinevaid (teenuse osutamise korrad, kodukorrad, töökorralduse reeglid ja inf o teenuste kohta kodulehel), mis hõlmavad teenuse osutamist erinevatest aspektidest. Oleks mõttekas koostada iga teenu se kohta üks konkreetne portsessikirjeldus, mis hõlmaks kogu teenuse osutam ise protsessi (teenusele tulekut, teenusel olemist ja teenustelt lahkumist). 37. The social service provi der review s this delivery process and maintains control over the deli very of t he servi ce. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments 30 Foundation staff has reviewed its The social ser vice provider has to qualit y manual (including the assure that the per f ormance of the perf ormance of the ser vice deliver y ser vice deliver y pr ocess is monitor ed process) during the process of and reviewed on regula r basis (also preparing f or EQUASS Assurance internal audit is conducted) after the audit. The test audits were used to f inal audit of EQUASS Assur ance. gain additional assurance. The See that the f ollowing criteria are results were protocolled. evaluated: 11, 18, 19, 21, 26, 44, 45. Regular meetings, checks, reviews Sotsiaalteenuse osutajal tuleb and controls are conducted t o assur e tagada, et teenuse osutamise maintaining control over the deliver y protsessi jälgitakse ja analüüsitakse of services. regulaarselt ( viiakse läbi ka siseauditeid) pärast EQUASS Assurance lõppauditit. Kindlustada, et järgmisi kriteeriumeid hinnatakse: 11, 18, 19, 21, 26, 44, 45. 38. The social service provider ensures that the person served can access a continuum of servi ces that span from earl y int ervention to support and respond t o changing requi rements over time. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Foundation ensures that the person s ser ved can access a continuum of As a major improvement the service ser vices as n eeds of persons served provider is planning to become a are evaluat ed and descr ibed in regional compet ence center individual plans. providing healt h care and social ser vices (f oundation of f irst level According to the individual plans, health center in Lihula, special care necessar y ser vices are provided. unit in Lihula (3 f amily houses) and Regular reassessments are made. If general car e unit in Kasar i ). needs change, the individual plans are amended. Suur ima aredustegevusena planeer ib teenuse osutaja 31 If the end of the ser vice is near, piirkondlikuks tervishoiu - ja Foundation makes sure with its sotsiaalteenust e cooper ation partners that the kompetentsikeskuseks kujunemist continuat ion of service provision is (esmatasandi tervisekeskus, guaranteed somewhere else . The erihoolekandeüksus Lihulas (3 continuat ion of service deliver y is peremaja), Kasar i hoolekandeüksuse monitored and evaluated regular ly. loom ine). 39. The social servi ce provi der develops a seamless continuum of services and reduces barriers in a multi -disciplinary or multi -agenc y setting. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication pro gram Strengths Improvem ent & developments The ser vices, that are part of the individual plan, are provided to the customers. All the obstacles in ser vice deliver y are reported. The criterion was verif ied f ulf illed by exploring the client work documentat ion, where evidence was f ound about multidisciplinar y approach. There is periodic r eporting on the f ulf illment of the plan and assessment of results. 40. The social service provi der operates servi ces from a holistic approach based on the needs and ex pectations of the person served w ith the aim of improving the qualit y of life for the person served. 32 Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Foundation uses client -centered holist ic approach, which is aimed to improve client ’s qualit y of lif e. The qualit y of lif e init iat ive’s eff ectiveness is measured and reported in individual plans . Regular assessments of individual plans are made. The criterion was verif ied f ulf illed by exploring the client work documentat ion, where evidence was f ound about measur ing the qualit y of lif e. 41. The social service provider identif ies the needed competences, skills and support for staf f to enhance the qualit y of life for person served. Remark from the auditor: The ser vices of the social ser vice pr oviders does not meet this cr iterion of the EQUASS Assurance certif icat ion program Strengths Improvem ent & developments Trainings are pro vided to employees, The necessar y competences and which was evidenced by training skills to enhance the qualit y of lif e plans of Foundat ion and came out f or person served need to be f rom inter views. descr ibed in job descript ions and/or staff policy. Vajalikud kompetentsid ja oskused tuleb kirjeldada ametijuhendites 33  ja/või personalipoliitikas, mis on vaj alikud teenuse saajate teenuse kvaliteedi tõstmiseks. 42. The social service provider identifies its business results and provides formal periodic and ind ependent revi ew and procedures t o achieve the targeted results. Remark from the auditor: The ser vices of the social ser vice pr oviders does not meet this cr iterion of the EQUASS Assurance certif icat ion program Strengths Improvem ent & developments The g oals, activities and expected results are descr ibed in the annual The key perf ormance indicators have plans. been set in the strategic plan. The annual plans should be Results are repor ted in annual complemented wit h the related f inancial reports and activit y reports indicators f or the year and of Foundation. inf ormation of the target values should also be available. For the External audits are conducted by the sake of f uture benchmarking it would f inancial auditors . be wise to develop a system of perf ormance measures so t hat changes in trends in time could be obser ved. See that the following criteria are measured and evaluated: 16, 42, 43, 44, 45, 49. Peam ised tulemusmõõdikud on esitatud strateegilises plaanis. Aastaplaane tuleks täiendada seotud indikaator itega aasta kohta ning inf o nende eeldatavate saavutusmäärade kohta peaks samas olema kättesaadav. Et tulevikus oleks võimalik võr dlusanalüüse läbi viia 34  ning jälgida indikaatoride trendide muutust ajas, tuleks välja töötada kõikehõlmav mõõdikute süsteem asutuse tegevuste tulemust e mõõtmiseks. Kindlustada, et järgmisi kriteeriumeid mõõdetakse ja hinnatakse: 16, 42, 43, 44, 45, 49. 43. The social servi ce provi der identifies and registers the outcomes and benefits for person served of the recei ve services o n individual and collecti ve basi s. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Foundation gathers and documents The organizat ion should put some inf ormation regarding results of more eff ort into developing an providing ser vices (both on optimal way on how to measure the individual and collective basis). achieved results on collect ive basis and the benef its f or persons ser ved Individual plans are assessed of received ser vices on collective regularly. Conclusions are dr awn and basis. summaries are made on collect ive basis annually. It would be good to establish a clear link bet ween indicators in individual The summary is presented in the plans and indicator s in the annual annual activit y report . plan. Organisatsioon peaks enam tähelepanu pöörama optimaalse viisi väljatöötamiseks, et mõõta osutatud teenuse tulemusi kollektiivsel tasemel ning teenuse saajate kasutegurit kollektiiv sel tasandil. Hea oleks luua otsene seos individuaalses plaanis esitatud 35  tulemusindikaator ite ning aastaplaanis esitat ud indikaator ite vahel. 44. The social service provider evaluates its business results in order to determine best value for purchasers a nd funders ( ‘best value’ can also be expressed in relation to the increased qualit y of life offered to the person bei ng served). Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif icatio n program Strengths Improvem ent & developments Foundation evaluat es the results and added value of its work during regular meet ings and through clients’ and other stakeholders’ sur veys . The added value of the ser vices t o individual service recipients is measured using the individual plan s. 45. The social service provider evaluates the indi vidual and collecti ve satisfact ion of persons served and other stakeholders by internal and/or external evaluation. Remark from the auditor: The ser vices of the s ocial ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments 36 Foundation organizes regular sur veys to receive fe edback f rom the persons ser ved. Also the satisf action of other stakeholders is evaluated by using diff erent means like meetings, questionnaires , sur veys etc. 46. The social service provider provides accessible and easil y understandable records on outcome, including personal perception and achievements Remark from the auditor : The ser vices of the social ser vice pr oviders does not meet this cr iterion of the EQUASS Assurance certif icat ion program Strengths Improvem ent & developments The records on outcome are The annual r eports should include communicated to stakeholders, staff more detailed inf ormation about the and persons ser ved. organizat ion’s per f ormance and results of various analysis and They are disclosed on the home evaluat ions. page of Foundation. There should be m ore emphasis in the annual activit y r eports to include personal perceptions and achievements. Aastaaruanded peaksid detailsemalt hõlmama inf ot asutuse tegevuse tulemuste kohta ning er inevate analüüside ja hindamiste tulemusi. Aastaaruannetes tuleb rohem rõhku panna personaalset e hinnangute ja saavutuste k ajastamisele. 37  47. The soci al service provider acti vel y disseminates organization performance among its staff, service users and external stakeholders. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUAS S Assurance certif ication program Strengths Improvem ent & developments Foundation reports its perf ormance to f unding bodies, staff and cooper ation partners . Activit y report is also available on the home page Foundation. Inf ormation is disseminated thro ugh e-mail, home page, staff meetings, etc. 48. The social service provider has a standard procedure for continuous improvement on the basis of an improvement cycle. Remark from the auditor: The ser vices of the social ser vice pr oviders does not meet this cr iterion of the EQUASS Assurance certif icat ion program Strengths Improvem ent & developments The PDCA cycle is used, but not Cont inuous impr ovement procedur e descr ibed. Annual plan s are drawn needs t o be dr awn up as an addition up and are reviewed periodically. to the annual planning and revie w process, that would ref lect the All the processes and activities are PDCA-cycle approach. reviewed regular l y. Clearer dist inct ion should be made The results and perf ormance of bet ween impro vement projects and Foundation is measured and innovat ions. descr ibed in annual reports. In f uture more attention could be Qualit y improvement activit ies are paid on carr ying out the improvement descr ibed in the annual plans , but projects f ollowing more precisely the 38 need to be m ore thoroughly principles of project management document ed. and TQ M (total quality management). F.e starting to f ollow t he EQUASS Välj a tuleb töötada pideva principles is one of the impr ovement täiendamise pr ot seduur lisaks projects f or the service provider. aastase planeer imise ülevaatuse protseduur ile, mis peegeldaks PDCA - tsüklil põhinevat lähenemist. Tuleks teha selget vahet parendusprojektide ning innovat iivsete töömeetodit e vahel. Tulevikus peaks enam tähelepanu pöörama sellele, et parendusprojektide puhul järgitakse projektijuhtimise ja TQM-i (täielik kvaliteedijuhtim ine) printsiipe. 49. The social service provi der identifies performance i ndicators for measuring the results of the improvement actions. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments EQUASS Assurance implem entation has been documented proper ly. This was verif ied through inspecting the relat ed doc umentation dur ing sit e visit. 50. The servi ce provider introduces and manages innovative w ays of w orking that have been identified based on the needs of stakeholders. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program 39  Strengths Improvem ent & developments Foundation f inds ways of being innovat ive, taking into account the As an innovat ion the service provider needs and expectations of is planning to start to use stakeholders. ext ensively diff erent IT solutions (electronic f iles system, electronic F.e. EQUAL methodolog y was started individual plans, clients’ computers to be used lately. etc). All innovation projects related Uuendusena planeerib teenuse inf ormation was ver if ied to be osutaja IT lahendust e document ed. laiaulatuslikumat kasutuselevõtmist (elektoonne f ailihaldussüsteem, elektroonsed individuaalsed, kliendiar vutid jne). 4. Agreed additional development / improvements The applicant decided on the following i mprovement actions and/or additional developm ent f or the period of two years: Criteria Short description of the actions (including SM ART objecti ves) The values on the home page and strategic plan and in the 1 personnel policy do not over lap, make the ne cessar y changes. Kodulehel ja ar engukavas esitatud väärtused ei ühti personalipoliitikas tooduga. Teha vajalikud korrektuurid. Renew the charter of the ser vice provider. 2 Give all documents numbers and make links bet ween related documents inside those do cuments. Uuendada sotsiaalteenuse osutaja põhikirja. Anda igale dokumendile number ning lisada dokumentide siss e 40  viited seotud dokumentidele. Complement the web page with some addit ional inf ormation about 4 the organization, in order to be more visible f or the stakeholders. More media cover age / publicit y could serve as an ambition f or the f uture. Täiustada kodulehte inf oga organisatsiooni kohta, et olla rohkem nähtav huvigruppidele. Meediakajastused / suurem teavitustöö võiks olla üheks tuleviku ambitsiooniks. Inf ormation has to be included to the annual planning process about 5 the inf ormation that is disclosed in the annual report, to ensure the integrit y of inf ormation. Aastane planeer imise protseduur peaks sisaldama inf ot selle kohta, missugune inf ormatsioon lisatakse aastaaruandesse, et tagada inf o terviklikkus. The annual plan of the f oundat ion f or 20 16 does not include detailed 6 (Q 11) inf ormation about the main ser vices deliver ed as well as expected outcomes and measures. Also perf ormance meas ures are missing that would make it possible to measure expected outcom es and eff iciency. Draw up a plan f or 2017 t hat included all necessar y inf ormation. Asutuse 2016. aasta tegevuskava ei sisalda inf ormatsiooni peamiste osutatavate teenust e ja oodatavate t ulemuste kohta. Saamuti puudub inf ormatsioon tulemusmõõdikute kohta, mis võimaldkas mõõta oodatavaid tulemusi ja tulemuslik kust. Koostada 2017. Aasta kohta plaan, mis sisaldaks kogu vajalikku inf ot. More attention and conscious act ions should be targe ted to satisf y 7 the needs and expectations of the local communit y and the wider societ y. Suunata enam tähelepanu ja teadli kke tegevusi kohaliku kogukonna ja ka laiemalt ühiskonna vajaduste ja oot uste rahuldamisele. Personnel policy / job descrip tions do not include detailed 9 (Q 18) inf ormation concer ning the required knowledge, skills and 41  competences of employees of diff erent positions. Add missing inf ormation. The staff policy lacks leaving principles, which should be included. Personalipoliitikast / am etijuhenditest puudub detailne inf ormatsioon erinevatelt ametikohtadelt oodatavate teadmiste, oskuste ja kompetentside nõuet e kohta. Lisada puuduv inf ormatsioon. Personalipoliitikast pu udub ametist lahkumise osa, mis tuleks lisada. Pay continuous effo rt to f inding volunteers, trainees and other 10 alternatives / addit ions to staff (f .e during vacations, if help is most needed). Pöörata järjepidevat tähelepanu tuleks vabatahtlike, praktikantide ja teiste alternatiivide leidm iseks täienduseks olemasolevale personalile (näiteks puhkuste ajaks, mil enim abi vajatakse). A wr itten summar y and analysis about the evaluation of the training 11 activities is missing and should be made and recor ded. An over view of the trainings planned and passed should be cr eated . Kirjalik kokkuvõte ja analüüs koolitustegevuse ef ektiivsuse hindamise kohta tuleb koostada ja säilitada. Planeer itud ja läbitud koolit ustest tuleks teha koond(tabel). The competences of personnel that help to rise the lif e qualit y of 12 (Q23) the persons ser ved have to be more clear ly described. Töötajate kompetentsid, mis on seotud teenuse saajate elukvaliteedi tõstmisega, peavad olema selgemalt kirjeldatud. There could be regular super vision off ered to staff to help to deal 14 with em otional stress (f rom work). Töötajatele võiks võimaldada regulaarset super visiooni, et aidata neil toime tulla (tööst tingitud) emotsionaalse stressiga. 42  It does not come out f rom the procedures ver y clearly, how the 19 annual perf ormance evaluation in f acilitating person s ser ved in having access to support ing persons is evaluated, this should be descr ibed in more detail in the self -evaluations procedur e more clearly. Kuivõrd pr otseduur idest ei tulnud selgelt välja, kuidas iga -aastaselt hinnatakse oma käitumist t eenuse sa ajate abistamisel t ugiisiku leidmisel, siis tulek s seda detailsemalt kirjeldada organisatsiooni sisehindam ise korras. It did not come out f rom the procedures ver y clearly, how the 21 ser vice provider evaluates the eff ectiveness of its policy to prevent physical, mental and f inancial abuse of persons ser ved, this should be descr ibed in more detail in the self -assessment procedur e. Kuivõrd protseduur idest ei tulnud selgelt välj a, kuidas asutuses hinnatakse oma käitumist teenuse saajate f üüsilise, vaimse j a majandusliku ärakasutamise ennetamisel, siis t uleks seda detaisemalt kirjeldada organisatsiooni sisehindam ise korras. The improvement actions der ived f rom the risk assessment should 22 be included in the annual plans. As new locations are planned, the y have to under go risk assessments while starting to use them. The territor y is surr ounded by a f ence, the gate of which should be closed f or the sake of the persons ser ved. Riskide hindam isest tulenevad parendustegevused tuleks lisada aastasesse tegevuska vasse. Kuivõrd plaanis on laiendada tegevust t eistesse kohtadesse, tuleb tagada nendes kohtades riskide hindamise läbiviimine nende kasutuselevõtmisel. Kuivõrd keskuse hoovi ümbr itseb aed, oleks soovitatav see kinni hoida teenuse saajat e turvalisuse tagami seks. 25 The job description of the manager needs to be developed. 43  Välj a tuleb töötada asutuse juhataja ametijuhend. It might be usef ul to descr ibe its internal and exter nal part nership 26 relat ions in the f orm of a table. Also a graphic depiction of th e var ious stakeholders of the organizat ion could be dr awn. Võib osutuda kasulikuks kirjeldada oma sisemised ja välise d huvigrupid tabeli vor mis. Samuti võib nt joonistada graaf ilise esituse oma parner itest. To ensure t hat the policy and procedures f or involvement are 29 reviewed annually and documented, this should be laid down in wr it ing. Tagamaks, et kaasamise põhimõtted ja protseduur id vaadatakse iga - aastaselt, tuleks see kirjalikus vormis sätestada. The individual planning process ( including the f ormation of the plan) 35 and the inclusion of persons ser ved should be better described in the ser vice deliver y processes. Teenuse saajate individuaalse planeer imise protsess (sh plaani koostamine) ning nende kaasam ine tuleks selgemalt kirjeldada teenuse osutamise kordades. 36 There exist var ious documents that describe the diff erent aspects of the deliver y processes of key ser vices. It would be advisable to draw up one concr ete document that would cover the whole process of one concrete ser vice. Põhiprotses se (põhiteenuseid) kirjeldavaid dokumente on mitmeid erinevaid, mis hõlmavad teenuse osutamist erinevat est aspektidest. Oleks mõttekas koostada iga teenuse kohta üks konkreetne portsessikirjeldus, mis hõlmaks kogu teenuse osutamise protsessi. The socia l ser vice provider has to assur e that the perf ormance of 37 the ser vice deliver y process is monit ored and reviewed on regular basis after the f inal audit of EQUASS Assurance. Sotsiaalteenuse osutajal tuleb tagada, et teenuse osutamise protsessi jälgitakse ja analüüsitakse reg ulaarselt pärast EQUASS 44  Assurance lõppauditit , 38 As a major improvement the service provider is planning to become a regional competence cent er providing health care and social ser vices. Suur ima aredustegevusena planeer ib teenuse osutaj a piirkondlikuks tervishoiu- ja sotsiaalteenuste kompetentsikeskuseks kujunemist. The necessar y competences and skills to enhance the qualit y of lif e 41 f or person ser ved need to be descr ibed in job descriptions and/or (Q81,82) staff policy. Kompetentsid ja oskused tuleb kirjeldada ametijuhendites ja/või personalipoliitikas, mis on vajalikud teenuse saajate teenuse kvaliteedi tõstmiseks. 42 (Q83) The annual plans should be complemented with perf ormance indicators and the ir target values. For the sake of f uture benchmarking it would be wise to develop a system of perf ormance measures so that changes in trends in time could be obser ved. Aastaplaane tuleks täiendada tulemusmõõdikutega ja nende eeldatavate saavutusmäärade ga. Et tulevikus oleks võimalik võrdl usanalüüse läbi viia ning jälgida indikaator ide trendide muutust ajas, tuleks välja töötada kõikehõlmav m õõdikute süsteem asut use tegevuste tulemuste mõõtmiseks. The organizat ion should put some mor e eff ort into developing an 43 optimal way on how to mea sure t he achieved results on collect ive basis and the benef its f or persons ser ved of received ser vices on collect ive basis. It would be good t o establish a clear link bet ween indicators in individual plans and indicators in the annual plan. Organisatsioon peaks enam tähelepanu pöörama optimaalse viisi väljatöötamiseks, et mõõta osutatud teenuse tulemusi kollektiivsel tasemel ning teenuse saajate kasutegurit kollektiivsel tasandil. Hea 45  oleks luua otsene seos individuaalses plaanis esitatud tulemusindikaator i te ning aastaplaanis esitatud indikaatorite vahel. The annual reports should include more detailed inf ormation about 46 (Q91, the organization’s perf ormance and results of var ious analysis and 92) evaluat ions. There should be more emphasis in the annual a ct ivit y reports to include personal per ceptions and achievements. Aastaaruanded peaksid detailsemalt hõlmama inf ot asutuse tegevuse tulemuste kohta ning er inevat e analüüside ja hindamiste tulemusi. Aastaaruannetes t uleb rohem rõhku panna personaalsete hinnangute ja saavut uste kajastamisele. Cont inuous improvement procedure needs to be drawn up as an 48 (Q95) addition to the annual planning and review process, that would ref lect the PDCA -cycle approach. Clearer distinction should be made bet ween improveme nt projects and innovations. In f uture more attention could be paid on carr ying out the improvement projects f ollowing more precisely the principles of project management and TQ M (total quality management). Välj a tuleb töötada pideva täiendamise protsedu ur lisaks aastase planeer imise ülevaat use protseduur ile, mis peegeldaks PDCA -tsüklil põhinevat lähenemist. Tuleks teha selget vahet par endusprojektide ning innovatiivset e töömeetodite vahel. Tulevikus peaks enam tähelepanu pöörama sellele, et parendusproje ktide puhul järgitakse projektijuhtimise ja TQM- i (täielik kvalit eedijuht imine) printsiipe. 50 As an innovation the ser vice provider is planning to start to use ext ensively diff erent IT solutions. Uuendusena planeerib teenuse osutaja IT lahenduste 46  laiaulatuslikumat kasutu selevõtm ist. 5. Closing remarks Lihula Municipal Council decided to f ound the Foundation of Lõuna - Läänemaa Center of Health and Social Welf are and to liquidate its predecessor Lihula Hospital . The f oundation celebrated its 15th anniversar y this year. The purpose of the f oundation is to off er healthcar e and social welf are ser vices to ever yone in the area. This health promot ing f oundation operat es in Läänemaa count y f rom Lihula town. There are the f ollowing services off ered by the f oundation: general social welf are, special car e (ever yday lif e support ser vice, employm ent support ser vice, supported living service, 24 hour special care ser vice) and domestic nurser y ser vice. The number employees is 87 and number of staff 33. The f oundation is a m ember of the Union of The Qualit y of Baltic Social Ser vices and theref ore qualit y orientat ed. The f oundation began with the preparat ion f or applying the EQUASS Qualit y Assurance certif icate approximately 2 years ago. Thinking things through, drawing up pro cedures, having discussions on what and how and why is done, clarif ying roles and responsibilities and putting things into a f ramework has helped the organizat ion on its qualit y path. The necessar y procedures exist and are implemented, the manage r and the board ar e supportive and staff prof essional. The f oundation implements person-centered approach in its ser vice provision, taking into account the needs and expectations of service users. The persons ser ved are systematically empowered and the aim is to ra ise the quality of their lives. The service user s found that the f oundation is f lexible and approachable; always an individual-centred approach is f ound. The manager is understandable towards the employees and the staff works as a good team. The development of staff is supported and they have great opportunities f or self -improvement in the f orm of trainings. Partners descr ibed the cooperation as constant ly developing and f lexible. The progressiveness , grand and br ave thoughts and innovative thinking of the manager help to run the organization and achieve improvements. The manager takes ever y change as a challenge and is always open to new ways of doing things. 47 The auditor experienced on site that the social ser vice provider perf orms in compliance with t he E QUASS Assurance cr iteria. The inter viewed representat ives of partners, f inancing bodies, employees and persons ser ved conf irmed this, which was ref lected through their inter views. The whole staff was kind and cooperative in introducing t he work of the Foundation, f inding necessar y evident ial materials and sharing inf ormation ab o ut f u lf i l l in g E Q U A S S c r i t er i a . For the per iod of following two years, some improvement actions were presented that are brought out in part 4 of the audit report. An over view of suggestions f or improvement that are mentioned under the specif ic criter ia is given as well in part 3. The improvement areas included in general the f ollowing: renewing documents, aligning inf ormation in different documents, adding links and numeration, also adding missing inf ormation to documents and procedur es; creating new home page and starting to use IT solutions; making self - evaluat ion process more thorough and record summaries and analyses to evaluate the perf ormance in diff erent f ields/criter ia. After verif ication of the indicators by r eviewing documentation, conduct ing inter views and performing site visit, the auditor was conf irmed that the criteria f or qualit y assurance of the Eur opean Quality f or Social ser vices are partially f ulf illed. In order t o become f ully compliant with EQUASS criter ia a thorough annual plan f or 2017 has to be drawn up that includes inf ormation about t he main ser vices and perf ormance indicators / their target values; the job descr iptions / staff policy has to include knowledg e, skills and competences of employees of different posit ions; also the competences of personnel that help to r ise the lif e qualit y of the persons ser ved have to be more clearly descr ibed; the annual reports should include more detailed inf ormation about the organizat ion’s perf ormance and results of var ious analysis and evaluat ions; cont inuous improvement procedur e needs to be drawn up and improvement projects should be properly recorded. The auditor wants to thank the employees of the Foundation f or good cooper ation dur ing the audit. *** 48 Sihtasutus Lõuna - Läänemaa Ter vishoiu j a Sotsiaalhoolekande Keskus loodi 2001. aastal Lihula Vallavolikogu otsusega, mil asutuse eelkäijaks olnud Lihula Haigla tegevus lõpetati. Sihtasutus tähistas oma 15. t egevusaastat sel aastal. Sihtasutus on Läänemaal Lihula linnas asuv ter vistedendav asutus, kelle eesmärgiks on ter vishoiu - ja hoolekande teenuste pakkumine kogu piirkonnale. Keskuses pakutakse järgmisi teenuseid: üldhoolekande teenus, erihoolekande teenus ( igapäevaelu toe tamine, töötamise toetamine, toetatud elam ine, ööpäevar ingne erihoolekanne sügava liitpuudeg a isikutele) ja koduõendus. Teenuse saajaid on 87 ning töötajaid 33. Asutus on Balt i Sotsiaalteenuste Kvaliteedi Liidu liige ning seeläbi kvaliteedi edendav organis atsioon. EQUASS Qualit y Assurance sertif ikaadi taotlemiseks vajalike ettevalmistustega alustas asutus ligikaudu kaks aastat tagasi. Asjade läbim õtlem ine, protseduur ireeglite koostamine, diskuteerim ine teemadel mida, kuidas ja miks teha, selged rollid ja va stutused ning asjade raamist ikku panemine on aidanud organisatsiooni oma k valiteedi teekonnal. Vajalikud pr otseduur ireeglid on paigas ning neid rakendatakse, nõukogu ja juhataja on toetavad ning töötajad prof essionaalsed. Sihtasutus rakendab teenuse saaja keskset lähenemist teenuse osutamisel, võttes arvesse teenuse saajate vajadusi ja ootusi. Järjepidevalt tegeletakse teenuse saajate jõustamisega ning eesm ärk on tõsta nende elukvaliteeti. Teenuse saaj ad leidsid, et asut us on paindlik ja vast utulev, alati p üütakse leida inimesekeskne lahendus. Juhataja poolt on mõistev suhtumine töötajatesse ja meeskond toimub kui hea tiim. Töötajate arengut toetatakse ja neil on palju eneset äiendamise võimalusi koolituste näol. Koostööpartner id kir jeldasid koostööd kui aren evat ja paindlikku. Asutuse tööd vedada ja edusamme saavutada aitab juhataja edumeelsus, suured ja julged mõtted ning innovaatilisus. Juhataja võtab igat muutust kui väljakutset ning on avatud uuendustele. Kohapeal koges audiitor, et sotsiaalteenuse osuta ja tegutseb vastavuses EQUASS Assurance kriteeriumit ega. Intervjuud huvigruppide ja rahastajate esindajatega, töötaj ate ning teenuse saajatega samuti kinnitasid seda, mis tuli välja nendega tehtud inter vjuudest. 49 Kogu asutuse töötajaskond oli lahk e ja koos tööaldis asutuse töö tutvustamisel, vajaliku tõendusmaterjali leidmisel ning inf ormatsiooni jagamisel EQUASS - i kriteeriumite täitmise kohta. Järgnevaks kaheks aastaks lepiti kokku mõned parendustegevused, mis on välja toodud aruande 4 -ndas osas. Ülevaade par endussoovit ustest konkreetsete kriteeriumite lõikes on esitatud ka aruande 3 - ndas osas. Parendusvaldkonnad hõlmasid üldises plaanis järgmist: dokumentatsiooni uuendamine, erinevates dokumentides sisalduva inf ormatsiooni ühtlustamine, seoste ja numerats iooni lisamine dokumentatsiooni, dokumentide ja kor dade täiendamine puuduoleva teabega; uue kodulehe loom ine ja IT lahendust e täieulatuslikum kasutamine; enesehindam ise protsessi kõikehõlmavamaks muutmine ning erinevat es valdkodades/teemades läbiviidavate analüüside ja tehtavate kokkuvõtete dokumenteerim ine. Pärast indikaator itele vastam ise tõendamist, tutvudes dokumentatsiooniga ning viies läbi inter vjuud, oli audiitor veendunud, et kriteeriumid Eur oopa kvaliteedimärgi jaoks sotsiaalteenust es on täidetud osaliselt . Täieliku vastavuse saavutam iseks EQ UASSi kriteeriumitega tuleb 2017. aasta plaani lisada inf ormatsioon peamiste teenuste ning nende mõõdikute / oodatavate siht väär tuste kohta; ametijuhendutesse / personalipoliit ikasse tuleb lisada inf ormatsioon erinevatel amet ikohtadel olevate töötajat e teadmiste, oskuste ja kompetentside kohta; samuti kirjeldada detailsemalt kompetentsid ja oskused, mis on vajalikud teenuse saajat e teenuse kvaliteedi tõstmiseks; aastaaruanded peaksid detailsemalt hõlmama inf ot asutuse tegevuse tulemuste kohta ning erinevate analüüside ja hindamiste tulemusi; välja tuleb töötada pideva täiendam ise pr otseduur ning parendusprojektide t uleks nõuetekohaselt dokumenteerida. Audiitor soovib tänada asutuse töötajaid hea koostöö eest audi t i läbiviimisel. Tallinn, 28. 12.2016 Mar iliis Männik -Sepp , EQUASSi audiitor / EQUASS auditor 50 EQUASS ASSURANCE APPLICATION ADDITIONAL INFORMATION 1. Short information about the organisation in the native language Lihula Vallavolikogu otsusega nr 56 (30.10.2001) lõpetati Lihula Haigla tegevus ja asutati Sihtasutus Lõuna-Läänemaa Tervishoiu ja Sotsiaalhoolekande Keskus. Sihtasutus on Läänemaal Lihula linnas asuv tervistedendav asutus, kelle eesmärgiks on tervishoiu- ja hoolekande teenuste pakkumine kogu piirkonnale. 2. Short information about the organisation in English (activities, clients, etc.) Lihula Municipal Council decided, with its resolution no 56 from 20.10.2001, to liquidate Lihula Hospital and to found the Foundation of Lõuna-Läänemaa Center of Health and Social Welfare. The purpose of the foundation is to offer healthcare and social welfare services to everyone in the area. This health promoting foundation operates in Läänemaa county from Lihula town. 3. Name of the organisation as you would want it to appear on the EQUASS Assurance certificate SA Lõuna-Läänemaa Tervishoiu ja Sotsiaalhoolekande Keskus 4. Name of services / departments of the organisation in the scope of the application as you would want it to appear on the EQUASS Assurance certificate: - üldhooldus - erihoolekanne: igapäevaelu toetamine, töötamise toetamine, toetatud elamine, ööpäevaringne erihoolekanne sügava liitpuudega isikutele - koduõendus 5. Organisation’s logo Information to be published on EQUASS website: 1 Name of the organisation: SA Lõuna-Läänemaa Tervishoiu ja Sotsiaalhoolekande Keskus Post address: Tallinna mnt 37, Lihula, Estonia Director: Vanda Birnbaum Contact person: Ilona Kastepõld Email: [email protected] Web: www.lihulatervis.eu 2 Saatja: Maarika Aro Saatmisaeg: 30. detsember 2016. a. 10:27 Adressaat: 'guusbeek'; 'Marie Dubost' Koopia: Keiu Talve Teema: SA Lõuna-Läänemaa Tervishoiu ja Sotsiaalhoolekande Keskus audit report Manused: AdditionalInformationForm.doc; Asutuse_kylastuse_vorm_Lihula.docx; EQ_Audit Report_Lihula.doc; EQUASS Assurance taotlusvorm_audit.xlsx Dear Marie, Dear Guus, Attached you’ll find an audit report and other documents of SA Lõuna-Läänemaa Tervishoiu ja Sotsiaalhoolekande Keskus EE2016-026. 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