Ambromed Grupp auditi raport Brüsselisse

EQUASS ASSURANCE AUDIT REPORT Site visit: 8.-9.03.2016 Ambromed Grupp O Ü Triin Kraavi © 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 Na me of th e so ci al Am b ro me d G rup p O Ü se rv i c e p rov id er Ad d re s s: Lai 28 , T a rtu 5 1 00 5 Po st bo x: P er so n re sp on sib le Je l ena Põ ld sa m (C EO ) : Cont ac t p e rs on: M irja m O ol Pho ne: + 37 2 7 4 5 11 7 5 Fa x: E- m a il: inf o @a mb rom ed . ee W eb s ite: w w w .amb ro me d. e e Na me of Au dit o r: T riin K r aav i Dat e s of aud it : 8.- 9. 0 3. 2 01 6 Cli en ts: Num ber of p ers on s er v ed : 4 74 As of ( d at e): p er i od 01 .0 1 - 08 .0 3 .2 0 16 St aff: Num ber of Fu l l t im e s t af f : 4 Num ber of P ar t t im e s t af f : Num ber of C on tr ac t e d s taf f : 24 Num ber of vo l un t eers (if ap p l ic a b l e) S erv ic e s: P s ych iat r ic se rv i c e, ps yc hol ogi c al (in div i dua l and c oup le a nd f a mi l y t he r ap y) s erv i c e, sp ee ch th er ap y, p h ys ioth e rap y, o c cup ati o nal t he ra p y, so ci a l w or k e r s erv ic e, so ci al a nd w ork r el at ed r eh ab il it ati on. 2  2. Audit program 08.03.2016 9:00-9.30 Opening meeting, introduction of the clinic – Mirjam Ool, Jelena Põldsam 9.30-12.30 Documentation review 12.30-13.30 Lunch break 13.30-14.30 Interview with the employee responsible for the qualit y of service – Mirjam Ool 14.30-14.45 Documentation review, updating files 14.45-15.45 Interview with the personnel – Tuuli Sedman ( psychiatrist ), Marina Cojocaru ( psychiatrist ), Reta Riitsaar (secretary) 15.45-16.00 Documentation review, updating files 16.00-17:00 Interview with the persons served – Kuldar, Kadri , Liina Mai 09.03.2016 9:00- 10.00 Interview with partners – Maria Visnapuu (Titanium Systems) 10.00.-10.15 Documentation review, updating files 10.15-11.15 Interview with funders – Ene Kiisk (Estonian Health Insurance Fund ), Kersti Kask (Social Insurance Board ) 11.15-11.30 Documentation review, updating files 11.30-12.30 Interview with the personnel – Karin Lätt ( clinical psychologist), Liine Põldsam (psychologist) 12.30-13.30 Lunch break 13.30-14.30 Interview with the persons served – Maarja 14.30-14.45 Documentation review, updating files 14.45-15.45 Interview with the CEO – Jelena Põldsam 15.45-16.00 Audit summary 16.00 Closing meeting 3  3. Detailed feedback on performance 1. The social ser vice provider def ines documents and implements its vision and mission values on ser vice provision. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Str e n gt hs Im pro vem e nt & de v e lo pm ents Am brom ed h as d oc u m ente d i t m is s i o n, v is io n an d c o r p or at e v a lu es . T h e y ar e a va i l ab l e on web s it e , Em pl o ye e Ha n db o ok an d C us t om er Inf or m at i o n Fo ld er . It was c onf ir m ed dur i ng i nt er v i e ws th at em pl o ye es wer e a war e of t h e m is s i on , v is io n a n d c or por a te v a lu es . 2. The social ser vice provider def ines, documents, and implements its qualit y policy by determining long term qualit y goals, and its commitment to cont inuous improvement. 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 4 Am brom ed ’s l o ng t er m go a ls and It is ad v is a bl e t o p u b lis h Am brom ed ’s c om m itm ent t o c o nt i n uo us im pr o vem en t l on g t erm go a ls and c om m itm ent to are d oc um ent e d in th e Em pl o ye e c on t in u ous im pr o vem en t als o to yo u r Ha n db o ok . A nn u a l p la n ni n g proc es s par t ners a nd p ers o ns s er v e d ( e. g. f ol l o ws P D CA - c yc l e . pu b l is h t h at o n t he we bs it e) . Im plem e nt i ng EQ UA S S q u al i t y s ys t em A ud i it or s o o vi t ab j ag a da i nf ot was o n e of t he im pr o v em ent pr oj ec ts i n p ik aaj a l is te ees m ärk i de ja pi d e va l e 20 1 5. are n g ul e p üh e nd um is e k oh ta ka k lie n ti d e le ja p ar t ner i te l e (n ä it ek s It was c onf ir m ed dur i ng i nt er v i e ws th at a va l d ad a s e e k o du l e h e l). em pl o ye es we r e a war e of Am br om ed ’s qu a l it y p o l ic y. 3. Persons ser ved, family members and ser vice user organisations are able to give f eedback on their individual and collective experience of programmes and ser vices. 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 5 Am brom ed has d e ve l o pe d dif f er en t wa ys to g i ve f e e db ac k – vi a webs i te , e- m ai l, on pa p er a t t he c l i ni c , d ir ec t l y t o t he em pl o ye e . Fe ed b ac k f r om per s ons s er v ed is doc um en te d , a na l ys e d an d s um m aris e d. Fe ed b ac k f r om f und i n g b o di es is e i th er doc um en te d or p r es e n te d v er ba l l y. T his was v er if i e d by i n s p ec t in g th e doc um en ta t io n and dur i ng th e i nt er v ie ws wit h t he c l i en ts , c o - o p era t io n par t ner s , re pr es en ta t i v e of f un d in g bo d y an d p ers on n e l th at t he y ar e a war e of th e d if f ere n t p os s i b i l i ti es h o w to gi v e f ee db ac k . 4. T h e s oc i a l s er v ic e pr o v i d er inf o rm s al l s tak e ho l de rs a b ou t t h e of f er ed pro gr am m es a n d s er v i c es a v ai l a bl e . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents Inf orm at i o n a b ou t th e s er v ic es , proc es s es a nd pr oc e d ur es , p er f or m anc e of th e org a n is a t io n , upc om in g r e le v a nt e ve n ts an d o p por t un i ti es f or i n vo l v em ent of p er s ons s er v e d is a va i l ab l e on the we bs it e and in Cus tom er I nf or m at io n Fo ld er . It was c onf ir m ed dur i ng i nt er v i e ws th at th e s tak e ho l d er s we r e a war e of t he s er v ic es of f er e d. 6  5. T he s oc i a l s er v ic e pr o v i der m an ag em en t es t a bl is h es a nd d oc um ents an an n ua l p l a nn i n g an d r e v ie w pr oc es s . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents Am brom ed ’s an n ua l p l an n i ng pr oc es s is doc um en te d a n d it f o l l o ws PD C A - c yc le . T he p la n n in g pr oc es s is r e v ie we d onc e a ye ar , l as t t im e in J a n uar y 2 01 6 . A nn u a l P l an r es u lts a r e r e v i e we d t wic e a ye a r – i n J u ne an d i n J a nu ar y. T his was c o nf i r m ed b y ex am in i ng th e an n ua l p l an n i ng d o c um ent at i o n an d i nt er v ie ws wit h t he per s on n e l a nd m anag ers . 6. T he p l a n i nc lu d es :  an n ua l o u tc om es / tar ge ts  th e ac ti v i t ies t o b e u n der t ak en i n ac h ie v i n g th e a nn u a l tar g ets  m onit or i ng of th e pe rf orm anc e of t he or g an is at i o n i n m eet in g its an n ua l t ar ge ts  tim e- s c al es a n d pr oc e dur es f or r e v i e w a n d r e v is i o n. 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 7 A nn u a l plan is we ll s tr uc t ur e d – it It is a d v is a b l e t o re v i e w t he ac t i vi t ies c ons is ts of obj ec t i v es , ex p ec te d r es u l ts , ad d ed to th e A nn u al P la n la t el y a nd ac t i ons , i n dic a tor s , t ar g e t da t es an d up d at e th e ir ac t i o ns a nd i n d ic a t ors ( e. g. res p o ns ib l e p er s ons . s oc ia l r eh a b il i ta t io n , work re la te d reh a b i li t at i on) . A nn u a l plan ac t i o ns ’ r es u l ts a re re v ie we d t wi c e a ye a r in J un e a n d i n O n s o o v it at a v ü l e v aa da t a j a uu e nd a d a J an u ar y. aas t ap l aa n i h i lj u t i l is at ud ees m ärk id e te g e vus e d j a m õõ d ik ud ( nt s ots i aa l n e A nn u a l P l a n is a ppr o v ed b y t h e Bo ar d of reh a b i li t ats i oo n, t ö öa l an e Ma n ag em en t. reh a b i li t ats i oo n) . 7. T h e s oc i a l s er v ic e p r o v i der d em ons tr at es org a n is a t io n ’s s uc c es s i n s at is f yi n g th e n e eds a nd ex p ec t a ti o ns of t h e s oc i et y. 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents Am brom ed c o ll ec ts f ee d bac k f r om the d if f ere nt s t ak eh o l d er s - c l i en ts , pers o n ne l , c o - o p er at i o n p ar t ne r s . Dur i n g the i nt er v i e ws it wa s dem ons tr at e d by s tak e ho l de r s t h at Am brom ed is ac t i ve l y c o n tr ib ut i n g to s at is f y t h e n ee ds a n d ex pec ta t io ns of th e s oc ie t y by or ga n is in g a nd par t ic ip a ti n g i n va r i o us ac t i v it i es wi t h c o- o p er at i on p ar tn er s , c l ie nts and pers o n ne l . 8. T h e s oc i al s er v ic e pr o v i d er dem o ns tr at es or ga n is at i on ’s s oc i a l res p o ns ib i l it y thr o ug h ac t i vi t ies c on t r i bu t in g t o th e s oc i et y. 8 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents O n e of th e o bj ec t i ves of Am br om ed is to i nf orm th e s oc i e t y a b ou t the ps yc h o l og ic a l pr ob l em s , th e ir pre v e nt i o ns , tr ea tm en t wa ys an d op p ort u n it i es . Am br om ed ac t i v el y par t ic ip a tes i n d if f er e nt s em in ar s , f a irs an d c o nf er e nc es wi th pr es e n ta t io ns , wri t es re g u lar l y ar t i c l es in m ed ic al m aga zi n e , e duc at es c h il dr e n i n s c h o ols , has c o- o p er at i on w i th un i v er s i t i es , T he Es t o n ia n Q u a lif ic at i o ns A ut ho r i t y an d Es t o n ia n Me nt a l H e a lt h a n d W ell - Be i n g Co a l it i on . T h e y ar e c om pet e nc e c en ter of e at i ng d is or der s a nd s h ar e t he ir k no w- ho w wi th d if f er en t s t ak eh o l ders . T he y par t ic ip at e d in pr e p ar at i on of Es t o n ia n m e nt a l he a l th s tr at e g y 20 1 6 - 20 2 5. T his was ve r if ie d t hr o u g h in t er v ie ws wi t h s t ak e ho l de r s an d ex am in in g t he doc um en ta t io n . 9. T h e s oc i a l s er v ic e pr o v i d er h as a s t af f rec r ui tm ent a nd r e te n ti o n p o l ic y th at pr om otes t he s e lec t io n of q ua l if i e d pe rs o n ne l b as e d o n r eq u ir ed k no wle d ge , s k i l ls a n d c om pet e nc es . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 9 St af f rec ru i tm ent p ol ic y , c r i ter i a, a nd proc es s t og et h er wi t h po l ic y f or eq u al i t y an d n on- d is c r im in at i o n is d oc um e nt ed i n th e Em p lo ye e Ha n db o ok . Em pl o ye e H a nd b ook h as des c r i p ti o ns of a ll p os it i ons a n d t h e ir j ob t as k s an d c om pet e nc e r eq u ir em ents . Am brom ed r ec r u its c om pet e nt p ers o ns wi t h n ec es s ar y e d uc a t io n , tr a i n i ng , s k il ls an d pr ef er a bl y wi t h oc c u p at i on a l qu a l if ic at i on . 10 . T h e s oc i al s e r vi c e pr o vi d er o per a tes i n c om pl i a nc e wi th m anda t or y na t io n a l le g is l at i on , pr o v id i ng a p pr opr i at e w ork in g c o nd i t io ns , a d e qu a te a n d agr e e d s t af f le v el a n d s t af f rat io , a n d a p p rop ri a te r e war d in g f or s taf f an d v o lu nt e er s . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 10 Am brom ed o p er a tes wi t hi n m an d at or y na t io n a l l eg is l at i on . Am brom ed h as doc u m ente d its p o l ic y f or s ho wi n g r ec o gn i t io n ( f lex i b le work i n g ho urs , c e l ebr a ti o n of bir t h da ys a nd ot h er im por t an t e v e nt s lik e gr a d ua t io n , c om m on e v en ts d ur i n g C hr is tm as a nd s um m er, c om f or ta b le r ec r e at i o n ro om etc ) . Am brom ed h as as s es s e d i ts wo rk en v ir o nm ent , per f or m ed r is k a n al ys is an d im pro vem e nt ac t i on p la n ac c or d in g to t h at. 11. The social ser vice trains all staff based on a plan f or leaning and development and evaluates the eff ectiveness of the training. 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 11 Am brom ed h as d oc um en t ed its p l an f or T o ge t m ore re g ul ar up - to - d at e f e ed - s taf f qu a l if ic at i on , s taf f de v e l opm en t bac k it is a d v is ab l e to c o l lec t t he an d s u p por t f or 20 1 6 in A n n ua l P l a n – f ee db ac k ri g ht af t er e a c h th e tr a in i n g. d if f ere nt s u per v is io ns a nd Et s a ad a re g u la ars e t aj ak oh as t ph ys i ot h er ap y tr a in i ng . Pr of es s io n a l ta g as is i d et k oo l it us te k oh ta on tra i n in gs ar e t h e p er s on a l r es p ons i b i li t y of e ac h em pl o ye e . s oo v i ta t a v k og u da s ed a p e al e iga k ool i tus t. P art ic i pa t io n i n t h e t r a in i n g or g a n is e d by Am brom ed ar e doc um en te d on Em pl o ye e C ar ds . P ers o n ne l g i v es f ee d - bac k of tra in i n g dur i n g de v e lo pm en t d is c us s i o ns an d A nn u a l Me e ti n g . T his was v er if i ed by e x am i n in g the doc um en ta t io n a n d b y i n te r vi e wi n g t he pers o n ne l . 12 . T he s oc ia l s er vic e pr o v i de r a pp l i es re q u ir em ents f or c om pet e n c e i n t h e i de nt if ie d r o l es a nd f u nc t i ons of s t af f a nd e v a lu at es t hem o n a n nu a l b as is . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 12 T he c om pe t enc e r eq u ir em en t of s taf f are d oc um en t ed in E m plo ye e Ha n db o ok wh er e all pos i t io ns ’ qu a l if ic at i on req u ir em ents , k no wl ed ge , s k il ls a n d j ob des c r i pt i o n ar e wr it te n . Com pe te nc e r e q u i r em ents wer e re v ie we d las t t i m e i n J an u ar y 2 01 6 . P erf orm anc e of s t af f is r eg u lar l y re v ie we d by in t er n a l i ns p ec t i o n t ha t re v ie ws at l eas t t w ic e a ye a r the th er ap y r ec or d i ngs in t he IT s ys tem . 13 . T he s oc i a l s er v ic e pr o v id er r ec o g n is e s th e s taf f as a r es ourc e f or f ee db ac k on or ga n is at i on a l perf orm anc e , s er v ic e d e ve l o pm ent an d s taf f de v e l opm en t 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 13 St af f has t h e a bi l i t y to gi v e f ee d - bac k to th e m an a ger or m ana ger ’s as s is ta nt v ia e- m ai l, f ee d - bac k qu es ti o nn a ir e, m onth l y, a n nu a l or s u m m er m eet i ngs or de v e l opm en t d is c us s i o ns . Fe ed- b ac k r ec e i ve d f r om th e s t af f is doc um en te d . Am brom ed h as im p l em ent e d or is p la n ni n g c ha n ges b as ed o n s t af f f ee d - bac k (e .g . c r ea t in g pos s i b i li t y t o us e m obi l e- I D s o l ut i o n, r ec or di n g s up er v is i ons f or s t af f tha t ar e n ot ab l e to p ar tic i p at e e tc .) . It was c onf ir m ed dur i ng i nt er v i e ws th at d if f ere nt s taf f pr o pos a ls t o m od if y or im pro v e th e s er v ic e s or to d e v el o p th e pers o n ne l wer e im pl e m ente d. 14. The social ser vice provider has mechanisms in place to enhance satisf action and mot ivat ion 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 14 S at is f ac ti o n an d m ot i v at i on is e v a lu a te d dur i n g d e ve l o pm ent d is c us s i ons . S um m ar y of d e ve l o pm en t d is c us s io ns is an in p ut f or a nn u al m eet i ng whe re m eas ur es f or inc r e a s i ng s at is f ac t io n an d m oti v at i o n ar e a gr ee d . S at is f ac ti o n a nd m ot i v at i on is s u es ar e a ls o d is c us s e d at m onth l y t h era p y m eeti n gs , s um m er m eet i ngs a nd as k ed af ter s om e p er i od af t e r r ec r u itm e nt . Am brom ed h as doc u m ente d its p o l ic y f or s h o wi n g r ec og n it i on and r ec ords pro v e d th a t it has be e n im pl em en te d. 15 . T h e s oc i a l s e r vi c e p ro v i de r as s ur es th e r i gh ts of p ers o ns s e r ve d ou t l in e d in a Ch ar ter of R ig h ts wh ic h is bas e d on t he E U C har t er of Fu nd am en ta l Ri g hts , t he E ur op e an C on v e nt i on f o r t he Pr ot ec t io n of Hum an Ri g hts a n d Fu n dam e nt a l Fre e dom s of the Cou nc i l of E uro p e an d o th er i nt er n a ti o n al h um an r i gh ts c on v e nt i ons , es p ec ia l l y t h os e e l ab or at ed u nd er th e U ni t ed N at i o ns . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 15 Am brom ed h as doc u m ente d th e R ig h ts an d D u ti es of per s o ns s er ve d . T h e y ar e a va i l ab l e on web s it e , Em pl o ye e Ha n db o ok an d C us t om er Inf or m at i o n Fo ld er . R i gh ts an d D ut i es c om p l y wi th a ll in t er n a ti o na l hum an r ig hts c on v e nt i on s . It was c onf ir m ed dur i ng i nt er v i e ws th at pers o n ne l is a war e of th e r i g hts an d du t ies of t he per s o ns s er ve d . 16 . T h e s oc i a l s er v ic e pr o v i d er inf orm s th e pers o n s er ve d a bo ut h is / h er ri gh ts a nd d ut i es es pe c i al l y t o eq u a l tre atm e nt o n gr ou n ds of a g e, d is a b i li t y, ge n de r , r ac e , r e l ig i o n or be l i ef an d s ex u al or ie nt a ti o n b ef or e rec e i vi n g t he s er v ic es . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents All p ers ons s er v e d s i gn a P ap er of Co ns en t t h at i nc lu d e s th e R i g hts an d Du t ies of p er s ons s er v ed . It was c onf ir m ed dur i ng i nt er v i e ws th at th e c l i e nts wer e a wa r e of th e ir r ig hts an d du t ies a nd k ne w wh er e t o f i nd th e i nf orm at io n w h e n n ec e s s ar y. 17 . T he s oc i a l s er v i c e pr o v id er h as ac c es s ib l e c om pl a i nt m ana g em ent s ys tem wh ic h r e gis t e r s f ee d bac k o n perf orm anc e f rom pers o n s s er v ed , purc h as er s an d o th er r e le v a nt s t ak eh o ld ers . 16 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents Am brom ed ’s c om pl a i n m an ag em en t s ys tem is d oc um ent e d i n th e we bs i te , Em pl o ye e H a nd b o ok an d C us t om er Inf orm at i o n F ol d er . C om pl a in ts c a n b e pres e nt e d v er b a l l y, b y p ho n e, m ai l or o n pa p er on s i te . C om pl a in ts a r e h an d l ed on c om pl a i nt f or m wh er e is wr it t en t he c om pl a in t, c om m ent f r om the em p lo ye e th at rec e i v ed t he c om pl a in t, t he dec is i on , h o w it was c om m unic at e d to th e p ers on c om p la i n i ng , wha t was th e s o lu t io n e tc . T he c om p la i nts r e v ie we d s ho we d tra ns par e nt h a nd l i n g o f th e c om pl a i nts . 18 . T h e s oc i a l s er v ic e pr o vi d er res p ec ts t he f u nd am en ta l r ig h t t o s e lf - de t er m in at i on of t h e per s o n s er ve d . T he y f ree l y de te rm ine t he ir po l i t ic a l s ta tus an d f r ee l y p ur s ue t h e ir ec on om ic , s oc i al an d c u lt ur a l d e ve l o pm ent . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 17 S up p ort t o s e lf - d et er m inat i o n is wr i tt en i n t he Ri g hts a nd Du t i es of t he p ers o ns s er ve d . I t is p ub l is h e d o n t h e we bs it e, Em pl o ye e H a nd b o ok an d C us t om er Inf orm at i o n F o l der . Am brom ed ’s p er f or m anc e i n r es p ec t i ng th e r i gh t t o s e lf - d et er m ine is e v al u at e d an n ua l l y, l at es t o n J a n uar y 2 0 1 6. P ers o n ne l d em on s tr a te d d ur in g i nt er v ie ws hi g h a p pr e c i at i on to t he r i g ht to s e lf - de t er m in at i on of th e p ers ons s er ve d . 19 . T he s oc i a l s er v ic e pr o v i der f ac i l i ta t es th e pers o n s er v e d in c ho os i ng an d h a v in g ac c es s t o ad v oc at es a nd / or s u pp ort i ng pers o ns . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 18 Inf orm at i o n wh o wi l l h e lp pers o ns s er ve d ac c es s a d voc a tes a n d/ or s up p ort i n g p er s ons i s doc um en te d i n th e Am brom e d’s R u l es of Pr oc ed ur e. Ru l es of Pr oc e d ur e ar e p u bl is h ed i n we bs it e a nd Em pl o ye e H an d bo ok . Am brom ed ’s p er f or m a nc e in f ac il i ta t in g pers o ns s er v ed in ha v i n g ac c es s to ad v oc at es a n d/ or s u p por t in g p er s o ns is e va l u at ed a n nu a l l y, l at es t o n J a nu ar y 20 1 6. T his was ve r if ie d dur i n g s t af f i nt er v ie ws . 20 . T h e s oc ia l s er v ic e pr o v i d er def in es a n d doc um en ts its p o l ic y o n et h ic s th at r es p ec ts a nd as s ur es th e d i gn i t y of th e p ers o ns s er v e d, pro tec ts th em f rom un du e r is k an d pr om otes s oc i a l j us t ic e 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 19 Am brom ed ’s p o l ic y of eth ic s is doc um en te d in Em p l ye e Ha n db o ok c ha p ter “ Et h ic a l pr in c i pl es ” a n d i t is a ls o a v a i la b l e o n we bs it e . A l l em p lo ye e s s ig n t h e Em pl o ye e Ca rd af ter th e y ha v e be e n i n tr o d uc e d Em pl o ye e H an d bo ok wh er e on e of t he to p ic s is “ Et h ic a l pr i nc i pl es ” . T his was v er if i ed by s tu d yi n g the doc um en ta t io n a n d b y i n te r vi e wi n g t he pers o n ne l 21 . T he s oc ia l s er v ic e pr o v id er op er at es m ec han is m s wh ic h pr e ve n t t he ph ys ic a l, m ent a l a nd f i na nc i al ab us e of u s ers . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 20 Am brom ed h as doc um en te d in Em pl o ye e Ha n db ook c h ap t er “Pr oc e d ur es of pr e v en t in g ph ys ic a l, m enta l a n d f i na nc ia l ab us e of p ers o ns s er ve d” . Am brom ed ’s s er v ic es pr ic e l is t is pu b l ic an d a v a i la b l e on w ebs i te to avoid f in anc i a l a bus e. Pe r s o nn e l f o l l o ws c o d e of et h ic s in th e ir wor k th at pr oh i b it th e ab us e of per s o ns s er v ed . T he ef f ec t i v en es s of the p o l ic y to pre v e nt ph ys ic a l, m eta l a n d f in a nc i a l ab us e of p er s o ns s er v ed was e va l u at ed l at es t o n J a n uar y 2 0 1 6. T his was v er if i e d by s t u d yi n g th e doc um en ta t io n an d b y in t er vi e wi n g t h e pers o n ne l . 22 . T he s oc ia l s er v ic e pr o v i der pr o v id es s er v ic es i n a s af e s ys t em of work i n g wi t hi n a s af e e n vi ro nm en t to e n s ure t h e p h ys ic a l s e c ur it y o f pers o ns s er v ed , t he ir f am il i es a nd c ar e tak ers . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 21 Am brom ed h as d oc um e nt ed oc c u p at i on a l he a lt h an d s af et y i ns tr uc t i o n, h as c a r r i e d ou t he a lt h a nd s af et y r is k an a l ys is a nd h as pu t to g et her an im p r o vem e nt pl a n ac c or d i ng t o t he r is k a na l ys is f i nd i ngs . W ork ing wi t h oc c u pa t i on a l h ea l th a n d s af et y was on e of th e im pr o vem en t proj ec ts in 20 1 5 and ac t i v i ti es ar e p la n ne d a ls o f or 2 0 16 ( e . g. ph ys i ot h er ap y tr a i ni n g ) . 23 . The s oc i a l s er v ic e pr o v i der d ef i n e s , d oc um ents , m on it ors an d e va l u at es a s e t of pr i n c i pl es , va l ues a nd pr o c ed ur es t h at go v er n b eh a v i our i n s er vic e d e l i ver y c o nt a in i n g as p ec ts of c o nf i de n ti a l it y, ac c u rac y, p ri v ac y an d i n te gr it 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 22 P er s o n ne l f o ll o w in t h ei r work Am brom ed ’s et h ic a l pr inc i p les ( wh ic h are b as ed o n Es t o ni a n As s oc i at i o n of Ps yc ho l o gis ts , S oc ia l W ork er s and Es t o n ia n M e d ic a l C o d e of E th ic s ) , c or e v a lu es an d d es c r ib e d pr oc es s es of s er v ic e d e l i v er y. A l l t h is i nf or m at io n i s wr it te n o n t h e we bs it e a nd Em pl o ye e H an d bo ok . P ers o n ne l h as s ig n ed Em pl o ye e C ard af ter the Em pl o ye e H an d b ook i ntr od uc t i ve tr a in i n g. It was c o nf i r m ed d ur i ng i nt er v ie ws t h at pers o n ne l is a war e of t he se t of pr inc i p les , v a l ues an d pr oc ed ur es t ha t go v er n b eh a v i our in s er v ic e d e l i v er y. 24 . The s oc i a l s er v ic e pr o v i der d ef i n e s , d oc um ents , m on it ors an d e va l u at es pr oc e d ur es f or as s ur i n g c onf id e nt i a li t y of d a ta re g ar d in g th e pers o ns s er v ed an d t h e s er v ic e pro v i d ed t o t hem . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 23 P ol ic y a n d pr oc e d ur e of c onf id e nt i a li t y is doc um en te d i n Em p lo ye e H a nd b ook an d o n C us tom er Co ns e n t F or m . It is wri tt e n wh o c an ac c es s t h e pers o na l da t a, wh e n c l i en t s i gn e d c ons e nt is req u ir ed to gi v e o u t da t a , t o whom it c an be g i v en . El ec t r on ic d oc um en ts c an b e ac c es s ed b y I D - c ar d an d pa p er doc um en ts ar e k ep t i n l oc k ed ar c h i v e. It is doc um en te d th at c o nf i de nt i a l it y po l ic y a n d pr oc e d ur es wi l l be r e v ie we d wi t h s taf f an d p er s on s s er v e d i n e v er y t wo ye ars . T h is was d on e l as t t im e wit h s taf f a t th e b e g in n in g of 2 0 16 . 25 . T h e s oc ia l s er v i c e pr o vi d er d ef i nes t he r ol es a nd r es p o n s i bi l i ti es , au t hor i ti es a nd t he i nt er r e la t io n of a l l pe rs on n e l wh o m an ag e , d es i g n, de l i v er , s up p or t a n d e v a lu at e t he s er v ic e pr o v is i o n to pers o n s er v ed . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 24 T he ro l es an d r e s po ns i bi l i ti es of m anag em en t ar e doc um en te d in Em pl o ye e H a n db o ok an d in tr od uc ed t o a ll em pl o ye es . T he r o le an d r es p o ns ib i l it i es of the f unc t i o ns d ir ec t l y i n vo l v ed wi th s er v ic e de l i v er y to the per s ons s er v e d is doc um en te d in th e R u les of pr oc e dur e an d a v a i la b l e at t h e w ebs i te t o a l l. A l l p os it i ons ’ j o b d es c r i pt i ons ar e a ls o doc um en te d i n Em p lo yee H a nd b ook . 26 . The s oc i a l s er v ic e pr o v i der wo rk s in p ar tn ers h ip wi t h o t her org a n is a t io ns i n t he pr o v is i o n of s er v ic es . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents Dif f er en t c o - op er at i o n par t ner s a re l is t e d i n th e we bs it e an d gr ou p ed i n Em pl o ye e H an d b ook ( f un d ers , un i v ers it i es , as s oc ia ti o ns , p ub l ic it y, te am de v e lo pm en t, web d e v e lo pm en t). P art n ers ’ f e ed b ac k is c o l lec t ed e i th er v erb a l l y or o n p ap er . 27 . T he s oc ia l s er v ic e pr o v i d er work s in par tn ers hi p wi t h p ers ons s er ve d , purc h as er s an d o th er s tak e ho l de rs i n th e d e v e lo pm en t of s er v ic es . 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 25  Str e n gt hs Im pro vem e nt & de v e lo pm ents Am brom ed h as as k e d f e ed b ac k f rom pers o ns s er v ed a nd f u nd er s or org a n is e d m ee t in gs ( e .g . wi th Es t on i a n He a lt h I ns ur a nc e F u n d wh er e c h a ng es in s er v ic e b il l i ng wer e m ade) . In i nf orm at io n d a ys a t d if f er e nt c ou nt i es th e y org a n is e d wor k g r ou ps wh er e loc a l pe o p le a n al ys e d t h e ne e ds of e l der l y, c h il dr e n a nd a du l ts . S e ver a l id e as ar e a ls o im p lem en t ed ( d if f er e n t s i ze s l ip p ers f or c us tom er s , r e v i e wi n g t h e op e n in g h ou r s etc .) 28 . The s oc ia l s er v ic e p ro v i de r inc l u de s p ers o ns s er v e d as ac t i v e par t ic ip a nts in p l a nn i n g a nd h a v e s et up ap p ra is a l m ade up of o n - go i n g of an on- g o in g s tr uc t ur ed di a l og u e pr oc es s i n t he m an ag em en t of th e s er v ic e , inc l ud i n g t h e d ef i n it i o n of t he ne e ds , th e def in i t io n of th e s er v ic es , as we l l as of t he e va l ua t io n of q ua l it y. 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 26 In v o l vem e nt of p er s ons s er v e d is It is a d v is a b le to c o ns id er t o c o l l ec t doc um en te d in t h e Em p lo ye e Ha n d bo ok m ore reg u l ar f ee d - bac k f rom the c ha p ter “ C us tom er f eed bac k ” an d pers o ns s er ve d ( e. g. reg u l ar m eet i n gs i nd i v i du a l p l an . etc .). In d i v id u al f e e db ac k is c ol l ec t ed at t h e A ud i it or s o o v it ab k o g ud a en d of th er a p y, d ur i ng s um m ar ies at reg u l aars em al t k li e nt i de t a g as is i d et ( nt th e en d of a ye a r or du r i n g t h e ye ar k lie n ti d e k o os o l ek ut e vm s (pr op os it i ons , c om pl a in ts , f e e d - b ac k k orr al d am in e). s ur ve y) . In a dd i ti o n it is p la n n ed t o d is c us s wi th c l ie n ts i n e v er y t wo ye ar s a bo u t n e w pro gr am m es an d s er v ic es and f ee d - bac k ab o ut c ur r e nt s e r v ic es . 29 . T he s oc i al s er v ic e pr o v id er i ns t i tu t es an an n ua l e v al u at i on of par t ic ip a ti o n of per s o n s s er v e d bo t h o n i nd i v i du a l a nd / or gr ou p b as i s . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents In d i v id u al p l a ns an d R ul es of Pr oc e d ur e ar e d is c u s s ed an d a gr ee d wi t h t h e c l ie n t s . R u l es of P r oc e dur e wer e re v i e we d i n J a nu ar y 2 01 6. T his was v er if i e d by e x am in in g th e doc um en ta t io n a n d a t th e i n ter v i e ws wi t h th e c l i en ts . 30 . T h e s oc i a l s er v ic e pr o v id er o per a tes s p ec if ic i ns tr um en ts f or us ers t o im pr o v e t he ir p er s o n a l em po we rm ent a nd p ers o n a l s i t ua t io n a n d. th at of th e ir c om m un it y 27 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents Fac i li t at i ng em po we r m ent is o n e t h e m ain o bj ec t i ves of A m br om ed’s work . T he proc es s is d oc um en t ed in Em pl o ye e Ha n d b ook c h ap t er “Em po werm e nt” . In d i v id u al Pl a ns ex a m ine d pr o v e d t h e im pro v em ent of e m po wer m e nt of pers o ns s er v ed . 31 . T he s oc i al s er v ic e pr o v id er o per at es s p ec if ic m ec h a ni s m s f or es t a bl is h in g a n em po w er in g e n v iro nm en t. 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents Am brom ed has doc um en te d in Em pl o ye e Ha n db ook c h ap t er “Em po werm e nt” . Em pl o ye es pa r t ic ip a te r eg u l ar l y in s up er v is i on to f ac i l it a te t he em po werm en t o n pe r s ons s er ve d. T his was v er if i ed b y ex am in i n g t he doc um en ts an d at t h e in t er v ie ws wi th th e p ers o n n el . 28  32 . T h e s oc i a l s er v ic e pr o v i d er s el ec ts pr ogr am m es wh ic h ar e bas e d on a ne e ds as s es s m en t a t th e loc a ti o n wh ic h i s m os t c on v e n ie nt f or th e pers o n s er ve d , f am i l y a nd c a r e tak er 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents T he ne e ds of c ur r en t c l i en ts are i de nt if ie d in i nd i v i d ua l p l ans and c us t om er f e ed - b ac k s u r v e y. T he n e eds of p o te n ti a l c l ie n ts wer e i de nt if ie d b y or g an is i n g wor k gr o u ps i n d if f ere nt c o un t ies wh er e l oc a l p e op l e an a l ys ed th e n e e ds o f c hi ldr e n, a du l ts an d el d er l y p e op l e. It is p l an n ed to org a n is e o n - l in e s ur v e y f or p ot e nt i a l c l ie n ts t o as k th e ir f ee d - b ac k of the ir ne e ds . Am br om e d h a s c ar r ie d o ut a p il o t pr oj ec t f or p e op l e wit h ea t in g d is or d ers a n d h as b u il t o ut t h e f ac i l i ti es to of f er t his s e r vic e i n th e f u t ur e wh en it wi l l b e f u n de d . It is c o nf ir m ed d ur i n g i n ter v i e ws th at c urr en t l oc a t io n is c o n ve n i en t f or s t af f an d pers o ns s er v e d. Am br om ed ’s lo n g term obj ec t i v e is to ex p a nd a ls o to T al li n n. 33 . T he s oc i a l s er v ic e pr o v id er of f ers pr o gram m es c ons is t en t wi t h th e i de nt if ie d n ee ds of i ts c us t om ers an d o bj ec t i v es f or t h e pr ogr am m e. 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 29  Str e n gt hs Im pro vem e nt & de v e lo pm ents Am brom ed h as c o ntr a c ts wit h Es t o ni a n He a lt h I ns ur a nc e Fun d and S oc i al Ins ur anc e B o ar d . Fe ed- b ac k f r om bot h f un di n g b od i es is v er y p os it i v e an d f und i n g h as i nc re as ed dur i n g th e ye ar s . Fe e d- bac k f rom c us tom er s an d r e vi e wi n g i nd i v i du a l p l ans pr o ve d t ha t t he ne e ds of p ers ons s er ve d ar e m et. 34 . T h e s oc i a l s er v ic e pr o v i d er o p er at es i nd i v i du a l pr oc es s es t ha t are dr i ve n b y t h e ne e ds of t he pers o n s er v ed . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents E ac h p ers on ’s n ee ds an d ex pec ta t io ns are e v a l ua t ed a t t h e t her a p y m ee t in gs . Ac c ord i n g t o th e e v al ua t io n r es u lts i t is dec i d ed wh ic h s er v ic e s s ui t t h e b es t f or th e p ers o n s er v e d. By re v i e wi n g i nd i v i du a l plan doc um en ta t io n i t was ver if ie d t ha t t he ne e ds a nd ex p ec t at i o n s wer e r ec or d e d. 35 . T h e s oc ia l s er v ic e pr o v id er d oc um ents t he p l a nn i n g of s er v ic e s b as e d on th e id e nt if ic at i o n of in d i v id u al n ee ds an d ex p ec t at i ons of pers o ns s er ve d i n a n I nd i v i du a l P l a n. 30 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents In d i v id u al p la ns ar e c om pos e d ei t her i n It is ad v is a b le to us e only one IT s ys t em or on p ap er ( O bj ec t i ves ap pr o ac h t hr ou g ho ut or g an is at i o n - Form ). I nd i v i du a l p la n has t he e it her e l ec tr o n ic a l or pa p er wh en i nf orm at io n of n e eds , ex p ec t at i o n o n c om pos in g in d i v i du a l p la ns a n d f i nd a th e t h era p y, o v er a ll o bj ec t i ves , s p ec if ic wa y f or a l l c l i en ts t o s i gn t h e p la n . m eas ur ab l e obj ec t i v es , s u it a bl e s er v ic es / m et ho ds / i n ter v e nt i o ns / A ud i it or s o o v it a b k as ut a da lä b i org a n is a ts io o n i üh te lä h en em is t tec h ni q ues / tr ea t m ents , i n vo l v e d i nd i v i du a a ls e te p l a an i de k oos t am is e l s pec i a l is ts and r ef er r al to o th er s pec i a l is t whe n n ec es s ar y. (k as el ek tro on i l is t või p ab erk an dj al ) n in g le i d a v õ i m alus k õik i d e E lec tr on ic p la ns ar e agr e ed v er ba l l y i nd i v i du a a ls e te p l aa n i de an d O bj ec ti v es F or m is s i g ne d b y th e a llk irj as t am is ek s k l ie n ti d e p oo l t. c l ie n t. It was c o nf i r m ed dur i ng in ter v i e ws t h at c l ie n ts wer e in a gr eem en t wi t h the i nd i v i du a l p la ns ( a gr e ed e i th er v er ba l l y or s i gn e d o n p ap er ) . 36 . T h e s oc i a l s er v ic e p r o v i der i d en t if i es , doc um en ts , a nd m a in t a ins th e k e y s er v ic e de l i v er y pr oc es s es t o th e p ers on s s er v e d i n l i ne wi th it s v is i o n, m is s io n s ta t em ent a n d q u al i t y p ol ic y. 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 31 S er v ic e d e li v er y pr oc es s es are doc um en te d i n t h e Em p lo ye e H a nd b ook an d they ar e c om p li a nt wi t h t he m is s io n, q ua l i t y po l ic y a nd s pec if ic a t io ns m a de b y f un d er s . T his was ver if ie d by e x am in i n g t he doc um en ta t io n an d f e ed - b ac k f r om the f un ders . 37 . T h e s oc i a l s er v ic e pr o v id er r e v i e ws th is de l i v er y pr oc es s a n d m aint a i ns c on tr ol o ver t h e d el i v e r y of th e s er v ic e. 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents Key s er v ic e d e l i ve r y pr oc es s es ar e m onit or e d a n d r e v ie w ed a t t h e r eg u l ar m eeti n gs a nd an n ua l m eeti n g. Am brom ed per f or m s r eg u lar i nt er na l au d its ab o ut t he r ec o r d in gs of th er ap y i n t he i nf or m at i on s ys tem s an d g i ves reg u l ar f e e d - bac k a b o ut t h e f i n d in gs . T his was v er if i e d by e x am in in g th e doc um en ta t io n . 38 . T he s oc ia l s er v ic e pr o v i d er e ns u res th at th e p ers on s er v ed c a n ac c es s a c on t i nu um of s er v ic es th at s pa n f r om ear l y i nt er v en t io n t o s u p por t a nd res p o n d t o c h a ng i n g r eq u ir em ents o v er t im e . 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 32  Str e n gt hs Im pro vem e nt & de v e lo pm ents S er v ic es ar e p la n n e d ac c or di n g t he f un di n g. Im p lem en t at i on of f und i n g is f ol l o wed m on th l y. I nd i v i du a l p l a ns , an n ua l p la ns an d a nn ua l r e por ts s ho w th at the c o nt i nu um of s er v ic es is c ons i d ere d ( e . g. new s pec i a l is t ar e h ire d wh e n n ec es s ar y) . 39 . T h e s oc ia l s er v ic e pr o v i d er de v e l ops a s e am les s c o nt i nu um of s er v ic es an d re d uc es bar r i er s i n a m u lt i - d is c i p l i nar y or m u lt i - ag e nc y s et t in g. 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents B arr iers a r e d is c us s ed a t r e gu l ar or an n ua l m ee t in gs . For ex am p le Am brom ed is p l a nn i n g t o r ec r u it n e w s ec re t ar y to be open lo n ger d ur i ng work d a y a n d in we e k - ends . T he i n pu t f or t his c h a ng e c am e f r om c us t om er f ee d- b ac k . Am brom ed h as h ir ed an d is p l a nn i n g t o h ire i n 2 0 16 n e w s pec i a l is ts ( da nc e th er ap is t, p e er - c ou n c e ll or ) to of f er e ve n b et t er m ult i di s c i p li n ar y a pp ro ac h to t h e pers o ns s er v ed . T his was v er if ie d du r i ng i nt er v i e ws wi t h pers o n ne l and ex am i n in g t he doc um en ta t io n . 33  40 . T h e s oc i a l s er v ic e pr o v id er o per a tes s er v ic es f rom a ho l is tic a ppr o ac h bas e d o n t h e n e eds a nd ex pec ta t io ns of th e pers o n s er v e d wit h t h e a im of im pro v i ng t h e qu a l it y of lif e f or t h e pe rs o n s er ve d . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents Am brom ed h as s ta r t ed to us e the It is ad v is a bl e t o ex pa n d t he us e of Q u al i t y of L if e q ues t i on n a ir e wh ic h is Q u al i t y of Lif e qu es ti o nn a ir e, s o a l l p la n ne d to r e pe at at the en d of pers o ns s er ve d h a ve th e qu es ti o nn a ir e th er ap y. f il l ed . Q u al i t y of l if e is a ls o e v a lu at e d i n t h e A ud i it or s o o v it a b la i e nd a da i nd i v i du a l p l ans wh er e the pr ogr es s c a n e luk v a l it ee d i k üs im us ti k u tä itm is t , n ii e t be s ee n. k õik id e l k l ie n t id e l o lek s s e e t äi d et u d. T his was v er if i ed by e x am i n in g the Q u al i t y of L if e qu es t i on n a ir es a nd In d i v id u al P la ns . 41 . T he s oc i a l s er v ic e pr o v i der id e nt if i es t h e n ee d ed c om pet enc e s , s k il ls an d s u p por t f or s taf f t o e nh a nc e t h e qu a l it y of lif e f or p ers o n s er v ed . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents 34 T he s k i lls and c o m pete nc i es t h at en h anc e t h e qu a l it y of lif e of pers o ns s er ve d is d oc um ent ed in Em p lo ye e Ha n db o ok c ha pt er “ J ob t as k s an d c om pet e nc y r e qu ir em ents ” . T he s k il ls an d c o m pete nc i es ar e e va l u at ed a n nu a l l y, l at es t i n J an u ar y 20 1 6. 42 . T he s oc ia l s er v ic e pr o v i d er i d en t if i es i ts bus i nes s r es u lts an d pro v i d es f orm al p er io d ic a n d i nd e pe n de n t re v i e w a nd pr oc e d ures to ac h i e ve th e tar g et ed r es u l ts . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents Am brom ed h as c om pos e d a nn u a l p la n an d is r e v ie wi n g th e r es ul ts t wi c e a ye ar i n J un e an d i n J a nu ar y. Am brom ed has c om pos ed an n u a l r e por ts a b ou t th e ir ac t i v it i es a nd r eac h i ng th e obj ec t i v es . Es t o n ia n H e al t h I ns u r anc e F u nd an d S oc i a l I ns ur a nc e B o a r d ar e r e v i e wi n g th e r es u lts a n d p er f or m anc e r e gu l ar l y. T his was v er if ie d by e x am i ni n g the an n ua l pl a n d oc um ent at i o n a nd ex t er na l b o d y r e v i e w d oc um en t at i on . 35  43 . T h e s oc i a l s er v ic e pr o v i d er id e nt if i es a nd re g is t ers t he o utc o m es an d be n ef i ts f or p er s o n s er ve d of t h e r ec e i v e s er v ic es o n i nd i v i du a l an d c o ll ec ti v e b as is . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents In d i v id u al pl a n r es u lt s ar e m e as ur e d an d doc um en te d in t h e i n d i v id u al p l an re v ie ws . Co l l ec t i v e r es ul ts ar e s um m ar is ed in an n ua l re p or ts and d is c us s e d in pers o n ne l m eet i ngs . 44 . T he s oc ia l s er v ic e pr o v i d er e v a lu a tes i t s bus i nes s r es u lts i n ord er to de t er m in e b es t v a lu e f or p urc has ers a nd f u n ders ( ‘b e s t v a lu e ’ c a n a ls o be ex pr es s e d in r e l at i o n to t he i nc r e as e d q ua l i t y of l if e of f er ed t o t h e pers o n be i n g s er v ed) . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents T he a dd e d v a lu e f or f und ers is e va l u at ed bas e d o n th e ir f e e d - b ac k . T he a dd e d v a l ue f or th e p er s ons s er ve d is e v al u at e d i n in d i v id ua l p l ans ho w th e qu a l it y of l if e h as i nc r eas e d. 45 . T h e s oc ia l s er v ic e pr o v i d er e va l u at es th e i n di v i d ua l a n d c o ll ec ti v e s at is f ac t io n of p er s o n s s er v ed a nd ot h er s t ak eh o ld ers b y in t ern a l an d/ or ex t er na l e v a l ua t io n. 36 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents Am brom ed h as as k ed th e s a t is f ac t i on It is a d v is a b l e to m ak e a la rg er of p ers o ns s er v ed , f u nd i n g b o d ies a nd s at is f ac t io n s ur v e y f or c l ie n ts a nd par t ners b y f e e d - b ac k qu es ti o nn a ir e. f un di n g a nd c o - op er at i on par t ners onc e e ver y ye a r t o ge t m ore f e ed - b ac k . I t is Cus tom er f e e d - b ac k is d oc um en t ed a n d ad v is a bl e t o f i nd a wa y t ha t f u n di n g s um m aris ed . bo d i es a nd p art n ers a re a ls o wi l l in g t o par t ic ip a te . Fu nd i n g b od i es a nd p ar t n er s h a ve no t f il l ed i n t h e q u es t i on n a ir e , s a t is f ac t i o n A ud i it or s oo v i ta b lä b i v ii a i ga l aas ta l is pr es e n te d e it h er v er b a l l y or i n e - s uur em a ra h u lo l u - uur i ng u k l ie n ti d e le , m ails . F u nd i n g bo d i es an d p art n ers rah as taj at e l e j a k oos t öö p art n er it e le , e t ex pr es s e d t h eir s a t i s f ac t io n a ls o in s aa d a r ohk em ta g a s is id e t . A u di i t o r i nt er v ie ws . s oo v i ta b m õe ld a v ä lj a l a he n d us i , k uid as r a has t aj a d j a k oos t ö öp ar tn er i d o lek s i d k a v a lm is uu ri ng us os a lem a. 46 . T he s oc ia l s er v ic e pr o v id er pr o vi des ac c es s i b l e and eas i l y un d er s t a nd a b le r ec or ds on o utc om e, i nc lu d in g p ers o n al p erc e p ti o n an d ac h i e v em ents 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents Am brom ed has c o m pos ed an n u al rep or ts t h at i nc l u de als o pe rs o n al perc e pt i o ns an d ac h ie v em ents . A nn u a l re por ts ar e in C us t om er Inf orm at i o n Fo l der a nd pr es e nt e d to par t ners wh en nec es s ar y. 37  47 . T he s oc ia l s e r v ic e pr o v i der ac t i v e l y d is s em in at es o rga n is at i on perf orm anc e am on g it s s t af f , s er v ic e us ers an d ex ter n a l s tak e ho l d ers . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents Am brom ed r ep or ts ab ou t th e ir T o ge t m ore pu b l ic i t y it is ad v is a b le to perf orm anc e in we bs it e, b l og , ad d an n ua l r e por ts t o th e we bs i t e a nd Fac eb o ok ac c ou nt an d v i a e- m a il . ad d 2 01 5 ye ar a n nu a l r e po rt to Cus tom er I nf orm at io n Fo ld er . Res u lts ar e s um m ar is ed in a nn u a l rep or ts . A ud i it or s o o vi t ab p an n a k od u le h e le ü les a as t ar ap or t id n i n g l is a d a k l ie nt i d e i nf ok aus ta 2 0 15 aas t a rap or t. 48 . T he s oc i a l s er v ic e pr o v i der h as a s t a nd ar d proc e dur e f or c on t in u ous im pro v em ent on t h e b as is of a n im pr o vem en t c yc l e. 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents Am brom ed is f o l l o wi n g t h e PD C A c yc le by im p lem e nt i ng th e a n nu a l plan proc es s wh er e obj ec t i v es a n d ac t i v it i es are s e t, ac t i v it i es im pl em ent e d, r es u l ts re v ie we d r e g ul ar l y a nd c or r ec ti v e ac t i ons im pl em ent e d w he n n ec es s ar y. Im pro vem e nt pr oj ec ts ar e a ls o i nc l u d ed i n th e a nn u a l p la n . 38  49 T he s oc i al s er v i c e pro v i d er id e nt if i e s p erf orm anc e in d ic at ors f or m eas ur in g t he r es u l ts of t h e im pro v em ent ac ti o ns . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents Im pro vem e nt pr oj ec ts ar e i nc lu d ed i n th e an n ua l p l an . T he y have s et obj ec t i v es a n d ac ti v i t i es a nd th e r es u lts are r e v ie we d r e g u lar l y. T wo lar g er im pr o v e m ent pr oj ec ts in 20 1 5 wer e im pl em en t in g EQ U A S S qu a l it y s ys t em an d im pr o vi n g oc c u p at i on a l he a lt h a nd s af e t y i n t h e org a n is a t io n . 50 . T h e s er v ic e pr o v i d er in tr od uc es a n d m an ag es i nn o v at i v e wa ys of wo rk in g th at ha v e b ee n i d en t if i ed bas e d on t h e n ee ds of s tak e ho l d ers . 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 Str e n gt hs Im pro vem e nt & de v e lo pm ents In n o va t io n p r oj ec t s ar e a ls o doc um en te d in an n ua l pl a ns and re v ie we d re g u lar l y. Am brom ed p l ans to im pl em ent 3 i nn o v at i on pr oj ec ts i n 2 0 16 : s t art to of f er p eer - c o u nc e l l i ng , d anc e th er ap y an d gr o up t h er a p y. 39 4. Agreed additional development / improvements < T he ap p l ic a n t d ec i de d o n t he f o l l o wi n g im pro v em en t ac ti o ns a nd / or ad d it i o na l d e v e lo pm en t f or t h e pe ri o d of t wo ye ars : > Sho rt d es c ri ptio n of the a cti on s ( in clud ing SM ART ob je ctiv es ) 1 It is a d v is a b l e t o p ub l is h Am brom ed ’s l on g te rm go a ls a n d c om m itm ent to c o nt i nu ous im pro v em en t a ls o to yo u r p art n ers an d p er s ons s er ve d (e .g . p ub l is h th at on t h e we bs it e). A ud i it or s oo v i ta b j a g ad a i nf o t p ik aaj a l is t e ees m ärk id e j a pü h en d um is e k oh ta p id e v al e are n gu l e ka k li e nt i de l e ja par t ner i te l e (n ä it ek s a v a ld a da s e e k od u le h el ). De ad lin e : 01 . 04 . 201 6 P er so n re sp on sib le : Mi rja m O o l 2 It is a d v is a b le to r e v i e w t h e ac t i vi t ies a dd ed to th e An n ua l P la n l a te l y a nd up d at e th e ir ac ti o ns an d i nd ic at ors (e .g . s oc ia l r e h ab i l it a ti o n, work re l at ed r eh a b il i ta t i on) . O n s o o v it a ta v ü le v a ad a ta j a u u en d ad a a as t a pl a an i h i lj u ti l is a t ud ees m ärk id e t eg e v us e d j a m õõ d ik ud (n t s ots i a al n e r eh a b i li t ats i oo n, t ö öa l an e re h ab i l it a ts i o on ). De ad lin e: 01 . 05 . 201 6 P er so n re sp on sib le : Mi rja m O o l 3 T o g et m ore r e gu l ar up - t o- d a te f e ed - b ac k it is ad v is a bl e t o c o ll ec t th e f ee d bac k r i gh t af t er e ac h t h e tra i n in g. Et s a ad a r eg u l aars e t aj ak o has t t a gas is i de t k ool i tus te k o ht a on s oo v i ta ta v k og u da s ed a p e al e i g a k o o li t u s t. De ad lin e: 15 .0 4 .2 01 6 P er so n re sp on sib le : Mi rja m O o l 40 4 It is a d v is ab l e t o c on s i der to c o l lec t m ore reg u l ar f e ed- b ac k f r om the pers o ns s er v ed ( e. g. r eg u la r m ee ti ngs etc .). A ud i it or s o o v it a b k og u da re g u la ars em al t k l ie nt i de t a gas is i de t ( nt k li e nt i d e k oos o l ek ute vm s k orral d am in e). De ad lin e: 01 .1 0. 2 016 P er so n re sp on sib le : Liin e Põ ldsa m 5 It is ad v is a bl e to us e on l y one a ppr oac h t hr ou g ho ut or g a n is a t io n - ei t her e lec tro n ic a l or pa p er wh e n c om pos i ng i nd i v i du a l p l ans a n d f i nd a wa y f or a l l c l i en ts t o s i gn t h e p la n . A ud i it or s o o vi t ab k as u t ad a lä b i org a n is ats i oo n i ü h te l äh e nem is t i n di v i d ua a ls e te p l aa n i de k o os t am is e l (k as e lek tr o o n i lis t võ i pa b erk an dj a l) n in g le i da v õ im al us k õik id e i nd i v i du a a ls e te pl a an i de al lk irj as t am is ek s k l i en t id e p oo l t. De ad lin e: 01 . 05 . 201 6 P er so n re sp on sib le : Liin e Põ ldsa m 6 It is ad v is a bl e to ex p a nd t he us e of Q u al i t y of L if e qu es ti o nn a ir e, s o a l l per s o ns s er v ed h a v e th e q ues t io n na ir e f il l ed . A ud i it or s oo v i ta b l a ie n da d a e luk v a l it e ed i k üs im us t ik u tä i tm is t, n i i e t k õ ik id e l k li e nt i de l o l ek s s e e tä i de tu d . De ad lin e: 01 . 04 . 201 6 P er so n re sp on sib le : Re ta Rii tsa a r 41 7 It is a d v is a b l e t o m ak e a l arg er s at is f ac ti o n s ur ve y f or c l i en ts an d f u n d in g an d c o - op era t io n p art n ers o nc e e ver y ye a r to g et m or e f eed - b ac k . It is ad v is ab l e t o f in d a wa y t h at f u nd i n g bo d i es an d p ar tn ers ar e a ls o wi l l in g t o p art ic i pa t e. A ud i it or s oo v i t ab l äb i v ii a i ga l aas ta l s u urem a r ah u lo l u - uur i n gu k l ie n ti d e le , rah as taj at e le j a k oos t öö p art n er it e le , e t s aa d a r o hk em tag as i s i de t. A ud i it or s oo v i t ab m õe l da v ä lj a l ah e nd us i, k ui d as r ah as t aj a d j a k o os t ö öp ar tn er id ol ek s i d k a v a lm is u ur i ng us os a le m a. De ad lin e: 01 . 09 . 201 6 P er so n re sp on sib le : Liin e Põ ldsa m 8 T o ge t m ore p ub l ic it y it is a d v is ab l e t o a d d an n ua l r ep or ts t o th e we bs it e an d a dd 20 1 5 ye ar a nn u a l r ep ort t o C us t om er Inf or m at i o n F o l der . A ud i it or s oo v i ta b pa n na k o du l eh e l e ü l es a as t ar ap or ti d ni n g l is a d a k l i en t id e i nf ok a us t a 2 01 5 a as t a r a p ort . De ad lin e: 01 . 04 . 201 6 P er so n re sp on sib le : Mi rja m O o l 42  5. Closing remarks Am brom ed G r up p O Ü was f o un d ed in 2 0 04 f or pr e v e nt i on a n d th era p y f or m en t al d is or d ers . Am br om ed c l in ic of f er s ps yc h i atr i c s er v ic e , ps yc h o l og ic a l ( in d i v id u a l a n d c ou p l e an d f am i l y th e r ap y) s er vic e , s pe ec h th er a p y, p h ys io th er a p y, oc c u pa t io n al th er ap y, s oc i al wor k er s er v ic e, s oc i a l a nd work re l at ed r eh a b il i ta t i on . Am brom e d is th e f irs t c l i nic i n Es to n ia s p ec ia l is ed i n e at i ng d is or der t her a p y i n a f orm of a d a y c en t er. Ser v ic es ar e p r o v id e d i n Es to n ia n , R us s ia n a nd E ng l is h. Am brom ed has s ig n e d c o ntr ac t wi t h S oc i a l Ins ur anc e Bo ar d s i nc e 20 0 8 a nd Es t o n ia n H ea l th I ns ur anc e F un d s i nc e 2 01 1. Am brom ed is a m em ber of Es t on i an Me n ta l H e al t h an d W ell - B ei n g Co a l it i o n ( V AT E K) s i nc e 20 1 4. T his is t he f ir s t EQ U A S S As s ur anc e a u di t i n Am br om ed. Am brom ed has im pl e m ente d q u a li t y s ys t e m bas ed on EQ U AS S As s ur a nc e c r i ter i a th at f o l l o ws PD C A - c yc l e . An n ua l p la n n in g c yc l e is p erf orm in g we ll . C l i en ts ’ i nd i v i du a l n ee ds ar e t ak en i n to ac c o un t. T h ere is g oo d c o - o per a ti on wi th dif f er en t c o- o p er at i on p ar t ne r s in or der to of f er b et ter s er v ic es . Pers o n n e l is v a lu e d a n d th e y ar e s at is f ie d wit h t he ir j o b. T here wer e d if f er e nt i nt er v ie ws wi t h c l i en t s , pers o nn e l, m an ag e rs , f u n di n g b od y an d c o- op er at i o n pa r tn er s d ur in g th e a ud i t. I nt er v ie w p art ic i pa nts wer e co - op er at i v e a nd ex pr es s ed t h ei r s at is f ac ti o n wit h Am brom e d’s ac ti v i t ies . Re q u ire d doc um en ta t io n wa s we ll pr e p ar e d a nd s uf f ic ie n t. D uri n g th e v is it a u d it or f o u nd v er if ic at i on m ate r i a l f o r a l l E Q U A S S As s ur an c e c r i ter i a. For t he per i o d of f ol l o wi ng t wo ye a rs , s om e im pro v em en t ac t i o n s an d a dd i ti o n al de v e l opm en ts wer e a gr e e d t ha t ar e br ou g ht o u t i n p art 4 of th e a ud i t re por t. A m ore de t ai l e d o v er v i e w of s u gg es t io ns f or i m prov em en t t ha t ar e m enti o n ed un d er th e s p ec if ic c r i t er i a is g i ve n i n d et a i l i n p art 3. Af t er v er if ic at i on of t he i n d ic a t or s dur i n g t he s i t e v is it , r e vi e wi n g doc um en ta t io n, c on d uc t i ng s e v er a l i nt er v ie ws wi t h pers o ns s er ve d , s t af f a nd ex t e rna l s t ak eh o ld ers (pa rt ners , f un d er s ) , t h e a ud i tor r eac h ed t o c onc l us io n t h at Am br om ed m eets f u ll y th e c r i te ri a f or EQ U A S S As s ur anc e c er t if ic at i on pro gr am m e. 43 Am brom ed G r up p O Ü as u t at i 2 00 4 . aas t al p s üü h ik ah ä ir et e e nn et a m is ek s j a r a vik s . Am brom ed Kl i i n ik os ut ab ps ü h hi a atr i l is t , ps ü hh o l oo g i li s t (i n d i vi d u a a ln e n i ng p a ar i - ja p er et er aa p i a) , l og o pe e d il is t, f üs io te rap e ut i l is t , te g e vus t era p e ut i l is t ja s ots i aa l tö ö taj a t e en u s t n i ng s o ts ia a ls e ja t ö öa l as t re h ab i l it a ts i o on i t ee n us t . Am brom ed K l i in ik on e s im en e s ö öm is h ä ire t el e s p ets i a l is e er un u d as ut us Ees t is , k us os u t at ak s e r a v i p ä e va k es k us e vo rm is . T ee n us e i d os ut a tak s e e es t i, v en e j a i ng l is e k eel es . A la t es 20 0 8. a as t as t on Am brom ed K l i in ik u l s õ lm it ud k oos t ö öl e p in g S ots i aa lk i nd l us t us am eti g a r eh a bi l i ta ts io o n it ee n us e os ut am is ek s n in g al a tes 2 01 1 . aas t as t o n Am br om ed K l i in ik Ees t i H a i gek a s s a l ep i ng u l i ne p art n er. A l a tes 2 0 14 . aas t as t k u u l u b Am br om ed K l ii n ik E es t i v a im s e ter v is e j a h e ao l u k oa l i ts i o o ni (V AT E K) . K äes o l e v EQ U AS S As s ur a nc e a ud i t o n Am brom ed i le es m ak ord n e. Am brom ed i l on j u ur u t at ud EQ U A S S As s ur a nc e põ h i m õtel e l e t ug i ne v k va li t ee d ij u ht im is s üs t e em , m is j älg i b PD C A - ts ük l it . Aas t as e p l an eer im is e ts ük k el on h äs t i t o im i v. K l ie nt i de l e lä h en e tak s e i nd i v i du a a ls e l t s i lm as pi d ad es ne n de v aj a d us i . T e e nus te p ar em ak s os ut am is ek s to im ub hea k oos t öö er i n e va te k oos t öö p ar t n er i t eg a . P er s o n a l i v äär t us t at ak s e n in g n a d on om a t öö ga r ah u l. A ud i ti l äb i v i im is e l t o im us i d er i ne v a d i nt e rvj uu d k li e nt i de , p er s on a l i, j u h ti d e, rah as taj a j a k oos tö ö par t ner i te g a. I nt er vj u ud es os al ej ad o l i d k oos t öö a lt i d n in g v ä lj e nd as i d om a r a hu l o lu Am br om ed i t e ge v u s eg a . Ko n tro l l it a v d ok um ent ats i o on o l i häs t i et t e va lm is t at u d n i ng am m end a v. A u d it i l ä bi v i im is e l l e i dis au d i it or tõ e nd us m at er j a l i k õ ik i de EQ U A S S As s ur a nc e k ri te er i um ite k oh ta . J ärg n e v ak s k ahek s aas t ak s le p it i k ok k u m õn e d p ar e nd us t e ge v u s ed j a t ä i en d a va d are n d us e d, m is on v ä lj a t o od u d ar u an d e 4 - n das os as . D e t a ils em ül e v aa d e par e n dus s o o vi t us t es t k onk r eets et e k ri t eer i u m ite l õik es o n es i t at u d aru a nd e 3 - nd as os as . P ea l e as ut us e k ül as t u s t, d ok um ent a ts i o o ni ü le v a at us t n in g in te r v j uu d e l ä bi v i im is t te e nus e s a a j a t eg a, t öö t aj a te j a v ä lis t e h u v ip o ol t eg a (p ar tn er i d j a ra h as t aj a d) , j õu d is audiitor otsusele, et Ambromed täidab täielikult EQUASS Assurance sertifikaadi nõudeid. Ta l li n n, 15 .0 3 .2 0 16 Tri i n Kr a av i 44 EQUASS ASSURANCE ASUTUSE KÜLASTUSE ETTEVALMISTAMISE VORM Asutuse külastus: 8.-9.03.2016 Ambromed Grupp OÜ Triin Kraavi © 2012 by European Quality for Social Services (EQUASS) Kõik õigused kaitstud. Antud dokumendi elemente ei tohi paljundada, kopeerida ega muul elektroonilisel moel salvestada ilma EQUASS kirjaliku loata.  Asutuse külastuse ettevalmistamise küsimused EQ U AS S As s ur a nc e t ao t lus v or m i le j a a nt ud l is ai nf orm ats i oo n i l e p õh i n ed es pa l um e te i l e tt e va lm is t us ek s v as t at a j är g ne v at e l e s e l gi t us t n õ ud v at e l e k üs i m us tel e : Üldised teemad (max. 10 küsimust) 1. K as j a k u i das t e ol e te om a t ee n us ei d v i i m as e k ahe a as t a j oo k s ul e d as i are n d an u d? Ku i d as to i m ub u ut e t ee n us t e ar e nd us ? 2. M il l is e d on t e ie or g an i s ats i oo n i h u vi gr u pi d , k uid as te n e nd e v aj ad us t e k o ht a ta g as is i d et s a at e n i n g k as j a k u id as k aas at e ne i d t ee n us t e ar en d a m is s e ? 3. M il l i n e on t ei e or g a n is a ts io o ni i ga - a as t a ne te g e vus t e p la n e e rim is e ja aru a n dl us e pr ots es s ? 4. K ui d as t o im ib or g a n is a ts io o ni p are n dus s üs t e em , m il l is e d on s e ll e tu l em us e d? 5. K ui d as to im i b pe r s o n a l i v är bam is e, ar e nd am i s e j a h in d am is e pr o ts e s s ? 6. K ui d as t o im ub k li en d i in d i v id u aa ls et e t e ge v us k av a de ees m ärk i de s ea dm in e j a tu l em us te m õõtm i ne ? 7. K ui d as T e m õõ d at e as u t us e t u lem us lik k us t? K u i das a n na t e s e ll e k o ht a i nf or m ats io o n om a h u v i gr u p p id e le ne i l e s o bi v a l v i is il ? 8. M il l is e id ar e nd us - j a i nn o v ats i oo n i proj ek t e t e o le t e v i im as e k ahe a as t a j ook s u l e l lu v i i n u d? Version 1.0 2  1. Kvaliteedi põhimõtetele ja EQ U ASS Assurance kriteeriumitele vastavuse küsimused / teemad: Te en us e s a aj a d Kv al i te e d i ju ht J uh t/ dir ek tor Huv i gr up i d P er s o n a l Juht im in e 1. Mi l l is ed on as u tus e v is i oo n , m is s io o n x x x j a v äär t us e d ? 2. M i da s is a ld a b as u tus e k va li t ee d ip o l i it ik a , k as j a k u i das on s e d a x x x per s o n al i l e tu t v us t at u d? 3. K as o l et e t ea d l ik as u tus e p o o lt pak u ta v at es t t e en u s tes t? Kus t Te as u t us e k o ht a i nf or m ats io o n i s aa te ja x x k uid as a nn a te t a gas is i de t te i e s o o v id e j a v aj a d us t e k o ht a te e n u s e le ? 4. K u id as t o im ub a s ut us e a as t a p la a ni k oos t am in e j a k as s e l le pr o ts es s i os as x x x on v i im as te l a as t a te l m ida g i m uu tu n ud ? 5. M i l lis t l is a v ä ärt us t o n as u tus a nd n ud om a k oguk o nd a j a l a i em alt ü h is k on da ? x x x x K as ja k uid as te hi nd a te s el l is te te g e vus te t u l em us l ik k us t ? P er so na l 1 Kas as u tus h i nd a b tö ö ti n g im us i, k as ne n de os as on v i im as te l a as t at e l x x x r ak en d at ud m in g ei d m uu d at us i? 2 M i l l is e d on nõ u de d tö öt aj at e k om pet e nts i l e, k us t ne e d on x x x k ättes a ad a v ad , k ui d as on v õ im al ik v aj a d us e l t eh a m uud a t us i? Version 1.0 3  3 K as , k u i das j a k u i t ih t i v i iak s e l äb i te e nus e s a aj at eg a ots es e l t k ok k u x x x pu u tu v a p ers on a l i h in dam is t , m i l l is e d o n s e ll e t u lem us e d ? 4 K u id as t o im ub p e rs on a l i v är b am in e , x x x tu n nus tam i ne j a r ah u o l u m õõ tm in e ? 5 K as ja k u id as h in d at e p ers o n a li x x k ool i tus te ef ek ti i vs us t ? Õ igu se d 1. K u i das t o im ub pers o na l i ja v ab a ta ht l ik e i nf orm eer im i ne te e nus e x x x s aaj at e õ i gus t es t j a k ohus t us t es t ? 2. K as t e e nus e s aaj a d o n te a d l ik ud om a õ ig us t es t j a k oh us t us t es t ? K u id as t oim u b x x x x te e nus e s aaj at e t ea v i tam i ne n en d e õ ig us t es t j a k oh us tus t es t ? 3. Ku i das t o im ub t ee n us e s aaj at e en es em äär am is õ ig us e p õh im õt te ar ves t am in e ig a pä e v as es t eg e v us es ? x x x x K ui d as h in d at e s e ll is e te g e vus e tu l em us l ik k us t i g a - aas tas e lt ? 4. K ui d as t o im ib k ae bus t eg a t e ge l em is e x x x x s üs t e em ? E et i k a 1. K as T e o le t e t e ad l ik ee t ik ap ol i i t ik as t ( põ h im õt et es t) ja k äit um is p õ h im õte tes t x x x te e nus e os ut am is e l ? K us te v aj a d us e l s e l l e i nf o l e i at e ? 2. Kas , k u id as j a k ui ti h ti hi n na t ak s e, et m eeto d i d, m i da rak e nd a tak s e te e nus e s aaj at e f ü üs i l is e, v aim s e j a m aj an dus l ik u x x x är ak as ut am is e e nn e tam is el , on ef ek ti i vs ed ? Version 1.0 4  3. K ui d as o n t a ga t u d t ee n us e s a aj a te k onf id e nts i aa ls us ja kui s ag e l i s e ll ek oh as e id põ h im õtt ei d üle v aa d at ak s e? K as s e l l e ü l e va at am is s e on x x x x k aas a tu d k a p ers o na l j a t ee n us e s a aj ad ? K ui d as te e nus e s aaj a id n e nd es t põ h im õt et es t t e a vi t at a k s e? 4. Kas T e t e at e, m i ll is ed ül es a nd e d o n as u t us e t ö öt aj at e l? K us Te v aj a d us e l x x x x x s e ll is t i nf ot s aa te ? 5. K u id as on t a ga t ud tu r va l i ne x x x tö ök es k k ond te e nus e os u t am is e l? Koo st öö suh t ed 1. K as , k el l e ga ja k uid as t eh ak s e te e nus te os ut am is e l ja ar en d am is e l x x x x x k oos t öö d ? 2. K u i das T e h i n da t e, k as te i e k o os t ö ö x x x x on ol n ud ed uk as j a e e s m ärgi pä ra n e ? 3. K as j a k u id as as u t u s on k üs in u d inf ot x x x x v ä lis t e hu v i gr up p i de v aj a d us t e k o ht a? O s al em in e 1. K as te e n us e s aaj a d os a le v a d x x x te e nus te p la n e erim is e l ja h i n dam is el n in g k ui d as s e e t o im ub? K as j a k u id as te h i nd a te e n da t e ge v us te e d uk us t os a l em is e os as ? 2. Ku i d as T ei d o n k aas a tu d t ee n us t e x ar e n d am is s e j a k as T eie et te p an ek ut e a lus e l o n te h tu d k a m uu d at us i? K as T e te at e , k ui d as te i l on õ i g us k aas a r ääk i d a? 3. K as j a k u id as a it ab as ut us k a as a x x x te e nus e s a aj at e j õ us t am is e l e? K as per s o n al i o n s e l l ek s k oo l i ta tu d ? Version 1.0 5  Is ik uk e sk su s 1. Ku i d as o l et e v ä lj a s e l g it a nu d x x x o lem as o l e v at e te e n us e s a aj at e ja po t en ts ia a ls e t e te en us e s a aj a te v aj a d us e d j är gm is e k olm e aas t a j ook s u l? 2. K as t ee n us t pak ut ak s e v as ta v a lt x x x x te e nus e s aaj a v aj a d u s e le j a ta l l e k õi g e s ob i v am as as uk o has ? K as t ee n us e s aaj a lt k üs it ak s e t em a ar v am us t j a k as na d o n t ee n us e g a r a h u l? 3. K u id as a r ves ta t ak s e ra h as t aj a t e j a x x m uude h u v i gru p p id e v aj a d us i , k as n ei d uur i tak s e /k üs i tak s e ? 4. Mi d a s is a l da b i n di v i d ua a l ne x x x x te g e vus p la a n n in g k as see k oos k õl as t at ak s e te e n us e s aaj ag a ? Lai ah a ar de li su s 1. N im et ag e om a a s ut us e pe am is e d x x x pr o ts es s i d . K as , k uid as , m il l es t tu l en e v a lt j a m il l is e r eg u l aars us eg a T e ne i d ül e v aa t at e? K a s T e aru ta t e om a as u t us e pr ots es s e om a te en us t e r ah as taj a(t e) g a? 2. K ui d as te t ag a te , et t ee n us e x x x os u t am in e t o im ub v as t a va l t p la n eer i tu l e n in g i lm a tak is tus te t a ? 3. K u id as te ta g at e k õ ig i x x x i nd i v i du a a ls es s e p l aa n i m ärg i tu d te e nus te os u tam is e? 4. K u id as j a k e l le p oo lt o n m äära t le t ud x x x te e nus e s a aj at e e l u k va li t ee t? K u id as h in d at e, et e l uk v a li t e ed i ees m ärg i d o n tä i de t ud ? Version 1.0 6  5. K as ja kui s a g e li a n a lü üs it ak s e x x x per s o n al i os k us e i d ja k om pete nts e te e nus e s a aj a el uk v a li t ee d i par a n dam is e l ? T ulemu st el e 1. K ui d as t e p l an e er it e j a m õõ da te i ga - x x x ori en t e e rit u s aas t as e l t om a ee s m ärk id e t u lem us i? M il l is e id m õõ d ik ui d te k as ut at e? 2. K as T e ie te a te , m il l is e d ol i d as u t us e x x x te g e vus e d ja t u l e m us ed e e lm is e l aas t al ? Kas t e at e, k us t v aj a d us e l s el l is e i nf o s a ak s it e? 3. K u id as t oim u b er i ne v a te h u v i po o lt e x x x r ah u l o lu h i n dam i ne ? Pi dev a r eng 1. Ku i d as to im ub te ie as u tus es x x x te g e vus te pl a n ee rim in e, ne n de tu l em us te h i n dam i n e ja v aj a dus e l m uuda t us t e s is s e v i im in e? Kus t v aj a d us e l s e l l is ed p õ h im õtt e d l e iak s i te ? 2. T o og e nä i te i d p ar en d us p roj ek ti des t. x x x K ui d as on proj ek ti p la n e erim is e l m äär at l et u d, k u i das s e ll e e duk us t h i lj em m õõta ? 3. K as os k at e t u ua m õn e nä i te , k ui d as x x on as u tus t e ie vaj a du s i om a t e ge v us t e p la n eer im is e l ar ves ta n ud ? 4.T o og e n ä it e id i n no v ats i o on i - x x x pr oj ek ti d es t . Version 1.0 7  2. Nõutav dokumentat sioon EQ U AS S As s ur anc e ta ot l us es s e m ärg i tu d i nf o le j a lis a de l e p õh i n ed es pa l um e v aa t lus ek s e tt e v a lm is ta d a j är g n e v d ok um ent ats i oo n : 1. T ööt aj a te k äs ir a am at 2. K l ie nt i d e, k oos t öö p a r tn er it e , ra h as t aj a te , po te n ts i a a ls e t e k li en t id e ja pers o n al i t a gas is i de k üs it l us t e tu l em us e d 3. K aus t J u he n dm ater j a l i d 4. Ar en g u ves t lus t e k ok k uv õt te d 5. A as t ak oos o lek u pr ot ok o ll i d 6. A as t ap l a an i d, t e ge v us ar u a n de d 7. T ööt aj a te k aar d i d 8. K aus ta d R e h i nf o j a M at er j a l i d 9. S is ek o ntr o l l i pr ot ok ol l i d j a r a por t id 10 . I nd i v i du a a ls e d t eg e v u s p la a ni d 11 . K od uk or d k l ie n d il e 12 . K ae b us t e ga t e ge l em is e s üs t e em i t u l em us ed 13 . Ris k i a na l üüs 14 . K aus t T ö öt er v is ho i d - j a o hu tus 15 . I nd i v i du a a ls e te t e g e v us p l a an i de k ok k uvõ te 16 . E luk v a l it e ed i k üs im us t ik 17 . V äl is te k on tr ol l i d e t u l e m us ed 18 . Me i l i v ah e tus t e ge v us t es t t e a vi t am is e k o ht a Version 1.0 8  19 . T ege v us k a va d , m is on v i i d at ud k od u le h e l k ät tes a ad a v at ek s 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. T eg e vj u h t 1 tu n d Personal Kestvus 1.T e en us te k v al i te e d i ees t v as tu ta v 1 tu n d tö öt aj a 2. P ers on a l igr u pp nr . 1 ( k uni 5 t ö öt aj at , 1 tu n d er in e v ad s pe ts ia l is ti d , v ä lj a a r va tu d j uh i d) 3. P ers on a l igr u pp nr . 2 ( k un i 5 t ö öt aj a t, 1 tu n d er in e v ad s pe ts ia l is ti d , v ä lj a a r va tu d j uh i d) Teenuse saajad Kestvus 1. K li e nd i gr up p n r . 1 ( k un i 5 k li e nt i, 1 tu n d er in e v at e t ee n us t e k l i en d i d) 2. K li e nd i gr up p n r . 2 ( k un i 5 k li e nt i, 1 tu n d er in e v at e t ee n us t e k l i en d i d) Teised huvigrupid Kestvus Version 1.0 9  1. Ra h as t aj a t e es in d aj a d ( k un i 2 in im es t) 1 tu n d 2. K oos t öö p ar t n er it e e s i nd aj a d ( k un i 4 1 tu n d i nim es t) 4. Asutuse kül astuse ajakava formaat As ut us e k ül as tus pe ak s o l em a k orra l da t ud v as t a v al t j är gn e v at e le j uh is te l e: a. As ut us e k ül as tus pe ak s o l em a k av a nd a tu d k ah e l e tö ö pä e v a le ( = 1 6 tu n d i) b. Dok um en ta ts io o ni g a t ut v um in e p e ak s olem a p l an e er it ud es im es e 3 h s is s e k ülas tus e es im es e l p ä e va l . c . P äe v ak a vas pe ak s ol em a s ag ed as ed pa us i d (1 5 – 3 0 m inu t it) , et a u d ii t or s aak s in d ik aa to r i t e tõ e nd e i d ü le va a d at a j a k orr as t ad a . d. In ter vj u ud j uh tk on n a, per s o na l i j a t e is te g a ( vä l is ed hu v i gr up i d/ par tn er i d) pe ak s k es tm a m ax 30 - 5 0 m in ü h e in ter vj uu k oh t a . I n ter vj u u d t ee n us e s aaj at e ga pe ak s id ol em a k orra l da t u d gr u p ii n ter vj u ud e na ( m ax 5- i n im es t k orr ag a) e. J uh i g a/ d ir ek tor ig a i n ter vj uu p e ak s ol em a p la n ee ri t ud as ut us e k ülas t us e te is e le p ä e va l e ( s o o v it a va l t p ea l e lõ u na l) . f. Lõ p l ik as ut us e k ül as t us e pr ogr am m peak s o lem a t ao t lej a j a au d i it or i va h e l k ok k u le p it u d j a s a ad e tu d EQ U A S S k o ha l ik ul e es in d aj a l e . Version 1.0 10  Asutuse külastuse ajakava kuup ä ev P äev 1 Ae g T egev us ( l üh ik e k irj e l dus ) 9: 0 0- 9 .3 0 A v ak oos o lek , k l i in ik u g a tu t v um ine 9. 3 0- 1 2. 3 0 Dok um en ta ts io o ni g a t ut v um in e 12 . 30- 1 3. 3 0 Lõ u na p aus 13 . 30- 1 4. 3 0 In ter vj u u te e nus t e k v a l it e ed i e es t v as t ut a v a tö öt aj ag a 14 . 30- 1 4. 4 5 In d ik aa tor i te t õ en d it e ü le v a at am in e 14 . 45- 1 5. 4 5 In ter vj u u p er s o n al i gr u p ig a nr .1 15 . 45- 1 6. 0 0 In d ik aa tor i te t õ en d it e ü le v a at am in e 16 . 00- 1 7: 0 0 In ter vj u u k l i en d ig ru p ig a nr. 1 kuup ä ev P äev 2 Ae g T egev us ( l üh ik e k irj e l dus ) 9: 0 0- 10 . 00 In ter vj u u k o os t öö p art n er it e es i nd aj a t eg a 10 . 00 .- 1 0 .1 5 In d ik aa tor i te t õ en d it e ü le v a at am in e 10 . 15- 1 1. 1 5 In ter vj u u r a has taj a t e e s i nd aj a t eg a 11 . 15- 1 1. 3 0 In d ik aa tor i te t õ en d it e ü le v a at am in e 11 . 30- 1 2. 3 0 In ter vj u u p er s o n al i gr u p ig a nr .2 12 . 30- 1 3. 3 0 Lõ u na p aus 13 . 30- 1 4. 3 0 In ter vj u u k l i en d ig ru p ig a nr. 2 14 . 30- 1 4. 4 5 In d ik aa tor i te t õ en d it e ü le v a at am in e 14 . 45- 1 5. 4 5 In ter vj u u te g e vj u h ig a 15 . 45- 1 6. 0 0 K ok k uvõt e te t e gem i ne 16 . 00 Lõ p uk oos o lek Version 1.0 11 EQUASS ASSURANCE APPLICATION ADDITIONAL INFORMATION 1 . S h o rt in fo rm a tio n a b o u t th e o rg a n is a tio n in th e n a tiv e la n g u a g e Ambromed Grupp OÜ on asutatud 2004. aastal psüühikahäirete ennetamiseks ja raviks. Alates 2008. aastast on Ambromed Kliinikul sõlmitud koostööleping Sotsiaalkindlustusametiga rehabilitatsiooniteenuse osutamiseks ning alates 2011. aastast on Ambromed Kliinik Eesti Haigekassa lepinguline partner. Ambromed Kliiniku põhieesmärk on psüühikahäirete, sealhulgas söömis-ja ärevushäirete, ennetus, ravi ja rehabilitatsioon spetsiaalselt selleks otstarbeks loodud keskuses. 2 . S h o rt in fo rm a tio n about th e o rg a n is a tio n in E n g lis h (a c tiv itie s , c lie n ts , e tc .) Ambromed Grupp OÜ was established in 2004 for the prevention and treatment of mental disorders. In 2008, Ambromed Clinic concluded a cooperation agreement with the Estonian National Social Insurance Board for the provision of rehabilitation services, and since 2011, Ambromed Clinic has been a contractual partner to the Estonian Health Insurance Fund. Ambromed Clinic mainly aims at the prevention, treatment and rehabilitation of mental disorders, including eating and anxiety disorders, in a center especially established for that purpose. 3 . N a m e o f th e o rg a n is a tio n a s y o u w o u ld w a n t it to a p p e a r o n th e E Q U A S S A s s u ra n c e c e rtific a te A m b ro m e d G ru p p O Ü 4 . N a m e o f s e r v ic e s / d e p a rtm e n ts o f th e o r g a n is a tio n in th e s c o p e o f th e a p p lic a tio n a s y o u w o u ld w a n t it to a p p e a r o n th e E Q U A S S A s s u ra n c e c e rtific a te : E ra te e n u s e d (P riv a te s e rv ic e s ) E e s ti H a ig e k a s s a ra h a s ta ta v a d te e n u s e d (S e rv ic e s fin a n c e d b y E s to n ia n H e a lth In s u r a n c e F u n d ) E ria rs ti p o o lt s u u n a tu d te e n u s e d (S e rv ic e re fe rre d by s p e c ia lis e d d o c to r s ) S o ts ia a ls e re h a b ilita ts io o n i te e n u s e d (S o c ia l re h a b ilita tio n s e rv ic e s ) T ö ö a la s e r e h a b ilita ts io o n i te e n u s e d (P ro fe s s io n a l re h a b ilita tio n s e r v ic e s ) 1 5 . O rg a n is a tio n ’s lo g o Information to be published on EQUASS website: N a m e o f th e o r g a n is a tio n : A m b ro m e d G ru p p O Ü P o s t a d d re s s : L a i 2 8 , T a rtu , 5 1 0 0 5 D ir e c to r: J e le n a P õ ld s a m C o n ta c t p e r s o n : M irja m O o l E m a il: in fo @ a m b ro m e d .e e W e b : w w w .a m b r o m e d .e e 2 Maarika Aro Saatja: Maarika Aro Saatmisaeg: 17. märts 2016. a. 9:59 Adressaat: 'Guus van Beek'; 'Marie Dubost' Koopia: Keiu Talve Manused: Additional Information Form.pdf; Asutuse auditi külastuse ettevalmistuse vorm_Ambromed.docx; EQ-ASS_AUD_Audit Report_Ambromed_2016.docx; EQUASS Assurance taotlusvorm Ambromed_1.xlsx Dear Marie, Dear Guus, Attached you’ll find an audit report and other documents of Ambromed Grupp OÜ EE2016-004. Please let Keiu to know in case there are some comments about the report. There is an error in excel ( leadership section -PC). Auditor told that she could not be able to change it. 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 1