TVTHK auditi raport Brüsselisse

EQUASS ASSURANCE AUDIT REPORT Site visit: 13.06.2016 Foundation Mental Health Care Center of Tartu 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 SA Tartu Vaimse Ter vise Hoolde keskus service provider (Foundation Mental Health Care Center of Tartu, hereinafter Care Center ) Address: Staadioni 52, 51008 Tartu Post box: N/A Person responsible : Indrek Sooniste (general manager) Contact person: Ülle Lepik Phone: (+372) 56658204 Fax: - E-mail: vthk.vt [email protected] Web site: http://www.tartuvthk.ee/ Name of Auditor: Mar iliis Männik -Sepp Dates of audit: 13.06.2016 Clients: 249 Staff: 35 Full time: 20 Part time: 11 Contracted: 2 Volunteers: 2 Services:  Assistance in ever yday lif e  Supported living  Assistance in working  Rehabilitation ser vices 2  2. Audit program 13.06.2016 Day 1 Time Acti vit y 9:30-12:30 Travel f rom Tallinn t o Tartu Preparat ions f or the audit; reading documents on the web -page of the organizat ion (Employee Handbook) 12:30-14:30 Documentation review Interview with Ülle Lepik 14:30-17:30 Travel f rom Tartu to Tallinn Making conclusions, up-dat ing f iles (application f orm) 3. Detailed feedback on performance 2. The social servi ce provider defines, documents, and implements its qualit y policy by determining long term qualit y goals, 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 W hile drawing up the next years’ goals and commitment to continuous annual plan, it should be kept in improvement are stated in the mind that the organization’s long Employee Handbook . term goals have to be clearly in line with the short term objectives. The development plan of the organizat ion is in the process of A f urther improvement to reduce the being over viewed and updat ed. amount of documentation and avoid duplication would be to make the The qualit y goals and commitment to Employee Handbook (or any ohter continuous impr ovement ar e 3 explained in the Employee important docum ent of the Handbook . organizat ion) t he central document, which includes all all important The documentat ion management inf ormation and links to the ot her system is being developed and documentat ion of the organizat ion. organized. Järgmise aasta plaani koostamisel peaks silmas pidama, et strateeg ilisest plaanist tulenevad asutuse pika-ajalised eesmärgid oleks selgesti seostatavad aastast e tegevuseesmärkidega. Järgmine sam m asutuse dokumentatsiooni hulga vähendamiseks ja dubleerim ise vält imiseks oleks muutma Töötaja Käsiraamat ( või mõni muu olulin e asutuse dok ument) nö keskseks dokumendiks, mis sisaldaks kogu olulist inf ormatsiooni ning viiteid muudele asutuse dokumentidele. 5. The social service provider management establishes 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 planning procedure is descr ibed Assure t hat the planning procedure in the Employee Handbook . will be reviewed annually dur ing the review of the Employee Handbook There are annual action plans , which and that evidence about the review are reviewed regularly and wr itten remains. summaries are made in the act ion plan quarterly (concerning the real Tagada, et aastase planeerimise execut ion of the plan) . protsessi kirjeldus vaadatakse üle igal aastal Töötaja Käsiraamatu The planning procedure will be ülevaatuse käigus ning et selle 4 reviewed annually during the review tegevuse kohta jääks jälg. of the Employee Handbook. 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 meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The staff of Tartu Care Center (scope A f urther improvem ent to the staff of EQUASS applicat ion) includes 35 policy would be descr ibing their employees whose exper ience and retention and leaving principles . prof essional know- how ensures the qualit y and consistency of the Edasine parendus soovitus oleks ser vices. personalipoliitikas ametishoidm ise j a lahkumise põhimõtet e kirjeldam ine. The principles f or personnel recruitment are described in the Employee Handbook. All employees have individual job descr iptions, which include required knowledge, skills and competences. The principle f or equalit y and non - discr imination is laid down in the code of ethics and thr Rules Of Work. Staff is awar e of their roles, rights and dut ies. 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 aud itor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program 5  Strengths Improvem ent & developments Staff development and training needs A f urther improvement would be are assessed annually during drawing up an annual summar y and perf ormance reviews. analysis of the annual training activit y f .e. SW OT analysis could be Annual training plan f or 2016 was conducted. drawn up. In autumn 2016 CARE methodolog y training will be Täiendava parendusena on organized f or the empolyees. soovitatav koostada aastas e koolitustegevuse kohta kokkuvõte, Also a new training policy was drawn kus hinnatakse ja analüüsitakse up, which descr ibes the organization koolitustegevuse ef ektiivsust. Nt võib of trainings. kasutada SW OT analüüsi. The staff is trained based on their needs and expectat i ons. Feedback on trainings is collected after each training , where the value and success of the training is evaluated. 21. The social service provider 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 & developments It is the dut y of the staff to ensure As a f urther improvement the ways that the customers are protected and methods how to prevent the f rom physical and mental and abuse of clients should be described f inancial abuse. as a procedur e a nd also imput f rom the clients themselves (client The Rules of Work bring out the representat ion) would be highl y principle that physical, mental and recommended. f inancial abuse of users should be prevented. Also, it should be r emembered that the organization has to evaluate Members of staff have had a 6 braingstorming session , where the regylarly its pr event ion activit ies f or topic of abuse prevent ion was the physical, mental and f inancial discussed. As a result they worked abuse of users , f .e SW OT analysis out ways and m ethods how to could be conducted. prevent abuse of their clients. Täiendava par endusettepaneku na on soovitatav ärakasutamise ennetamiseks väljat öötatud viisid ja meetodid pr otseduurina kirjeldada ning samut i oleks väga soovitatav küsida sisendit teenuse saajatelt endilt (kliendiesindus elt). Samuti tuleks meeles pidada, et teenuse saajal tuleb viia läbi regulaarseid enesehindamisi ennetamistegevuste osas , nt viies läbi SW OT analüüs . 36. The social service provider identif ies, documents, and maintains the key 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 & develop ments The main social services of Tartu The review of service deliver y Care Center are: assistance in processes should be assur ed ever yday lif e, supported living, regularly in f uture . assistance in working, rehabilitat ion ser vices. Edaspidi t uleb tagada teenuse osutamise protsesside regulaar ne The ser vice deliver y processes have ülevaatamine. been recent ly reviewed and updat ed. The service deliver y process es are descr ibed in the ser vice deliver y procedures and are accessible also on the home page of Tartu Care 7 Center. The main ser vice deliver y pr ocesses are in line with Tartu Care Center ’s vision, mission and qualit y principles. 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 Procedures f or conducting inte rnal It is recommended to cover the main audits/controls have been reviewed ser vice deliver y processes wit h and updated. internal audits re gularly. Four int ernal audits/controls wer e Soovitatav on katta asutuse conducted in the f irst half of 2016. peamised protsessid siseaudititega teatava regulaarsusega. The servide deliver y processes ar e discussed during meetings and improvements proposed by employees. 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 this criterion of the EQUASS Assur ance certif ication program Strengths Improvem ent & developments The PDCA cycle is used and It should be kept in mind that t he descr ibed br ief ly in the Employee qualit y approach expects systematic Handbook . and coninuous self -assessment, review and improving of processes Annual plans are drawn up and are and also related documentation. reviewed quarterly. Tuleb meeles pidada, et k vlit eedi 8 The results and performance of Tartu lähenem ine eeldab süsteemset ja Care Center is measured and järjepidevat enesehindamist, descr ibed in reports. ülevaatamist ning parendam ist nii protsesside kui seot ud Qualit y improv ement projects are dokumentatsiooni osas. descr ibed in the annual plans and are documented. Inf ormation about t he improvement projects is also available on the home page of Tartu Care Center. 4. Agreed additional development / improvements The applicant decided on the following improvement actions and/or additional development for the period of two years: Crite Short description of the actions rion (including SM ART objecti ves) 2  W hile drawing up the next years’ annual plan, it should be kept in mind that the organizat ion’s long term goals have to be clearly i n line with the short term objectives.  A f urther imp rovement to reduce the amount of documentation and avoid duplication would be t o make the Employee Handbook (or an y ohter important document of the organization) the central document, which includes all all important inf ormation an d links to the ot her documentat ion of the organizat ion. *****  Järgmise aasta plaani koostamisel peaks silmas pidama, et strateegilisest plaanist tulenevad asutuse pika -ajalised eesmärgid oleks selgesti seostatavad aastaste tegevuseesmärkidega.  Järgmine samm asutuse dokumentatsiooni hulga vähendam iseks ja dubleer imise vält imiseks oleks muutma Töötaja Käsiraamat ( või m õni muu oluline asutuse dokument) nö keskseks dokumendiks, mis 9  sisaldaks kogu olulist inf ormatsiooni ning viiteid muudele asutuse dokumentidel e. ***** Person responsible / vast utav isik: Indrek Sooniste Due date / tähtaeg: 30 .06.2018 5  Assure that the planning procedure will be reviewed annually dur ing the review of the Employee Handbook and that evidence about the review remains. *****  Tagada, et aastase planeer imise protsessi kirjeldus vaadatakse üle igal aastal Töötaja Käsiraamatu ülevaatuse käigus ning et selle tegevuse kohta jääks jälg. ***** Person responsible / vast utav isik: Indrek Sooniste Due date / tähtaeg: 30.06.2018 9  A f urther improvement to the staff policy would be describing their retention and leaving principles . *****  Edasine parendussoovitus oleks personalipoliit ikas ametishoidm ise ja lahkumise põhimõtete kirjeldam ine. ***** Person responsible / vast utav isik: Indrek Soonis te Due date / tähtaeg: 30.06.2018 11  A f urther improvement would be dr awing up an annual summ ary and analysis of the annual training activit y f .e. SW OT analysis could be conducted. *****  Täiendava parendusena on soovitatav koostada aastase 10  koolitustegevus e kohta kokkuvõte, kus hinnatakse ja analüüsitakse koolitustegevuse ef ektiivsust. Nt võib kasutada SW OT analüüsi. ***** Person responsible / vast utav isik: Indrek Sooniste Due date / tähtaeg: 30.06.2018 21  As a f urther improvement the ways and methods how to prevent the abuse of clients should be descr ibed as a procedure and also imput f rom the clients themselves (client repr esentation) would be highly recommended.  In the f ollowing years t he organization has to evaluate regylar ly its prevent ion activit ies f or the physical, m ental and f inancial abuse of users, f .e SW OT analysis could be conducted. *****  Täiendava parendusettepanekuna on soovitatav ärakasutamise ennetamiseks väljatöötatud viisid ja meetodid protseduur ina kirjeldada ning samuti oleks väga soov itatav küsida sisendit teenuse saajatelt endilt (kliendiesinduselt).  Järgnevatel aastatel tuleb teenuse saajal tuleb viia läbi regulaarseid enesehindam isi ennetamistegevust e osas, nt viies läbi SW OT analüüs. ***** Person responsible / vast utav isik: Indre k Sooniste Due date / tähtaeg: 30.06.2018 36  The review of service deliver y processes should be assured regularly in f uture . *****  Edaspidi tuleb tagada teenuse osutamise protsesside regulaarne ülevaatamine. ***** 11  Person responsible / vast utav isik: Indre k Sooniste Due date / tähtaeg: 30.06.2018 37  It is recommended t o cover the main ser vice deliver y processes with internal audits regularly. *****  Soovitatav on katta asutuse peamised protsessid siseaudit itega teatava regulaarsusega. ***** Person responsib le / vast utav isik: Indrek Sooniste Due date / tähtaeg: 30.06.2018 48  It should be kept in mind that the qualit y approach expects systematic and coninuous self -assessm ent, review and improving of processes and also related documentation, which shuld be do ne in the f ollowing years . *****  Tuleb meeles pidada, et k valiteedi lähenemine eeldab süsteemset ja järjepidevat enesehindamist, ülevaatamist ning parendamist nii protsesside k ui seotud dokumentatsiooni osas, mida tuleb teha järgnevatel aastatel . ***** Person responsible / vast utav isik: Indrek Sooniste Due date / tähtaeg: 30.06.2018 12  5. Closing remarks Foundation Tartu Mental Health Ser vice Center supports t he per sons with mental health problems to live at home, work, lear n and participate in the communit y. Ser vice users are counseled by psychologists, social workers, physiother apist, activit y therapist, disabilit y pedagogue, creative ther apist, speech therapist. In the day center t utors are guiding activities that maintain and improve ever yday living skills . In work teams tutors are promot ing working skills improvement. The work is based on com munit y work, provided at home or in care home, or in the center. Half of the service users are f rom Tartu. Ever y year the organization provides the possibilit y f or st udents f or traineeship and it also cooperates with the schools of higher educat ion in developing new activit ies. The organizat ion cooperation partners are local governments, state, employment off ice, cooperatives and entrepreneurs. Tartu care center has on ce already gained EQUASS Qualit y Assurance certif icate ( in 2013). Tartu Care Center has continued applying the principles of EQUASS Assurances in its work since then. They apply EQUASS certif icate f or 4 services: assistance in ever yday lif e, supported livi ng, assistance in working and rehabilitation ser vices. There ar e 35 employees working in the organizat ion, who are responsible f or providing the mentioned ser vices, including two volunt eers. The number of persons served is 249. The initial audit was condu ct ed on November 17 -18, 2015. During that time the auditor was of the opinion that the or ganizat ion was motivated to achieve high qualit y and compliance with the EQUASS criter ia, but had some improvement areas t hat needed to be addressed in or der to do so. During the f ollow-up audit, that was carr ied out on June 13, 2016 the auditor gained assurance on site that the social ser vice provider Tartu Care Center perf orms in compliance with t he EQUASS Assurance criter ia. The def iciencies wer e dealt with, the syst ems were amended and necessar y evidence presented t o the auditor. According to the inf ormation received f rom the auditee, many positive changes took place in the organization after the initial audit. It had also an eff ect on the culture of the organizatio n, which has become more open and 13 participation is mor e valued. The Employee Handbook was reviewed and updated. The development plan of the organizat ion was reviewed and new plan is in the process of being developed. The management style in the organizat ion has become more open and employees and also clients are more involved. The client repr esentat ion was strong already bef ore, and has become even strong er in time. Comprehensive act ion plans were developed in the f our f ields of the organizat ion and they ar e being quarterly reviewed now. Internal contr ol/audit system was put into place and controls were started to be executed. The principles of client abuse prevent ion were discussed with staff and methods and ways f or avoiding abuse have been developed. Staff motivation system has become more transparent, annual training plans ar e now drawn up and staff is expect ing CARE methodolog y training to be carried out in autumn. In general the main areas of improvement include opt imizing the amount of documentat ion, reviewing the documentation regularly, conducting regular analysis and audits/controls in var ious ar eas and improving some documents. It has t o be kept in mind that qualit y management approach expects syst ematic and cont inuous self -assessment, review and i mproving of processes and also r elated documentation. The f urther improvement actions are brought out in part 4 of the audit r eport. An over view of suggestions f or improvement that are mentioned under the specif ic criter ia is given as well in part 3. There are many sug gestions in part three of the pr evious audit report (04. 12.2015), that the ser vice provider should also take notice of , when wishing to improve the f unctioning of the organizat ion and f or ensur ing better quality and conf ormance to the EQUASS criteria. After verif ication of the indicators by r eviewing documentation, conduct ing inter views and perf orming site visit, the auditor came to the conclusion that the criter ia f or quality assurance of the European Qualit y f or Social ser vices were f ulf illed . The auditor f elt that the organizat ion is motivated to achieve high qualit y and com pliance with the EQUASS cr iter ia. The auditor wants to thank Foundation Tartu Mental Health Service Center f or good cooperat ion during the audit. *** 14 SA Tartu Vaimse Terv ise Hooldekeskus aitab vaimse ter vise probleemidega inimestel elada oma kodus, töötada, õppida ja rakendada end kogukonnas. Vaimse ter vise pr obleemidega inimesi ja nende lähedasi nõustavad valdkonna spetsialistid: sotsiaaltöötajad, psühholoogid, psühhiaat er, f üsioterapeudid, tegevusterapeudid, eripedagoogid, loovterapeut ja logopeed. Töös läht utakse inimesest. Päevakeskustes juhendatakse tegevusvõimet säilitavaid ja parandavaid tegevusi; töör ühmades aitavad töövõime taastamisele kaasa koolitatud tegevusj uhendajad. Töötatakse inimeste kodus, kogukonnapõhiselt ja hoolekandeasust uses. Teenuse saajatest ligikaudu pool on tartlased. Igal aastal pakutakse kõrgkoolides õppivatele tudengile prak tiseer imise võimalust ja tehakse koostööd kõrgkoolidega uute t egevus te ellu rakendamiseks rehabilitatsioonis. Asutuse koostööpart neriteks on Töötukassa, kohalikud omavalitsused, ühistud ja ettevõtjad, kellega koostöös probleemidele lahendusi leitakse. Tartu Vaimse Tervise Hooldekeskus on var asemalt juba EQUASS Assurance kvaliteedimärgi saanud (2013. aastal). Tartu hooldekeskus on jätkanud EQUASSi kvaliteedipõhimõtete rakendamist sellest ajast. Nad taotlevad EQUASSi sertif ikaati neljale teenusele: rehabilitatsiooniteenus, igapäevaelu toetamise teenus, töötamise toetamise tee nus, toetatud elam ise teenus. Organisatsioonis töötab 35 töötajat, kes vastutavad nim etatud teenust e osutamise eest, sh kaks vabatahtlikku. Teenuse saajate ar v ulatub 249ni. Esialgne audit viidi läbi 17. -18. novembril 2015. Auditi tulemusena oli audiitor ar vamusel, et asutus oli motiveeritud saavutama kõrget kvaliteet i ning vastavust EQ UASS kvaliteedi kriteerium idele, kuid esines valdkondi, millega tuli täiendavalt tegeleda, et täieliku vastavus e saavutamiseks . Järelaudit i käigus, mis toimus 13. juunil 2016 , sai audi itor kohapeal kindlustunde, et sotsiaalteenuse osutaja Tartu Vaimse Tervise Hooldekeskus tegutseb vastavuses EQUASS Assurance kriteerium idele. Puudustega oli tegeletud, süsteeme täiustatud ning vaj alikud tõendusmater jalid selle kohta edastati aud iitorile. Vastavalt auditeeritavalt saadud inf ormatsioonile leidsid mit med posit iivsed muutused aset pärast esialgse auditi aruande väljastamist. Auditil oli mõju 15 ka asutusesisesele kultuurile, m uutes organisatsiooni sisest kultuur i avatumaks ning rohkem kaasamist väär tustavamaks. Töötajate Käsiraamat vaadat i uuest i üle ja seda täiendat i. Samuti vaad at i üle asutuse arengukava ning alustat i uue arengukava koostamise pr otsessiga. Organisatsiooni juhtimise stiil on muutunud avatumaks ning töötajaid ja ka teenuse saajaid kaasatakse enam. Kliendiesindus oli t ugev ka juba varasemalt, kuid on muutunud ajas veel tugevamaks. Koostat ud on kõikehõlmavad tegevuskavad asutuse neljas põhivaldkonnas, mille t äitmist nüüd k vartaalselt jälgitakse. Paika pandi sisekontrolli/a udit i süsteem ning alustati kontrollide läbiviimisega. Töötajatega on arutatud klient ide ärakasutamise ennetamis e temaatikat ja meetodid ära kasutamise ennetamiseks on välja töötatud. Personali motiveer imise süsteem on muutunud läbipaist vamaks, koostatakse iga-aastased koolitusplaanid ning sügisel plaanitakse töötajatele läbi viia CARE metoodika koolitus. Üldiselt, põhilised parendusvaldkonnad hõlmavad dokumentatsiooni hulga optimeer imist, dokumentatsioon regulaarset ülevaatust, regulaarsete analüüside ja k ontrollide/audit ite läbiviim ist er inevates valdkondades ja mõnede dokument ide täiendam ist. Tuleb meeles pidada, et kvaliteedi süsteem i rakendam ine eeldab süsteem set ja järjepidevat enesehindam ist, ülevaatamist ning parendam ist nii protsesside kui seotud do kumentatsiooni osas. Soovitatavad edasised parendustegevused on välja t oodud aruande 4 -ndas osas. Ülevaade par endussoovitust est konkreetsete kriteeriumite lõikes on esitatud ka aruande 3 -ndas osas. Eelmise audit i aruande (04.12.2015) kolmandas osas on välj a toodud samut i mitmeid soovitusi, millele teenuse osutaja peaks oma tähelepanu pöör ama, sooviga asutuse toimim ist parandada ning tagamaks parem kvaliteet ning vastavus EQUASSi kriteeriumidele. Pärast indikaatoritele vastamise tõendamist, tutvum ist dokumen tatsiooniga ning olles viinud läbi int er vjuud, oli audiitor veendunud, et kriteerium id Euroopa kvaliteedim ärgi jaoks sotsiaalteenust es on täidetud. Audiitor sai veendumuse, et asutus on pühendunud oma töös k valit eedi tagamisele j a täiustam isele. Audiitor soovib tänada Tartu Vaimse Tervise Hooldekeskus t hea koostöö eest auditi läbiviimisel. 16 Tallinn, 16. 06.2016 Mar iliis Männik -Sepp EQUASSi audiitor / EQUASS auditor 17 EQUASS ASSURANCE ASUTUSE KÜLASTUSE ETTEVALMISTAMISE VORM Asutuse külastus: 13.06.2016 SA Tartu Vaimse Tervise Hooldekeskus 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 : 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. K as on v ä lj a tö öt at u d x k va li t ee d is t a nd ar d? 2. K as a as t as e p la n eer im is e x pro ts es s on dok um en t eer i tu d ? 3. K as a as t as e p la n eer im is e pro ts es s i v a ad at ak s e reg u la ars e lt x ü le ? P er so na l 1. K as o n o l em as pr ots e s s pers o na l i x v ärb am is ek s ? 2. K as pers o na l i k oo l it us p l a an on v ä lj a tö ö ta tu d j a s e da v a ad at ak s e x reg u l aars e lt ül e ? 3. K as k oo l it us t e ge v us e ef ek ti i vs us t x h in n at ak s e? E et i k a 1. K as o n v ä lj a tö öt a tu d e es k ir i j a pro ts ed u ur id f ü üs il is e , v a im s e j a x m aj and us l ik u ä r ak as u tam is e en n et am is ek s ? Version 1.0 2  2. K as e es k irj a ja pro ts e d u ure f üüs i lis e , v a im s e j a m aj and us l ik u x ärak as ut am is e e nn e tam is ek s v aa d at ak s e r e gu l aa rs e lt ül e ? Lai ah a ar de li su s 1. K as t e en us e os u tam is e p e am is e d x pr o ts es s i d o n re g u la ar s e lt ü l e v a ad at u d? 3. K as v i i ak s e l äb i pe am is t e x pro ts es s i d e s is ea u d it e i d ni n g rap or te er i tak s e n en d e tu l em us i ? Pi dev a r eng 1. K as rak en da t ak s e x dok um en te er it u d par e n dus s üs t e em i, k us j uur es h in n at ak s e t e ge v us te t u lem us i? 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. T ööt aj a k äs ir a am at 2. S A T ar t u V a im s e Ter v is e H oo l dek es k us e re h a bi l i ta ts io o n i ja to et a v at e te e nus te os ak o nn a 2 0 16 . a. T eg e vus k a v a j a k oos o l ek u p ro tok o l l 3. Re h ab i l it ats i o on i - j a t o et a v at e te e nus t e os ak on n a k o ol i tus k a v a 2 01 6 4. Re h ab i l it ats i o on i - j a t o et a v at e te e nus t e os ak on n a 2 01 5. a . Ar ua n n e 5. S A T ar t u V aim s e T er r v is e Ho o ld ek es k us e k li en d it ö ö k or d 6. Re h ab i l it ats i o on i - j a t oe t a va te t e en us te os ut am is e k ord , S A T ar tu Va im s e T erv is e Ho o ld ek es k us e k l i en d it ö ö k or d 7. s is ea u di t i pr ot ok ol l 2 8 .0 4. 2 01 6 .a 8. Re h ab i l it ats i o on i - j a t o et a v at e te e nus t e os ak on n a 2 01 6 t eg e v us k av a Version 1.0 3  9. Re h ab i l it ats i o on i - j a t o et a v at e te e nus t e te e n us t e os ut am is e k ord 10 . T een us t ej uh t id e ar u an de d I k var ta l i t u lem us t es t 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. r eh a bi l i ta ts io o n i - ja to et a va t e 2 tu n d i te e nus te os ak o nn a j u h at aj a 4. Asutuse kül astuse ajakava formaat Asutuse külastuse ajakava kuup ä ev P äev 1 Ae g T egev us ( l üh ik e k irj e l dus ) 11 . 00- 1 4. 0 0 Dok um en ti d e k o ntr o l l j a i nt er vj uu Ü l l e Le p ik u ga Version 1.0 4 Maarika Aro Saatja: Maarika Aro Saatmisaeg: 4. juuli 2016. a. 11:52 Adressaat: 'Guus van Beek'; 'Marie Dubost' Koopia: Keiu Talve Teema: Tartu Vaimse Tervise Hooldekeksus audit report?? Manused: Additional Information Form_TVTH.odt; Asutuse auditi külastuse ettevalmistuse vorm_2016.docx; SA Tartu VTHK EQUASS Assurance taotlus_2016.xlsx; TVTHK_aruanne_2016.doc Dear Marie, Dear Guus, I will write again, because I Cant find a sent e-mail to Guus and he has not send a report answer. I know that I send it, but it has disappeared somewhere. Attached you’ll find an follow-up audit report and other documents of Tartu Vaimse Tervise Hooldekeksus EE2016- 010 ( the first audit nr was EE2015-017- is it remains the same or do we have to put another nr like EE2016-010??). Please let Keiu to know in case there are some comments about the report. Best, 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 1