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EQUASS ASSURANCE AUDIT REPORT Site visit: 17.-18.11.2015 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 Ho oldekeskus 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: 17.-18.11.2015 Clients: 249 Staff: 35 (as of 18.11.201 5) 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 17.11.2015 Day 1 Time Acti vit y 10:45-11:00 Opening meeting 11:00-12:00 Documentation review, up -dat ing f iles 12:00-13:00 Lunch break 13:00-14:00 Documentation review, up -dat ing f iles 14:00-15:30 Interview w ith EQUASS contact person – Ülle Lepik 15:30-15:45 Documentation review, up -dat ing f iles 15:45-16:15 Interview w ith cooperation partner – Jaanika Hõim, Municipal Maintenance Ser vice 16:15-16:30 Documentation review, up -dat ing f iles 16:30-17:00 Interview w ith funding body – Kr ista Normak, Social Insurance Board 17:00-18:45 Documentation review, up -dat ing f iles 18.11.2015 Day 2 Time Acti vit y 8:00-9:30 Documentation review, up -dat ing f iles 9:30-10:15 Interview w ith persons served 10:15-10:30 Documentation review, up -dat ing f iles 10:30-12:00 Interview w ith staff – Anneli Ahse, Kersti Roosmets, Dea Ein 12:00-13:00 Lunch break 13:00-13:45 Interview w ith general manager – Indrek Sooniste 13:45-14:00 Documentation review, up -dat ing f iles 14:00-15:30 Documentation review, up -dat ing f iles 15:30-16:00 Closing meeting 3  3. Detailed feedback on performance 1. The social servi ce provider defines documents and implements its visi on and mission values on servi ce provision. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The mission, vision and values of As the mission and vision were the Care Center are stated in the reviewed recently, make sure, that Employee Handbook and on the the valid ones ar e used in the website http:// www.tartuvthk.ee/ . documentat ion of the organization which is available in Estonian, and are depicted on the home page Russian and English. (f oreign languages section). Add mission and vision into the The employees of Care Center were organizat ion’s development plan. involved in the renewal of the mission, vision and values and Kuivõrd missiooni ja visiooni vaadati demonstrated through inter views hiljuti ümber, veenduda, et a sutuse their aware ness and they im plement dokumentatsioonis ning asutuse them on ser vice provision. kodulehel (sh võõrkeelsetel) on kasutusel keht ivad sõnastused. Lisada missioon ja visioon asutuse arengukavasse. 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 do not meet this crit erion of the EQUASS Assurance certif icat ion program Strengths Improvem ent & developments The qualit y standard , long -term The development plan of the goals and commitment to continuous organizat ion f or 2013-2017 has not improvement are stated in the been over viewed annually as Employee Handbook . mentioned in the document and could use an overlook as the It appeared f rom the inter views that 4 the staff of Care Center is inf ormation ther e needs update. knowledgeable of the qualit y standard and goals of the As the development plan is quite a organizat ion. generic document, it does not include the overall long -term Also, the staff seemed to be devoted objectives of the organizat ion that to deliver qualit y services and could be directly associated with the pursue f or continuous improvement. annual object ives. T he organization’s long term goals should be aligned with the short term objectives. Also the previous EQUASS audit brought out that “some annual targets are declarat ive, their realizat ions is diff icult to measure”. The qualit y goals and commitment to continuous improvement should be explained and demonstrated in more detail. There seems to be several diff erent ver sions of the Employee Handbook in the organizat ion , which include diff erent inf ormation (the document has not been approved) – it would be advisable to approve one version of the manual and make sure that this is available to all related stakeholders. There is no documentation management syst em in the organizat ion. T he unsystemat ic approach of the organization’s documentat ion has t o be brought into order (f .e a list of all policies would be a starting point). Asutuse arengukava aastateks 2013 - 2017 ei ole pärast kinnitamist üle 5  vaadat ud, nagu dokumendis kirjas ning see vajab uuendamist. Kuivõrd asutuse arengukava on üldsõnaline dokument, et sisalda see asutuse pika-ajalisi eesmärke, mida saaks otseselt seostada iga -aastaste tegevuseesmärkidega. Asutuse pikaajalised eesmär gid peaks olema kooskõlas/seostatud lühiajaliste eesmärkidega. Ka eelnev EQUASSi audit tõi välja, et mõned aastaeesmärgid on deklarat iivsed ja nende realiseerim ist on keerulin e mõõta. Kvaliteedi eesmärgid ja pühendumus pidevale arengule peaks olem a täpsemalt välja toodud ja selgitatud. Töötaja käsiraamat ust on asutuses mitmeid er inevaid versioone (dokument on kinnitamata) – oleks soovitatav kinnitada üks käsiraamatu ver sioon n ing teha see kättesaadavaks kõigile seotud huvipooltele. Asutuses puudub dokumendi - haldussüsteem. Mittesüstemaat iline lähenem ise asutuse dokumentatsioonile tuleb kõrvaldada (nt koostades algatuseks asutuse regulatiivsete dokumentide nimekiri). 3. Persons served, famil y members and servi ce user organisations are able to give feedback on their individual and collecti ve experience of programmes and services. Remark from the auditor: The ser vices of the social ser vice pr oviders meet 6 this cr iterion of the EQUA SS Assurance certif ication program Strengths Improvem ent & developments The Care Center has asked f eedback Feedback is not asked on regular f rom stakeholders using diff erent basis. methods. Somet imes a meeting, other time a sur vey, next time a A regular system of f eedback should conversation f .e . be developed and descr ibed in the Employee Handbook (f.e when, f rom yThis year the klient represen tation whom, in what way f eedb ack is is conducting a f eedback asked and how it is processed , questionnaire by themselves among summarized and analyzed). the persons ser ved. W hen timing the receiving of f eedback it should be considered that it could be used f or improving ser vices and making plans f or the coming per iod. Tagasisidet ei küsita regulaarsetel alustel. Välja t uleks töötada regulaarne tagasiside süsteem ning ära kirjeldada see töötaja käsiraamatus (nt millal, kellelt, millisel viisil tagasisidet küsitakse, kuidas seda menetletakse, kokkuvõetakse ja analüüsitakse). Tagasiside küsimise ajastamisel peaks arvesse võt ma, et andmed oleks piisavalt värsked, et neid kasutada teenuste parendam isel ning järgneva perioodi plaanide tegemisel. 4. The social service provider i nforms all stakeholders about the offered programmes and services avai lable. 7 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 Tartu Care Center has inf ormed its possible stakeholders about its ser vices using mainl y the home page of the organizat ion, which is quit e inf ormative about t he ser vices and other related inf ormation. Inf ormation to per sons ser ved is availab le on the walls of the building and given at meet ings. Inf orming and involving staff is described in the Employee Handbook . Stakeholders are aware of the ser vices of the Tartu Care Center, which was verif ied implemented through inter views wit h per sons ser ved, staff and partners. 5. The social service provider management establishes and documents an ann ual planning and review process. Remark from the auditor: The ser vices of the social ser vice pr oviders do not meet this crit erion of the EQUASS Assurance certif icat ion program . Strengths Improvem ent & developments The planning procedure is descr ibed The planning procedure is descr ibed in the Employee Handbook . in ver y general terms in the Employee Handbook. Eventhough the There are annual action plans , which Annual planning procedure works in are reviewed regularly and wr itten practice, it should be described in summaries are made in the act ion more detail. plan t wice a year (concerning the There appears no evidence 8 real execut ion of the plan) . support ing the regular over view of the planning procedure. Aastast planeer imise protseduur i kirjeldatakse t öötaja käsiraamatus. Hoolimata sellest, et planeerim ise protseduur on tegelikkuses toimiv, tuleks see detailsem alt ära kirjeldada asutuse käsiraamatus. Aastase planeerim ise protseduur i ülevaatamise kohta ei olnud tõendeid leida. 6. The plan includes:  annual outcomes / targets  the acti vities to be undertaken in achieving the annual targets  monitoring of the performance of the organisation in meeting its annual targets time-scales and procedures for revi ew and revi sion. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The annual work plan of Tartu Day Aligning the annual activit ies with Care Center includes the f ollowing the vision and the strategic pla n is data in a table f ormat: objectives, unclear (see also criteria 2). main activit ies, due dates, persons responsible and expected results. The wording of objectives is done in There is also room left f or the f orm of naming activit ies (the semiannual review (results) of the goal may be derived f rom that), but it annual work plan. would be better if the object ives were worded as expected goals The annual plan is approved by the (desir ed hange/state). board of Tartu Day Care Cent er. Aastaplaani seosed visiooni ja strateegilise plaaniga ei ole üheselt selged ( vt ka kriteerium 2). 9  Eesmärkide sõnastamine on esitatud tegevust e vormis (tegelik eesmärk on sellest tuletata v), kuid oleks parem kui eesmärg id oleks sõnastatud siht idena (oodatav muutus/olukord). 7. The social servi ce provider demonstrates organisation’s success in satisf ying the needs and expectations of the societ y. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assur ance certif ication program Strengths Improvem ent & developments Tartu Care Center has taken act ion , The organization could take more when it comes to satisf ying the active r ole in collecting f eedback needs and expectations of the f rom stakeholders in the societ y societ y. (using sur ves) in or der to f ulf ill their needs. It serves as the traineeship base f or students, participat es in Estonia - It could also play a more active role wide projects; organizes inf ormation in inf orming the soc iet y about the days to publicit y. necessit ies of the persons ser ved, give inf ormation on how to handle / interact wit h them and also provide inf ormation about the activit ies/ results of the organizat ion ’ work . Organisatsion võiks olla aktiivsem tagasiside kogumisel huv irühmade lt (kasutades uuringuid), et vastata nende vajadustele. Samuti saaks aktiivsemat rolli mängida ühiskonna teadlikkuse tõstmisel teenuse saajate vaj adustest, andes inf ormatsiooni teenuse saajat ega toime tulemiseks / suhtlemiseks ning t eavitada laiemat üldsust asut use tegevustest. 10  8. The social service provider demonstrates organisati on’s social responsibilit y t hrough acti vities contri buting to the societ y. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQU ASS Assurance certif ication program Strengths Improvem ent & developments Tartu Care Center has demonstrated social responsibilit y through diff erent activities contributing to the communit y and also to wider societ y. There is a small shop selling th e handicrafts made by the persons ser ved, in the cant ine f ood (prepared by the persons ser ved) is sold to the clients of the organization and to guests. The accommodation section of the Tartu Care Center is also opened to the society. 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 do not meet this crit erion of the EQUASS Assurance certif icat ion program Strengths Improvem ent & developments The staff of Tartu Care Center (scope As there is no separate personnel of EQUASS applicat ion) includes 35 policy and no separate personnel employees whose exper ience and manager ’s posit ion , it would be prof essional know- how ensures the advisable to descr ibe the personnel qualit y and consistency of the relate d principles in more detail in ser vices. There is no per sonnel the Employee Handbook ( steps of manager position, the dut y is f ulf illed recruit ing, retention of employees by the general manager. and leaving principles), that would 11 There is no separate personnel make the process more transparent. policy, the pr inciples f or personnel recruitment are described in the Kuivõrd asutuses puudub Employee Handbook. eraldiseisev personalipoliit ika ning ka eraldiseisev personali juhi All employees have individual job ametikoht, oleks soovitatav personali descr iptions, which include required poliitika põhimõtted täpsemat laht i knowledge, skills and competences. kirjutada töötaja käsiraamatus (vär bamise, ametishoidmise ja The principles f or equalit y and non - lahkumise etapid), et protsess oleks discr imination are laid down in the läbipaist vam. code of ethics. It appeared f rom the inter views wit h the staff that they are aware of their roles, r ights and du t ies. It also cam e out that the employees are like their jobs and are devot ed to deliver ing high qualit y ser vice. 10. The social service provider operates in compli ance w ith mandator y national legislation, providing appropriate w orking conditions, adequate and agreed staff level and staff ratio, and appropriate rew arding for staff and vol unteers. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The documentat ion of Tartu Care The knowledge, skills and Center meets legal r equirements and competences of the employees are is reviewed to do this. The staff level descr ibed in the job descriptions in is kept at opt imum (ratio com es f rom detail, but ar e not mentioned in the contracts with f under s) . Employee Handbook. It would be advisable to add related inf ormation The principles f or showing also to the handbook to make it more recognit ion to employees have been comprehensive. developed. F.e best of the year is selected. Töötajate kompetentsid, oskused j a teadmised on kirjeldatud töötajate 12 The Rules of the Organization ametijuhendites, kuid neid ei esitata descr ibe t he staff related pr inciples töötaja käsiraamatus. Oleks and in more detail. soovitatav lisada seotud inf ormatsioon ka käsiraamat usse, et The working condit ions are evaluated see oleks kõikehõlmavam taebe (risk assessm ents are carried out mõttes. and related action plans made). 11. The social service provider trains all staff based on a plan for leaning and development and evaluates the effecti veness of the training. Remark from the auditor: The ser vices of the social ser vice pr oviders do not meet this crit erion of the EQUASS Assurance certif icat ion program Strengths Improvem ent & developments Staff development and training needs Training of staff should be based on are assessed annually during off icial Annual Training Plan, which perf ormance reviews. should include inf orma tion f .e about the trainees and the time, place, There is no off icial annual training name, topics and amount of the plan, but it cam e out of the trainings. This should be done inter views that t he staff is trained according to the valid training policy, based on their needs and but is not f ollowed in real lif e. expectat ions on ong oing basis. As f eedback on trainings is collected The inter viewed em ployees showed after each training, an annual satisf action concerning the trainings summary and analysis of the annual received. Last year a training related training plan should be made. F.e. a to preparing the individual plans was SW OT analysis could be conducted. organized to all employees. There exists the training policy of the Feedback on trainings is collected organizat ion, which goes back to after each training , where the value 2011 and has not been revised since and success of the training is that – dur ing the audit it became evaluated. Training certif icates ar e evident t hat the principles in that stored. policy ar e not f ollowed in f ull in practice. A review of this policy is recommended. 13  Töötajate koolitamine peaks baseer uma dokumenteeritud aastasel koolitusplaanil, mis sisaldaks nt järgmist inf ormatsiooni: koolitatavat e nimed, k oolit use aeg, koht, nimetus, teemavaldkonnad ja maht . Seda tuleks teha kehtiva koolituste korraldamise korra järgi, kuid ei järgita tegelikkuses. Koolituste kohta kogutakse tagasisidet, kuid t äiendavalt tuleks koostada iga-aastase koolitustegevuse kohta ko kkuvõte, kus hinnatakse ja analüüsitakse selle ef ektiivsust. Nt võib kasutada SW OT analüüsi. Asutuses eksisteer iv koolituste kord on kinnitatud 2010. aastal ning seda pole sellejärgselt ülevaad atud – auditi jooksul selgus, et seda tegelikkuses ei järgita. Soovitatav on kord ülevaadata/muuta. 12. The social servi ce provi der applies requirements for competence in the identified roles and functions of staff and evaluates them on annual basis. Remark from the auditor: The ser vices of the social ser vice pr ovid ers meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The competence r equirements f or employees are descr ibed in their job descr iptions and are reviewed annually dur ing perf ormance reviews. A sum mary of the perf ormance reviews is prepared, 14  13. The social servi ce provi der recognizes the staff as a resource for feedback on organizational perf ormance, service development and staff development Remark from the auditor: The ser vices of the social ser vic e pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The involvement of staff in the As the descr iption of the involvement planning and evaluat ion of services of staff in the planning and is descr ibed in the Employee evaluat ion of ser vices is described in Handbook of the Tartu Care Center. a generic way in the personnel policy The part of the Employee Handbook , it would be advisable to complement New staff members are appointed this inf ormation in the re. mentors, who help them in the adapt ion period. Kuivõrd töötajat e kaasamine teenuste planeerimisse ja Tartu Care Center recognizes staff hindamisse on töötajate käsiraamatu as a usef ul tool f or gaining pesonali põhimõtete osas kirjeldatud inf ormation. It has staff meetings , üldsõnaliselt, on soovitatav seda perf ormance reviews, satisf action inf ormatsiooni täiendada. sur veys, etc. There is open -doors policy and the manager is available f or employees. 14. The social service provi der has mech anisms in place to enhance satisfaction and motivation of staff Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Ways of provid ing satisf action and As there are no detailed policies motivat ion are described in the explaining the principles f or Employee Handb ook. providing satisf action and motivat ion, it would be advisable to Besides f .e the nominat ion of the complement this inf ormation in the 15 Best of the Year and highlighting Employee Handbook. personal achievements also sp ecial events f or showing recognit ion to Kuna puuduvad üksikasjalikud staff have been organized. põhimõtted töötajate tunnustamise ja rahulolu tagamise kohta, on On the walls of the care cent er one soovitatav seda osa t öötajate could witness diff erent certif icates, käsiraamatus täiendada. diplomas and thank you notes f or achievements and good cooperat ion. 15. The social servi ce provi der assures the rights of pe rsons served outlined in a Chart er of Rights w hich is based on the EU Charter of Fundamental Rights , the European Convention for the Protection of Human Rights and Fundamental Freedoms of the Council of Europe and other int ernati onal human ri ghts conventio ns, especiall y those elaborat ed under the United Nations. 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 Tartu Care Center has developed the rights and dut ies of persons ser ved . The rights and duties are available on the walls of the care center. They are introduced to persons ser ved b y staff . The persons served and staff demonstrated their knowledge of the rights and duties through the inter views. 16. The soci al service provider informs the person served about his/her rights and duties especiall y to equal treatment on grounds of age, disabilit y, gender, race, religion or belief and sexual orientation before recei ving the serv ices. 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 Strengths Improvem ent & developments The rights and duties are introduced to persons ser ved by staff and are available on the walls of the care center. Their ser vice provision is also regulated by the ser vice contract, which includes the same inf ormation and is signed. The rights and dut ies are discussed during meetings of the persons ser ved. The clients demonst rated their knowledge of the rights and dut ies through the inter views. 17. The social service provider has accessibl e complai nt management s ystem w hich registers feedback on performance from persons served, purchasers and other relevant stakeholders. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Tartu Care Center has developed a The complaint management polic y procedure f or handling complaints goes back to 2009. It might be usef ul and a special f orm. to review t he policy a nd update it, where needed. The various ways on complai ning include sending an e -mail and Kaebuste menet lemise kord pä rineb wr itten complaint. There are boxes aastast 2009. On soovitatav vasta v available in the care center f or kord üle vaadata ja uuendada selles gaining this kind of feedback osas, mis vajalik. 17 If was verif ied during the inte rviews that the persons served and other relevant stakeholder s were awar e of the ways of submitting complaints . All wr itten complaints are dealt wit h and answered. The complaint management system proves to be transparent. 18. The social service provider respects the fundamental right to self-determination of the person ser ved. They freel y det ermine their political status and freel y pursue their economic, soci al and cultural development. Remark from the auditor: The ser vices of the social ser vice pr oviders does meet this crit erion of the EQUASS Assurance certif icat ion progr am Strengths Improvem ent & developments The self -determination supporting The care center has to conduct its related pr inciples are descr ibed in annual self -assessment on the Empowerment Handbook of the respect ing the r ight to self - organizat ion. determination (and record the results). F.e. SW OT analysis could It became evident through the be used. inter views that the staff supported the right to self -determinat ions of Teenuse osutaja peaks viima iga - clients and that the persons ser ved aastase lt läbi enesehin damise, mille were handled wit h respect. käigus antakse hinnang te enuse saajate enesem ääratlemise õigusest They claimed to have assessed their kinnipidamise kohta (kasutade s nt perf ormance on respecting the right SW OT analüüsi). to self -determinat ion with the persons, but there was no wr itten evidence f ound during the audit that the social s ervice provider evaluateds ser ved on annual basis. 18  19. The social service provi der facilitates the person served in choosing and having access to advocates and/or supporting persons. Remark from the auditor: The ser vices of the social ser vice pr oviders do es meet this crit erion of the EQUASS Assurance certif icat ion program Strengths Improvem ent & developments The care center has to conduct its The staff knows their customers well, annual self -assessment on their and knows, who would need the perf ormance in f acilitating persons appointment of a support person / ser ved in having access to advocate. Help is pr ovided if there is advocates and/or supporting persons a need. (and record the results). F.e. SW OT They claimed to have assessed their analysis could be used. perf ormance in f acilitating persons ser ved in having access to Teenuse osutaja peaks viima iga - advocates and/or supporting aastaselt läbi ene sehindamise, mille persons. käigus antakse hinnang oma käitumisele teenuse saajat e abistamisel eestkostja/tugiisiku leidmisel (kasutades nt SW OT analüüsi). 20. The social service provi der defines and documents its policy on ethics that respects and assures the dig nit y of the persons served, protects them from undue risk and promotes soci al justice Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & develo pments In their work the employees of Tartu Care Center f ollow t he principles set in the code of ethics of the center. It was verif ied through the inter views that the employees and the ser vice users were aware of the ethical 19 principles of the Tartu Care C enter. The ethical principles respect and assure the dignit y of the persons ser ved, pr otect them f rom undue risk and promote social justice. The clients have been inf ormed about the et hical principles by staff . 21. The social service provider operat es m echanisms 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 do not meet this crit erion of the EQUASS Assurance certif icat ion program Strengths Improvem ent & developmen ts It is the dut y of the staff to ensure In the Tartu Care Center ’s that the customers are protected documentat ion ther e was no polic y f rom physical and mental and and no mechanisms identif ied, which f inancial abuse. prevent the physical, mental and f inancial abuse of users. Members of staff showed awareness about the importance of abuse It might be helpf ul to draw up prevent ion. procedures f or abuse prevent ion. Also guidance f or the problem behavior management should be an issue of f urther discussion. The organizat ion should evaluate its prevent ion act ivities f or the physical, mental and f inancial abuse of users , f .e SW OT analysis could be conducted. Teenuse osutaja dokumentatsioonis puudusid kord ning protseduur ireeglid teenuse saajate f üüsilise, vaims e ja majandusliku 20  ärakasutamise ennetamiseks. Kasulik oleks koostada protsessikirjeldused ennetamaks ärakasutamist. Samuti juhend probleemkäitum ise haldam iseks oleks asi, millega edasi minna. Teenuse saajal tuleb viia läbi regulaarseid enesehindamisi ennetamistegevuste osas. 22. The social servi ce provi der provides services in a safe system of w orking w ithin a safe environment to ensure the physical securit y of persons served, their families and caretakers. Remark from the auditor: The ser vices of the s ocial ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Tartu Care Center provides ser vices There exist the internal control in a saf e system of working wit hin a procedures f or health and saf ety. saf e envir onment. Risk assessment These go back to the year 2005. It of the work place has been would be advisable to review and conducted and related action plan update these procedures. created. Koostatud on t ööter vishoiu ja The Employee Handbook and Rules tööohut use sisekontrolli of the Organization descr ibe the protseduur id, mis pärinevad aastast health and saf ety pr inciples. 2005. Oleks soovitatav need protseduur id üle vaadata ja uuendada. 23. The social service provider defines, docu ments, monitors and evaluat es a set of principles, values and procedures that govern behavi our in servi ce deli ver y containing aspects of confidentialit y, accuracy, pri vacy and integrit y. Remark from the auditor: The ser vices of the social ser vice pr ovider s meet this cr iterion of the EQUASS Assurance certif ication program 21  Strengths Improvem ent & developments The principles, values and procedures in ser vice deliver y are descr ibed in t he Em ployee Handbook and in the service deliver y procedures. Employees f ollow the code of ethics of the organizat ion . It was demonstrated through the inter views of staff that they ar e aware of the values and procedures that govern behavior in the ser vice deliver y process and the et hical principles related to their work. 24. The social service provider defines, documents, monitors and evaluat es procedures for assuring confidentialit y of data regardi ng the persons served and the service provided to them. Remark from the auditor: The ser vices of the social ser vice pr oviders me et this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The procedures f or assuring The procedures f or f or assuring conf ident ialit y of data have been conf ident ialit y of data go back to def ined and documented. 2012. They have been over looked dur ing It might be usef ul to review the the course of this year with the policy (f rom the legal point of view) members of staff and the per sons and update it, where needed. ser ved. Andmekaitse kord pärineb a astast 2012. Oleks soovitatav see kord üle vaadata ( õigusraam istikule vastamise vaat enurgast) ja uuendada, kui tarvis. 22  25. The social service provider defines the roles and responsibilities, authorities and the interrelation of all personnel w ho manage, desi gn, deli ver, support and evaluate the service provision to person served. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The roles and re sponsibilities of the There appears to be a possible management and the board are conf lict of interest concerning of one descr ibed in the Statue of the Tartu board member of the Tartu Care Care Center. Center, who is at the same the general manager of another social The roles and responsibilities of the ser vice provider (competitor) in persons, who are direct ly involved Tartu. The two organizations off er with ser vice provision are described same type of services to same target in the job descr ipt ions of employees. groups in the same r egion. The relat ed roles and responsibilit ies The board is responsible among are presented in mor e detail in the in other dut ies f or planning and the service deliver y processes of organizing the management of Tartu Tartu Care Center. Center and conducts oversight over the social ser vice provder (including Relevant inf ormation is available approving the budget, annual plans, also on the web page of Tartu Care annual reports etc). Center and has been communicated to the clients. It would be advisable to look into this case in all ser iousness and discuss this matter with the representatives of the Tartu City Government , as a high risk area. Ühe nõukogu liikmega on seotud võimalik huvide konf likt, kuivõrd ta on samaaegselt ühe teise sotsiaalteenuseid osutava asutuse (konkurendi) juhataj a. Nõukogu on muuhulgas vastutav 23  Tartu VTHK tegevuse planeer imise ning juhtim ise korraldamise eest, samuti teostab jär elevalvet asutuse tegevuse üle ( sh kinnitab eelar ve, aastaplaanid, aastaaruanded jne ). Soovitatav on sellesse juhtum isse suhtud a täie tõsidusega ning arutada seda Tartu Linnavalitsuse esindajatega, k uivõrd on tegemist kõrge riski alaga. 26. The social service provi der w orks in partnership w ith other organisations in the provision of ser vi ces. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Tartu Care Center works wit h In the f ield of cooperation, it would diff erent types of cooperation be advisable to draw up a plan of partners. partners, indicating what is the common point of interest, related The organization’s partners are local activities and desired outcome. This governments, state, employm ent off ice, cooper atives and could be used when evaluating the entrepreneurs. added value of partnership. During the audit there were br ought In f uture it would be expected to pay out examples of successf ul more attention to analyzing the cooper ation. F.e projects f inanced b y added value f rom partnership (and the f oreign aid, which included document the results of such cooper ation with par tners. analysis if possible). Tartu Care Center evaluat es the Koostöö kohta oleks soovitatav cooper ation during the discussions koostada plaan, milles tuuakse välj a (meetings) with partners and has ühised huvipunktid, seotud asked written f eedback. tegevused ja oodatavad tulemused. Seda oleks hea kasutada koostöö lisaväärtuse hindamisel. 24  Tulevikus tuleks enam tähelepanu pöörata partner lus est tulenevale lisaväärtuse hindamisel e (ning võimalusel dokumenteerida sellise analüüsi tulemused). 27. The social service provider w orks in partnership w ith persons served, purchasers and other stakeholders in the development of services. Remark from t he 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 There is cooperat ion with f amily In f uture more attention should be doctors and local government in the paid to the assessm ent of the needs f ield of improving the ser vices. of stakeholders using var ious studies and or sur veys. The persons ser ved, co-operat ion partners, f inancing bodies and other Tulevikus võiks enam tähelepanu stakeholders are involved in t he pöörata huvirühm ade vajaduste development of services of Tartu hindamisele, kasutades selleks Care Center through meeting s. uuringuid. 28. The social service provi der includes persons served as acti ve partici pants in planning and have se t up appraisal made up of on- going of an on -going structured dialogue process in the management of the service, incl uding t he definition of the needs, the definition of the services, as w ell as of the evaluation of qualit y. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The principle of involving the It would be advisable to draw up a persons ser ved in t he management statue of the client representation. of the service is described in the Also the pr inciples of involvement Employee Handbook. should be described in more detail in 25  the policies of the organizat ion. Clients are involved in the ser vice planning, deliver y and appraisal Soovitatav on välja töötada procedure. There ar e also meetings kliendiesinduse töökord. Samut i of client representat ions. oleks soovitatav detailsemalt kirjeldada teenuse saajat e The criterion was ver if ied sat isf ied kaasamise pr intsiibid. also through exploring client work documentat ion and through inter views with s taff and clients. 29. The social service provi der institutes an annual evaluation of partici pation of persons served bot h on indi vidual and/or group basis. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The activit ies of client participation In f uture it would be advisable t o pay are agreed with the persons ser ved. more attention to the analysis of They are discussed f .e in client client involvement related p olicies to meetings. make them more clear and if possible record the results of such Clients’ f eedback is gained through analysis. client representation, also through client meet ings and sur veys. Tulevikus on soovitatav pöörata enam tähelepanu t eenuse saajate The procedures f or the involvement osalemise korra hindam isele, of the persons ser ved wer e recentl y tagades võimalusel analüüsist kirjalik discussed dur ing the client meeting. jälg. 30. The social service provi der operates specific instruments f or users to improve their personal empow er ment and personal situation and that of their communit y. Remark from the auditor: The ser vices of the social ser vice pr ovi ders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments 26 Empowerment of persons ser ved is an int egral part of service deliver y. Empowerment is described in the Employee Handbook. Empowerment r elated activit ies were evidenced in ser vices’ deliver y processes - the client work is aimed at improving or maintaining the qualit y of lif e of the customers. Tartu Care Center uses CARe methodolog y. The criterion was ver if ied sat isf ied through exploring client wor k documentat ion and through inter views with staff and clients. 31. The social service provi der operates specific mechanisms for establishing an empow ering environment. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Empowerment of persons ser ved is an int egral part of service deliver y. Related act ivities were evidenced in ser vices’ deliver y pr ocesses and also came out f rom the inter views wit h staff and persons served. The employees ar e trained about empowerment and the subject is discussed dur ing organizat ion’s meetings. The results of empowerment 27 activities can be evidenced in the individual plans of the persons ser ved. 32. The social servi ce provider sel ects programmes w hich are based on a needs assessment at the location w hich is most convenient for the person served, famil y and care takers Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Tartu Care Center has an over view of The average age of the ser vice users the needs of the persons ser ved of the day car e center is above 30. (wait ing lists , meetings with There are potential clients of the day cooper ation partners , clients’ care center younger than that age, f eedback , individual plans of persons but there is lack of acti vities to off er ser ved). them and lack of int erest in them to participate. The Care Center is located off the cit y center and is accessible by This is an area f or f urther public transportation. It is accessible improvement, to find ways and by wheelchair. There is slight possibilit ies to involve also younger shortage of rooms (taking into people. account the needs day center). Teenuse saajate keskmise vastus On the home page of Tartu Care Tartu VTHK-s on üle 30 eluaasta. Center, the maps were presented Potentsiaalseid päev akeskuse showing the location and kliente on vanuselt nooremaid, kuid accessibilit y of the organizat ion. neile pakutavaid tegevusi on vähe ning nende huvi teg evustes osaleda on madal. Tegemist on potentsiaalse parendusvaldkonnaga, et leida võimalusi ja viise kaasata ka nooremaid inimesi. 28  33. The social service provider offers programmes consistent w ith the identified needs of its customers and objecti ves for the programme. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Tartu Care Center does cooperation with t he f unding body Estonian Social Insurance Board and has ascertained the needs and expectat ions of them. Contract has been signed with Estonian Social Insurance Board that includ es inf ormation about their expectations related to ser vice amounts. The needs and f eedback of diff erent stakeholders (social partners, employers of clients, educat ional inst itutions etc ) have been discussed during meetings and dur ing dail y cooper ation (tho ugh e-mails, telephone) . The results of the services have been determined and are descr ibed in the report on the implementation of the activit y plan. 34. The social service provi der operates indi vidual processes that are dri ven by the needs of the perso n served. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Individual action plans or support It appear ed f rom the sur veillance 29 plans ar e compiled in cooperat ion report of the f under that they expect with customers and team, which the wor ding of the individual plans to consists of specialists and f amily be more thorough and detailed. As members and/or support persons and this was quite recent f eedback, f ocus advocates. on the wording of the plans should be a point of f ocus for a while. The needs of the persons ser ved are asked and taken into account when It would be an idea to describe the drawing up the plans. process or compilin g individual action plans in the Employee Handbook or any other procedures. Rahastajate pools est järelevalve aktist ilmnes, et individuaalse d plaanid peaksid olema põhjalikumad ja üksikasjalikumad . Kuivõr d tegemist on suhteliselt hiljut ise tagasisidega, tu lek s mõnda aega f okusseerida tähelepanu plaanide sõnastam isele. Hea mõte võiks olla individuaalsete tegevusplaanide koostamine kirjeldada töötaja käsiraamatus või mõnes muus asutuse korras. 35. The social service provider documents the planni ng of servic es based on the ident ification of indi vi dual needs and expectations of persons served in an Indi vidual Plan. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengt hs Improvem ent & developments The clients’ individual needs and expectat ions are wr itten down in the individual plans. The individual plans involve all the inf ormation set by the criter ion and 30 are agreed by the persons ser ved, which was verif ied by examp les of client documentation seen during the site visit. Interviews were conducted with persons ser ved that ver if ied that the clients were knowledgeable of their objectives and related activities. The individual plans were agreed with t he customers or their f amily members or their advocates. 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 do not meet this crit erion of the EQUASS Assurance certif icat ion program Strengths Improvem ent & developments The main social services of Tartu The audit or did not f ind wr itten Care Center are: assistance in evidence that the ser vice deliver y ever yday lif e, supported living, processes are r egular ly analyzed assistance in working, rehabilitat ion and reviewed. Written evidence ser vices. about the regular r eview of service deliver y processes should be The service deliver y process es are preser ved. descr ibed in the ser vice deliver y procedures and are accessible also Teenuse osutamise protsesside on the home page of Tartu Care ülevaatamise kohta ei olnud tõendeid Center. leida. Teenuse osutamise protsesside ülevaatamise kohta The main ser vice deliver y pr ocesses tuleb kirjalikud tõendid säilitada. are in line with Tartu Care Ce nter ’s vision, mission and qualit y principles. 31  37. The social service provi der review s this delivery process and maintains control over the d eli very of t he servi ce. Remark from the auditor: The ser vices of the social ser vice pr oviders do not meet this crit erion of the EQUASS Assurance certif icat ion program Strengths Improvem ent & developments Procedures f or conducting inte rnal The internal audit policy ( which is audits have been developed, but part of the organizat ion’s qualit y they are outdat ed. management, control and external audit policy) goes back to the year The service deliver y processes are 2004. As the inf ormation ther e is discussed during meetings and outdated, the policy should be improvements proposed. reviewed and updat ed. There have been no inter nal audits conducted, that f ollow the principles of internal auditing, nor self - assessments made. It would be advisable to cover the cor e processes wit h inter nal audits within a certain inter val. Renew the audit policy. Siseuadit i läbiviim ise kord (mis on osa asutuse kvaliteedijuhtimise, kontrolli ja välisauditi korrast), pärineb aastast 2004. Kuna selles sisalduv inf ormatsioon on aegu nud, tuleks kord üle vaadata ja uuendada. Siseauditeerim ise tunnustele vastavaid siseaudit eid ei ole läbi viidud, samuti pole teostatud enesehindam isi. Soovitatav on katta asutuse peamised protsessid siseaudit itega teatava regulaarsusega. 32  Uuendada siseaudi tite läbiviimise korda. 38. The social service provider ensures that the person served can access a continuum of servi ces that span from earl y int ervention to support and respond to changing requi rements over time. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Tartu Care Center ensures that the persons ser ved can access a continuum of services as n eeds of persons ser ved are ev aluated and descr ibed in individual plans. According to the individual plans, necessar y ser vices are provided. Regular reassessments are made. If the services of Tartu Care Cent er do not meet the needs of the client, other ser vice providers are suggested and the continuat ion of ser vice provision is guaranteed. The continuat ion of service deliver y is monitored and evaluated regular ly. 39. The social service provi der develops a seamless continuum of services and reduces barriers in a multi -disciplinary or multi-agenc y setting. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Annual act ivit y reports are composed, which address the 33 continuum of services . The ser vices, that are part of the individual plan, are provided to the customers. In addition a lot of events are organized to the clients. The criterion was verif ied f ulf illed by also explor ing the client work documentat ion, where evidence was f ound about multidisciplinar y approach. The team consists of specialists of diff erent f ields , including activit y super visor, support person etc. 40. The social service provi der operates servi ces from a holistic approach based on the needs a nd expectations of the person served w ith the aim of improving the qualit y of life for the person served. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Tartu Care Center uses client - centered holistic approach, which is aimed to improve client ’s qualit y of lif e. The qualit y of lif e init iat ive’s eff ectiveness is measured and reported in individual plans . CARe methodoly is used Tartu Care Center, which a helpf ul tool in measuring the qualit y of lif e of persons ser ved. Regular assessments of individual plans are made. The criterion was verif ied f ulf illed by also explor ing the client work 34 documentat ion, where evidence was f ound about measur ing the qualit y of lif e. 41. The social service provider identif ies the needed competences, skills and support for staff to enhance the qualit y of life for person served. Remark from the auditor: The ser vices of the social ser vice pr oviders mee t this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The necessar y competences and skills are described in job descr iptions of Tartu Care Center. These are evaluated annually during employees’ perf ormance evaluations. Trainings are provided to employees, which was conf irmed the employees and the cert if icates of trainings of the staff . 42. The social service provider identifies its business results and provides formal periodic and independent revi ew and pr ocedures t o achieve the targeted results. 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 Tartu Care Center has developed perf ormance indicat ors to measure the results of its activit ies. The goals, act ivities, perf ormance indicators and expected results are descr ibed in the annual plans. 35 Results are repor ted in annual f inancial r eports and in t he reports on the implementat ion of the annual activit y plan. Checks are made by the f unding body – Estonian Social Insurance Board. 43. The social servi ce provi der identifies and registers the outcomes and benefits for person served of the recei ve services on individual and collecti ve b asi s. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Tartu Care Center gathers and More f ocus should be paid on the documents inf ormation regarding registering outcomes and benef its f or results of providing ser vices (bot h on persons ser ved (of the received individual and collective basis). ser vices) on collect ive basis. Individual plans are assessed Enam tähelepanu tuleks pöörata regularly. Conclusions are dr awn and teenuse kasutamisest saadud kasu summaries are made on collect ive dokumenteerim isele kollektiivsel basis annually. tasandil. The summary is presented in the reports on the implementation of the annual activit y plan. 44. The social service provider evaluates its business results in order to determine best value for purchasers and funders ( ‘best value’ can also be expressed in relation to the increased qualit y of life offered to the person bei ng served). Remark from the auditor: The ser vices of the social ser vice pr oviders does meet this crit erion of the EQUASS Assurance certif icat ion program 36  Strengths Improvem ent & developments Tartu Care Center evaluat es the As dif erent metohologies are used, results of its work during regular there is no clear way ho w to identif y meetings and throu gh surveys, f .e the best value f or the f unders or meeting with the E stonian Social persons ser ved. Insurance Board. Theref ore it is advisable to clar if y The added value is summarized also the understanding of the best value in the year book, which is available (and the methodology on how to to the publicit y thr ough the web page evaluate it) f or evaluatin the of the organizat ion. organizat ion’s results in delivering this kind of value. Kuivõrd kasutatakse erinevaid viise, puudub selge m eetod teenuse saajatele või rahastajatele lisaväärtuse hindamiseks. Seetõttu on soovitatav täpsustada, mida mõistetakse lisaväärtuse all (ja metoodika, mille alusel seda hinnatakse) asutuse tegevuse läbi lisaväärtuse pakkumisel. 45. The social service provider evaluates the indi vidual and collecti ve satisfact ion of persons served and other stakeholders by internal and/or external evaluation. Remark from the auditor: The ser vices of the social ser vice pr o viders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments 37 Tartu Care Center organizes r egular sur veys to receive fe edback f rom the persons ser ved. Also the satisf action of other stakeholders is evalua ted by using diff erent means like meetings, questionnaires etc. 46. The social service provider provides accessible and easil y understandable records on outcome, including personal perception and achievements Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The records on outcome are There should be more conscious communicated to stakeholders, staff approach towards adding inf ormation and persons served. F.e to reports concerning personal presentat ions are made to the staff percept ions and achievements. At and persons ser ved. the moment this seems more random, than systematic conscious Annual reports and reports on the activit y. implementation of the annual activit y plan include personal percept ions Soovitatav on teadlikumalt lisada and achievements to some extent. inf ormatsiooni personaalsete arusaamade/kogemuste kohta aruandesse. Hetkel on see pigem juhuslik kui teadlik süsteemn e tegevus. 47. The soci al service provider acti vel y disseminates organization performance among its staff, service users and external stakeholders. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS As surance certif ication program 38  Strengths Improvem ent & developments Tartu Care Cent er reports its perf ormance to f unding bodies, staff and ser vice users. Related inf ormation is also available on the home page of Tartu Care Center. Inf ormation is dissemi nated through home page, staff meetings, client representat ion meetings, etc. 48. The social service provider has a standard procedure for continuous improvement on the basis of an improvement cycle. Remark from the auditor: The ser vices of the social ser vice pr oviders do not this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The PDCA cycle is used and The PDCA process should be f ully descr ibed br ief ly in the Employee integrated into the management Handbook . process of the organizat ion. It seems like the real lif e and the polic y Annual plans are drawn up and are documents of the or ganizat ion do not reviewed semiannually. correspond to each other or ar e incompatible (especially the The results and performance of Tartu checking and acting part of PDCA Care Center is measured and sycle). Some policy documents have descr ibed in reports. been appr oved up to ten years ago Qualit y improv ement projects are and have not under gone the renewal descr ibed in the annual plans and procedure in time. are documented. The qualit y approach expects Inf ormation about t he improvement systematic and conscious self - projects is also available on the assessment, review and impr oving of home page of Tartu Care Center. processes and also r elated documentat ion. 39  In the documents of the organization one should avoid giving TQM theor y, but explain how the qualit y circle is integrated into the daily pract ice and works in this particular organizat ion. PDCA protsess t uleks täielikult integreer ida asutuse juhtim ise protsessidesse. Tundub, et tegelik elu ja asut use tööd reguleer ivad korrad ei ole vastavuses või ole kooskõlas (er iti, mis puudutab kontrollimise ja tegutsemise osa PDCA tsüklist). Mõned asutuse korrad on kinnitatud kuni 10 aa stat tagasi ning ei ole läbinud uuendusportsessi. Kvaliteedi lähenemine eeldab süsteemset ja teadlikku enesehindam ist, ülevaatamis t ning parendam ist nii protsesside kui seotud dokumentatsiooni osas. Asutuse dokumentatsioonis tuleks hoiduda PDCA teooria es itam isest , vaid tuleks selgitada, kuidas kvaliteediring on asut use igapäevastesse tegevustesse integreer itud konkreetses organisatsioonis. 49. The social service provi der identifies performance i ndicators for measuring the results of the improvement actio 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 Strengths Improvem ent & developments 40 The improvement pr ograms of Tartu There seems to be a slight Care Cent er are documented, they misapprehension abou t the include goals and respective diff erence of the innovat ion projects perf ormance indicators. and impr ovement pr ojects. It would be advisable to clarif y the diff erence. F.e Cooperat ion project with the Universit y of Tartu - training program Asutuses tundub olevat kerge f or stroke patients . ebakõla innovatsiooni ja arendusprojektidel vahet tegemisel. This was verif ied through inspecting Oleks soovitatav nendevaheline f ew examples during site visit. erinevus selgeks teha. 50. The servi ce provider introduces and manages innovative w ays of w orking that have been identified based on the needs of stakeholders. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assura nce certif ication program Strengths Improvem ent & developments Tartu Care Center f inds ways of being innovative, taking into account the needs and expectat ions of stakeholders. An example: Project Hooldustugi (co - f inanced by the ESF) The innovation pr oject related inf ormation was ver if ied to be document ed and also available on the home page of Tartu Care Center. 41  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 • Review t he development plan f or 2013 -2017. • Align the strategic objectives in the development plan with the annual objectives . • Descr ibe qualit y goal s and commitment to continuous improvement in more detail in the Employee Handbook. • Approve the f inal ver sion of the Employee Handbook. • Create a documentation management system in the organizat ion. • Üle vaadata asutuse arengukava aastateks 2013 -2017. • Muuta asut use pikaajalised eesmärgid seostatavaks iga -aastaste tegevuseesmärkidega. • Tuua täpsemalt välja asutuse k valiteedi eesmärgid ja pühendumus pidevale arengule töötaja käsiraamatus. • Kinnitada töötaja käsiraamat u viimane versioon. • Luua asut uses dokumendihaldussüsteem. Person responsible / vast utav isik: Indrek Sooniste Due date / tähtaeg: 01.06.2016 5 • Descr ibe in more detail the annual planning procedures in the Employee Handbook. • Assure evidence to support the regular over view of the planning procedure. • Kirjeldada aastast planeer imise protseduuri detailsemalt töötaja käsiraamatus. • Kindlustada tõendid aastase planeer imise protseduur i ülevaatamise kohta. Person responsible / vast utav isik: Indrek Sooniste Due date / tähtaeg: 01.06.2 016 9 • Descr ibe the per sonnel related principles in more detail in the Employee Handbook (steps of recruit ing, retention of employees and 42  leaving principles) to make the process more transparent. • Kirjeldada personali poliit ika põhimõtted täpsemat tööt aja käsiraamatus ( värbamise, ametishoidm ise ja lahkumise etapid), et protsess oleks läbipaist vam. Person responsible / vast utav isik: Indrek Sooniste Due date / tähtaeg: 01.06.2016 11 • Draw up annual training plan that includes inf ormation f .e about the trainees and the time, place, nam e, topics and amount of the trainings. • Create an annual summary and analysis of the annual training plan using f .e. SW OT analysis. • Review and updat e the organization’s training policy. • Koostada aastane koolitusplaan , mis sisaldab nt järgmist inf ormatsiooni: koolitatavate nimed, koolituse aeg, koht, nimetus, teemavaldkonnad ja maht. • Koostada iga -aastase koolitustegevuse kohta kokkuvõte, kus hinnatakse ja analüüsitakse selle ef ektiivsust. Nt kasutades SW OT analüüsi. • Üle vaadata ja uuendada asutuse koolituste korraldamise kord. Person responsible / vast utav isik: Indrek Sooniste Due date / tähtaeg: 01.06.2016 21 • Draw up procedures to prevent the physical, mental and f inancial abuse of service users. • Evaluate the organization’s prevent ion activities f or the physical, mental and f inancial abuse of users, f .e SW OT analysis could be conducted. • Koostada protseduurireeglid teenuse saajate f üüsilise, vaimse ja majandusliku ärakasutamise ennetamiseks. • Teenuse saajal tuleb viia läbi regulaarseid enesehindamisi ennetamistegevuste osas. Person responsible / vast utav isik: Indrek Sooniste Due date / tähtaeg: 01.06.2016 25 • Avoid sit uations wit h conf licts of inter est (there is a possible conf lict of interest concerning one board member of the Tartu Care Center, who is at the same the general manager of another social ser vice provider (competitor) in Tartu). 43  • Vält ida huvide konf likti olukordi (eksisteerib võimalik huvide konf likt, kuivõrd üks Tartu VTHK nõukogu liige on samaaegselt ühe teise sotsiaalteenuseid osutava asutuse (konkurendi) juhataj a). Person responsible / vast utav isik: Indrek Sooniste Due date / tähtaeg: 01.06.2016 36 • Preser ve wr itten evidence about the regular review of service deliver y processes. • Teenuse osutam ise protsesside ülevaatamise kohta tuleb kirjalikud tõendid säilitada. Person responsible / vast utav isik: Indrek Sooniste Due date / tähtaeg: 01.06.2016 37 • Cover the core processes wit h int ernal audits within a certain inter val. • Renew the audit policy. • Katta asutuse peamised protsessid siseauditit ega teatud regulaarsusega. • Uuendada siseauditit e läbiviimise korda. Person responsible / vast utav isik: Indrek Sooniste Due date / tähtaeg: 01.06.2016 48 • Integrate the PDCA process f ully i nto the management process of the organization. Assure that the qualit y approach includes systematic and conscious self -assessment, review and impr oving of processes and also related documentation. • Integreerida PDCA protsess asutuse juhtimise protsessid esse. • Tagada, et kvaliteedi lähenemine hõlmab süsteemset ja teadlikku enesehindam ist, ülevaatamist ning parendam ist nii protsesside kui seotud dokumentatsiooni osas. Person responsible / vast utav isik: Indrek Sooniste Due date / tähtaeg: 01.06.2016 44  5. Closing remarks Foundation Tartu Mental Health Ser vice Center supports t he per son s with mental health problems to live at home, work, lear n and participate in the communit y. Main values of the or ganizat ion are honest y, keeping agreements, trustworthiness, ex pert ise, person centeredness, the entire action is based on ser vice user, doing the work in a way it is motivat ing, proactivet y and accountabilit y. Ser vice users ar e 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, provide d 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 students f or traineeship and it also cooperates with the schools of higher educat ion in developing new activit i es. The organizat ion cooperation partners are local governments, state, employment off ice, cooperatives and entrepreneurs. Tartu care center has once already gained EQUASS Qualit y Assurance certif icate ( in 2013). Tartu Care Center has continued applying th e principles of EQUASS Assurances in its work since then. In 2015 they apply EQUASS certif icate f or 4 services: assistance in ever yday lif e, supported living, assistance in working and rehabilitation ser vices. There ar e 35 employees working in the organiza t ion, who are responsible f or providing the mentioned ser vices, including two volunt eers. The number of persons ser ved is 249 at the current time being. The auditor exper ienced on site that the social ser vice pr ovider Tartu Care Center perf orms in partial compliance with the EQUASS Assurance criter ia. The inter viewed representatives of partners, f inancing body, employees of the center and persons ser ved conf irmed the auditor that EQ UASS pr inciples were f ollowed in ser vice deliver y, which was ref lected in t heir sat isf action. Even though the organizat ion did not achieve f ull compliance with the EQUASS qualit y cr it eria. 45 The staff was kind and cooperat ive in introducing the work of the center, f inding necessar y evidential mater ials and shar ing inf ormation abou t f ulf illing EQUASS cr iteria. In general the main areas of improvement include making the organizat ion’s management / adm inistrat ion more systematic. Also regular and conscious self -assessment and reviewing process should be put in place that is an important part of the PDCA cycle and basis f or continuous improvement processes. The policy documents of the organizat ion are in need of review and update. Also more attent ion should be paid to recording periodic self -assessments and reviews. The main qualit y p r inciples and activit ies of the organizat ion are described in general in the Em ployee Handbook . The approach to descr ibing important inf ormation should be more detailed, to be more clear and transparent. To achieve f ull compliance with EQUASS Assurance cri teria, some improvement act ions are brought out in part 4 of the audit report. An over view of suggestions f or improvement that are ment ioned under the specif ic criter ia is given as well in part 3. Ther e are many sug gestions in part three of the report, tha t the service pr ovider should take notice of , when wishing to improve the f unctioning of the organizat ion and f or ensur ing better qualit y 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 part ially f ulf illed. The auditor f elt that the organizat ion is motivated to achieve high qualit y and compliance with the EQUASS criter ia, but has some improvement areas t hat need to be addressed in order to do so. *** SA Tartu Vaimse Tervise Hooldekeskus aitab vaimse ter vise probleemidega inimestel elada oma kodus, töötada, õppida ja rakendada end ko gukonnas. Tartu VTHK töötajad väärtustavad oma töös ausust ja asjatundlikkust. Vaimse ter vise pr obleemidega inimesi ja nende lähedasi nõustavad valdkonna spetsialistid: sotsiaaltöötajad, psühholoogid, psühhiaat er, f üsioterapeudid, tegevusterapeudid, eripe dagoogid, loovterapeut ja 46 logopeed. Töös läht utakse inimesest. Päevakeskustes juhendatakse tegevusvõimet säilitavaid ja parandavaid tegevusi; töör ühmades aitavad töövõime taastamisele kaasa koolitatud tegevusjuhendajad . Töötatakse inimeste kodus, kogukon napõhiselt ja hoolekandeasust uses . Teenuse saajatest ligikaud u pool on tartlased. Igal aastal pakutakse kõrgkoolides õppivatele tudengile prak tiseer imise võimalust ja tehakse koostööd kõrgkoolidega uute t egevuste ellu rakendamiseks rehabilitatsioonis. Asu tuse 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 ho oldekeskus on jätkanud EQUASSi kvalit eedipõhimõtete rakendamist sellest ajast. 2015. aastal taotlevad nad EQUASSi sertif ikaati neljale teenusele: rehabilitatsiooniteenus, igapäevaelu toetamise teenus, töötamise toetamise teenus, toetatud elamise teenus. Organisatsioonis töötab 35 töötajat, kes vastutavad nimetatud teenuste osutamise eest, sh kaks vabatahtlikku. Teenuse saajate ar v ulatub tänasel päeval 249ni. Audiitor koges kohapeal, et sotsiaalteenuse osutaja on osalises vastavuses EQUASS Assurance kriteer iumitega. Intervjueeritud koostööpartner ite ja rahastaja esindaja ning asut use töötaj ate hinnangul EQ UASSi põhimõtteid rakendatakse tegelikkuses, mis välj endus nende r ahulolus. Sellele vaatamata ei saavutanud asutus täielikku vastavust kõigile kvaliteedik riteeriumidele. Töötajad olid abivalmid ja tegid koostööd oma töö tut vustamisel, vajalike dokumentide / tõendusmaterjalide otsimisel ning teabe jagamisel EQUASSi kriteeriumide rakendamise kohta. Üldiselt, põhilised parendusvaldkonnad hõlmavad asutuse juhti m ise / haldamise süsteemsemaks muutmist. Paika tuleks panna r egulaarne ning teadlik enesehindamise ning ülevaatamise protsess, mis on oluline osa PDCA tsüklist ning on aluseks pideva par endam ise protsessile. Asutuse tööpõhimõt teid reguleer ivad dokumendid vajavad ülevaatust ja uuendamist. Lisaks tuleb täiendavalt tähelepanu pöörata perioodilistele 47 enesehindam istele j a ülevaatustele. Peamised kvaliteedipõhimõtted ning organisatsiooni tegevused on üldiste põhimõtetena kirjeldatud töötaja käsiraamatus. Tegevus te kirjeldusedl peaksid olema detailsem ad, et olla ühese lt mõistetavam ad ja et tagada läbipaist vus . Et saavutada EQUASSi kvaliteedi kriteerium itega täielik vastavus, on soovitatavad parendustegevused välja toodud aruande 4 -ndas osas. Ülevaade parendussoov itustest konkreetsete kriteerium ite lõikes on esitatud ka aruande 3-ndas osas. Kolmandas ar uande osas on välja toodud mitmeid soovitusi, millele teenuse osutaja peaks oma tähelepanu pöörama, sooviga asutuse toimimist parandada ning tagamaks parem kvaliteet ning vastavus EQUASSi kriteeriumidele. Pärast indikaatoritel e vastamise tõendamist, tutvum ist dokumentatsiooniga ning olles viinud läbi int er vjuud, oli audiitor veendunud, et kriteerium id Euroopa kvaliteedimärgi jaoks sotsiaalteenustes on täidetud osalise lt. Audiitor sai veendumuse, et asutus on pühendunud oma töös kvaliteedi tagamisele ja t äiustamisele , kuid tema tegevus es on olulisi parendusvaldkondi, millega tegelem ine on eelduseks täieliku vastavuse saavutam isele. Tallinn, 04. 12.2015 Mar iliis Männik -Sepp EQUASSi audiitor / EQUASS auditor 48 Maarika Aro Saatja: Guus van Beek <[email protected]> Saatmisaeg: 8. detsember 2015. a. 12:37 Adressaat: Maarika Aro Koopia: Keiu Talve; Marie Dubost; Mariliis Männik-Sepp Teema: Re: Tartu Vaimse Tervise Hooldekeskus audit raport Tähtsus: Kõrge Dear Keiu / Maariko, I h a ve r e vi e w e d t h e a u d i t r e p o r t f r o m Tartu Vaimse Terries Hooldekeskus (Reference number EE2015-017) a n d I c o n c l u d e t h a t t h e s e r vi c e s (w i t h i n t h e s c o p e o f th e a p p l i c a t i o n ) o f t h i s o r g a n i z a t i o n d o e s N O T m e e t a l l t h e E Q U AS S a s s u r a n c e c r i t e r i a . B a s e d o n t h e delegated power, which is described in the EQU ASS internal procedures and approved by the I nternational EQU ASS Awarding Commi ttee, th e s e r vi c e s (w i t h i n t h e s c o p e o f t h e a p p l i c a t i o n ) o f Tartu Vaimse Terries Hooldekeskus (Reference number EE2015-017) w i l l N O T b e c e r t i f i e d w i t h E Q U AS S As s u r a n c e i n S o c i a l S e r vi c e s y e t . I w i s h t h e o r g a n i s a t i o n l o t s o f s u c c e s s i n i m p l e m e n t i n g t h e s u g g e s t i o n s g i ve n i n t h e r e p o r t . Th e f e e d b a c k i n t h e a u d i t r e p o r t g i ve e x t e n s i ve a n d r e l e v a n t i n f o r m a t i o n a n d s u g g e s t i o n s t h a t c a n b e u s e d f o r i m p r o vi n g t h e p e r f o r m a n c e o n t h e E Q U AS S c r i t e r i a . Kind regards, Guus van Beek European Quality in Social Services (EQUASS) c/o EPR, Avenue des Arts 8, c/o CCI, B-1210 Brussels Belgium Phone: +31653770121 Email: [email protected] / website: www.equass.be Van: Maarika Aro <[email protected]> Datum: maandag 7 december 2015 11:29 Aan: Guus van Beek <[email protected]> CC: Marie Dubost <[email protected]> Onderwerp: Tartu Vaimse Tervise Hooldekeskus audit raport 1 Dear Marie, Dear Guus, Attached you’ll find an audit report and other documents of Tartu Vaimse Tervise Hooldekeskus EE2015-017. Please let Keiu to know in case there are some comments about the report. NB! Additional information form is missing, but I will send it later when they will send this document to me. Best regards, Maarika 2