EQUASS ASSURANCE APPLICATION
ADDITIONAL INFORMATION
1. Short information about the organisation in the nati ve language
Tallinna Vaimse Tervise Keskus on 2000. aastal loodud Tallinna linna
sotsiaalhoolekandeasutus, mis pakub ja arendab vaimse tervise teen useid
psüühilise erivajadusega inimestele ja nende peredele. Meie eesmärk on
aidata inimesel psüühilisest haigusest taastuda ning olla talle toetav ja
nõustav partner. Peame väga oluliseks ka ühiskonna teavitam ist
psüühikahäirete olemusest ning nende kohta levinud müüt ide kummutamist.
Keskus koosneb kuuest üksusest, mis pakuvad erihoolekande- ja
rehabilitatsiooniteenuseid ning -programme. Erihoolekandeteenustest
osutame igapäevaelu toetamise, toetat ud elamise ja töötamise toetamise
teenust. Pakume klient id ele nende individuaalsetest vajadustest läht uvat
igakülgset toetust. Meie töö põhineb kõikehõlmava psühhosotsiaalse
rehabilitatsiooni ehk CARe (Comprehensive Appr oach of Rehabilitation)
metoodikal.
Meie meeskonda kuuluvad psühholoogid, sotsiaaltöötajad,
tegevust erapeudid, tegevusjuhendajad, psühhiaatr id ja psühhiaatr iaõed ning
kogemusnõustajad.
Aastas pakume teenuseid üle 700 - le psüühilise erivajadusega inimesele.
Teenuseid pakume nii eest i kui ka vene keeles.
2. Short information about the organisation in English (acti vities,
clients, etc.)
Tallinn Mental Health Center is a Tallinn Cit y social welf are inst itution that
provides and develops various mental healt h ser vices f or adults with
psychiatric special needs and their f amilies. Our mission is to support the
recover y process of persons with mental health problems by off ering mental
health ser vices with the hig hest qualit y and sharing our knowledge about
mental health.
We help the person with mental health problems to have the best possible
qualit y of lif e, purpose and meaning of lif e and to f eel oneself as a valued
member of societ y.
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We off er our clients comprehensive support which is based on psychosocial
rehabilitat ion pr inciples and CARe (Comprehensive Approach of
Rehabilitation) methodolog y.
Our main services are support in ever yday lif e in a day care centre as well
as individually, using case management method ; supported living ;
employm ent support and a var iet y of rehabilitat ion ser vices and programs.
We have social workers, pshycologists, psychiatrists, occupational
therapists, psychiatric nurses, support persons and peer wor kers working in
our team.
We provide ser vices f or over 700 clients annually.
3. Name of the organisation as you w ould w ant it to appear on the
EQU ASS Assurance certificate
TALLINN A VAIM SE TERVISE KESKUS
4. Name of services / departments of the organi sation i n the scope of
the application as you w ould w ant it to appear on the EQU ASS
Assurance certificate :
5. Organisation’s logo
Information to be published on EQUASS webs ite:
Name of the organi sation : Tallinn Mental Health Center
Post address: A. Weizenbergi 20b, 10150 Tallinn, Est onia
Director: Merike Ot epal u
Contact person: Merle Tomberg
Email: tallinn@ vai mnetervis.ee
Web: http://w ww.vaimnetervis.ee
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EQUASS ASSURANCE
ASUTUSE KÜLASTUSE
ETTEVALMISTAMISE VORM
Asutuse külastus: 11.-12. mai 2015
Tallinna Vaimse Tervise Keskus
Mariliis Männik-Sepp
© 2012 by European Quality for Social Services (EQUASS)
Kõik õigused kaitstud. Antud dokumendi elemente ei tohi paljundada, kopeerida ega muul elektroonilisel moel
salvestada ilma EQUASS kirjaliku loata.
Asutuse külastuse ettevalmistamise küsimused
EQ U AS S As s ur a nc e t ao t lus v or m i le j a a nt ud l is ai nf orm ats i oo n i l e p õh i n ed es pa l um e
te i l e tt e va lm is t us ek s v as t at a j är g ne v at e l e s e l gi t us t n õ ud v at e l e k üs i m us tel e :
Üldised teemad (max. 10 küsimust)
1. M ik s al us ta t i EQ U A S S i r ak en dam is eg a ja m id a on k v a l it e ed i s üs te em i
rak en d am is eg a s a a v ut at u d?
2. M id a o l et e t e i nu d t e e nus t e k va l it e ed i t a ga m is ek s j a tõs tm is ek s om a as u tus es
pär as t ee lm is t EQ UA S S i a ud i ti t ?
3. K ui d as o n k va l it e e di s üs t e em i rak en dam i n e m õj ut an u d as ut us e j uht im is t j a
pers o n al ij uh t im is t ? M il l is e d m uut us ed o n t o i m unud ?
4. K irj e l d ag e om a as ut u s e p õh i pr ots es s e: pl a ne er im is e pro ts es s i, k es tv a ar e ng u
pro ts es s i ( PD C A ts ük l i) j a te e nus te os a ut am is e pr ots es s i r ak e nd am is t om a
as u t us es .
5. M il l is e d o n as ut us e hu v i gr u p i d? Ku i d as o n v ä lj a s e l g it at u d h u v igr u pp i d e o ot us e d
j a v aj a d us e d ? K u id as k üs it ak s e ne n de l t ta g a s is id e t?
6. K el l e ga ja m ill is t k oos t öö d t ee t e n in g m il l is t l is a v ä ärt us t s ee l äb i o l et e
s aa v u ta n ud ?
7. K ui d as k aas at ak s e te en us e s a aj a i d, pe rs o na l i j a m ui d h u v i gru pp e t e en us t e
are n d am is s e?
8. M il l is te k o guk o nn p õh i s te te g e vus t eg a ol e te s e o t ud o ln u d j a k u id a s üh is k o nn a le
l is a v ä är t us t pak k unu d ?
9. M il l is e id par e nd us pr oj ek te/ in n o va ts io o n ipr oj ek te o l et e e l lu v ii n u d?
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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
Huv i gr up i d
P er s o n a l
Dir ek tor
Juht im in e 1. K ir j e l d ag e T ei e as ut us e j u h tim is e
k or r al d us t j a a as t as e p l an e er im is e x
k or r al d us t ?
2. K as o l et e te a d li k ud as ut us e
m is s io o nis t, v is i oo n is t ja
x
v äär t us h i n na n gu tes t ? Pa l un
s õn as ta g e.
3. M il l is e id on T ei e as u tu s e
x x x
k va li t ee d ip õ h im õtt ed ?
4. K ir j e l d ag e, m il l is e i d as u t us e
te e nus e id te at e ning k uida s o le te x x
ne n des t t ea d a s aa n u d ?
5. K as T ei lt o n k üs it u d j a k uid as o n T ei l
v õ im al ik an da ta g as is i de t p ak ut a v at e x x
te e nus te k oh ta ?
6. K ui d as k ogu t e i nf ot ü h is k on n a
v aj a d us t e k oh ta n in g m i ll is e id
üh is k o nn a v aj a d us t e le / k og uk on na l e x
s uu n at u d te g e v us i o le te
k or r al d an u d ?
P er so na l 1. K ui d as j ä lg i tak s e t ee n us e
pak k um is eg a ots es e lt te g el e v at e x x
tö öt aj at e te g e vus t (p er i oo d i lis e lt )?
2. K ui d as k a as a t ak s e p er s on a l i x x
te e nus te pl a ne er im is s e, ar e nd am is s e
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j a h in d am is s e ?
3. K ui d as o n ta g at u d pe r s on a l ip o l i it ik a
x
k oos k õl a tö ös ea d us a n d lus e ga ?
4. K ui d as h i nn at ak s e tö ö taj at e
k om pet e nts us nõ u de i d n in g k u i das x x
tö öt i n gim us i?
5. K ir j e l d ag e as ut us e
m oti va ts io o n is üs t eem i j a k ui das x x
to im ub t öö t aj a te t u nn u s tam in e ?
6. K ui d as a na l ü üs i t ak s e
x
k ool i tus te g e vus e ef ek ti i vs us t ?
Õ igu se d 1 A. Se l g it ag e , k u id as T eid on
i nf or m eer it u d j a k u id a s t un n et e
„ k lie n ti d e õ i gus j a k oh us t us i“, t u ues
m õned nä i te d ?
x x
1 B. Kas o l et e t ea d l ik (T eid on
i nf or m eer it u d) om a õi g us t es t j a
k ohus tus tes t t ee n us e s aaj a na n i n g o le t e
an d ud v as t a va k in n i ta v a a l lk irj a ?
2 A. Ku i das on k orra l d at u d et te p an ek ut e
j a k ae b us t e m e ne t lem i ne ni n g ta g at u d
s e ll e pr o ts es s i as j ak ohas us j a
l äb i pa is t vus ? x x
2 B. Ku i das t e en us e s a aj a d s a a va d
es it ad a e tt e pa n ek ui d v õ i k ae b us i?
3. Ku i das a it ab t e en us e os ut aj a k aas a
pa ts ie n ti d e e nes em äär at l em is e l e j a x x
k uid as s e da ig a - a as t a s e lt h i nn a tak s e ?
4. Ku i das i nf orm eer it a k s e te e nus e
x x
s aaj at õi g us es t s a a da ees tk os tj at võ i
tu g i is ik u t j a k u id as s e da ig a - a as t as e l t
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h in n at ak s e ?
5. Ku i das T e h i nd at e , k uid as T e i d
x
k ohe l dak s e t ee n us e s aaj at e na ?
E et i k a 1. K ui d as T e i d o n i nf orm eer i tu d
ee t ik ak ood ek s is t j a k u i das t u nn et e
x x
v as t a v ai d p õ him õt t ei d (to o ge
nä i te i d) ?
2. K ui s ag e l i v a ad at ak s e ü le j a
an a l üüs i tak s e (k oos p ers o n a l ig a)
k onf id e nts i aa ls us eg a s eo t ud n õ ud e d x x
n in g m i l l is e i d m uu d at u s i v i im at i
te ht i ?
3. M il l is e d on T e ie a s u tu s e te e nus t e
os u t am is e p õh im õt te i d n i ng x x
v äär t us h i n na n gu d ?
4. K ui d as p ääs e te li g i om a is ik l ik el e
x x
an dm et e le ? (k l i e nd i to i m ik )
5. K us on k irj e l d at ud /k l ie nt i de l e
k om m unik e er it u d j a k a s T e t e at e
x x
om a j a j u h at us e / j u htk on n a r o l l i j a
v as t ut us u la tus t ?
Koo st öö suh t ed 1. K el l e ga j a m il l is t k oos t öö d t ee t e
( s e lg i ta g e n äi d et e v ar a l, s h
x x
s ots i aa l v a ldk o n na p ar t ner i d,
r ah as taj a d, t ee n us e k as u t aj a d) ?
2. K ui d as k a as a t ak s e t e e nus t e x x x
ar e n d am is s e te e n us e s aaj a id ( ne n de
es in d aj a i d), t e en us e o s tj a i d j a
ha nk ij a i d ?
3. K ui d as k a as a t ak s e (n e nd e) x x
v aj a d us t e v ä lj as e l gi t a m is e p ro ts es s i
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hu v i gr up p e?
4. K ui d as a na l ü üs i t e j a h i nd at e x
k oos t öös t tu l e ne v at l is an d v ää rt us t ?
5. K ui d as o l et e r a hu l k oo s tö ö ga ? x
O s al em in e 1. K ui d as os a le v a d k l ie n d id vaj a dus te x x x
v ä lj as e lg i tam is el , t ee n us t e
p la n eer im is e l j a an a lü üs im is e l?
2. K as j a k u id as o n p ers on a l i k o ol i ta t ud x x x
te e nus e s a aj a te j õ us ta m is e t e em al
n in g k u i das s e e t o im ub i ga p äe v as es
e lus ?
3. K ui d as a it a b te e nus e os u t aj a k aas a x
te e nus e s a aj a te j õ us ta m is el e j a
m ill is e id m õõ de t a va i d tu l em us i o n
s aa v u ta tu d ?
4. K as j a k u id as o n t ee n us e s aaj at e x x x
os a l em is ek s vaj a l ik ud m eetm ed,
te g e vus e d j a k or d k oo s k õlas ta t ud
te e nus e s a aj a te g a v õ i ne n de
es in d aj a te g a?
5. K ui s ag e l i v a ad at ak s e ü le t e en us e x x
s aaj at e võ i n e nd e es i n daj at e
os a l em is e g a s eo t ud m ee tm ed n i ng
m ill is e d on ol n ud v i im as e d
m uuda t us e d ?
Is ik uk e sk su s 1. K ui d as o n k i nd l ak s t eh tu d x x
r ah as taj at e vaj ad us ed n in g t eis t e
o lu l is t e or g an is ats i o on i de
hu v i gr up p i de vaj a dus e d j a k u id as
ne n de g a ar v es t at ak s e ?
2. K ui d as o l et e r a hu l t e e nus e pak k uj a x
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as uk o ha g a?
3 A. Ku i das on t a ga tu d , et t ee n us e x x
os u t aj a p ak ub om a t ee nus e i d v as t a v al t
te e nus e s a aj a vaj a dus te l e?
3 B. Kas in d i v id u aa l n e te g e vus p la a n
v as t a b T e ie v aj a d us t e l e j a o ot us t e le ?
4. Ku i das v aa d at ak s e as u t us e p o o lt x
pak u ta v a id t e en us e id ü le , ar v es t a des
s am as t ee n us e s aaj at e o od at a v a t e
tu l em us te g a?
5. Kas in d i v id u aa l n e t eg e v us p l a an o n x x
k oos k õl as t at u d j a s e d a o n k orr ig e er it u d
v as t a v al t t ee n us e s a aj a ta g as is i d e le ?
Lai ah a ar de li su 1. K ui d as ta g at e , et p ers on a l i l on üh tn e x x
s ar us a am pe am is t es t t e en us e
os u t am is e pr ots es s id e s t j a en d a
v as t ut us es t n e nd es ?
2. K ui d as k as ut at e m ult i d is ts i p l in a ars e t x
l äh e nem is t k l ie n di l e i n d i vi d ua a ls e
te g e vus p la a n i k o os t a m is el j a
r ak en d am is e l?
3. K ui d as ta g at e , et t e en us e s aaj a x x
e luk v a l it ee t o n i n di v i d ua a ls el t
m äärat l et u d te e nus e s aaj a v õ i t em a
per ek o nn a p oo l t?
4. K ui d as ta g at e j a h i nd a te t e en us e x x
j ätk u vus t h i nn at ak s e i ga - a as t as e lt ?
5. K ui d as o n ta g at u d te e nus t e j a x
pr o gr am m id e os u t am is e l ü lem i nek ut e
s uj u v us ?
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T ulemu st el e 1. K ui d as v õrr e ld ak s e k l i en d i x
ori en t e e rit u s i nd i v i du a a ls e t e ge v us p la a ni t u l em us i
os u t at ud t e en us te t u le m us teg a e hk
k uid as i g a i nd i v i du a a l ne pl a an
pa n us t a b ü ld is es s e te en us e
tu l em us l ik k us es s e ?
2. K ui d as m õõ d et ak s e te en us e x x
ha nk ij a t e / te l l ij a t e j a r ah as taj at e
r ah u l o lu ?
3. K el l e l e j a m il l is t ü le v a ad e t an t ak s e x x
as u t us e t e ge v us es t n i ng k as s ee on
s i htr ühm a de l e ar us a a d a vas k ee l es ?
4. K ui d as h i nn at ak s e as u tus e t eg e v us t e x
tu l em us te l is a v ä ärt us t ?
Pi dev a r eng 1. K ir j e l d ag e P DC A ts ük l i t o im im is t om a x
as u t us es ?
2. K ui d as o l lak s e k urs is hu v i gr up p i de x
uu t e j a m uu tu v a te vaj a dus t eg a ?
T oog e n ä it e id hu v i gr u pp i d e
es il ek erk in u d v aj a d us t es t
3. T oog e n ä it e id in n o va a ti l is tes t x x
tö öm eet o d it es t /
i nn o v ats i oo n i proj ek ti d es t ?
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2. Nõutav dokumentat sioon
EQ U AS S As s ur anc e ta ot l us es s e m ärg i tu d i nf o le j a lis a de l e p õh i n ed es pa l um e
v aa t lus ek s e tt e v a lm is ta d a j är g n e v d ok um ent ats i oo n :
1. K v al i te e d is t a nd ar d
2. Ra v i tö ö ü l dis e d p õh im õt te d
3. P ers o n a li p o l i i t ik a
4. E et ik ak oo dek s
5. T ege v us k a va k oos tam i s e k irj el d us
6. T ege v us k a va d 2 0 12 - 2 01 4
7. K om m unik a ts i o on is tr at ee g i a
8. T agas is i de s üs t eem
9. St a ts i o na ar s e r a v i tö ö k or d
10 . Am bu l at oo r s e r a v i tö ö k or d
S am uti p a lum e a u d i i tor i j aok s v a lm is p an n a t a ot l us d ok um en d is m ärg it u d
ü lej ää n ud t õ e nd us dok um end i d .
3. Personali, teenuse saajate ja tei ste oluliste huvi gruppide
intervjueerimine
EQ U AS S As s ur anc e t ao t lus es an tu d v as t us te l e j a t õ en d it e l e p õh i ne d es p a lum e
k orral d ad a i n ter vj u ud j är gm is te in im es t eg a (f unk ts io o n j a k es t v us ) :
Juhtkond Kestvus
1. D ir ek tor 45 m in ut i t
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Personal Kestvus
4. K v al i te e d ij u ht 30 m in ut i t
2. P ers on a l (2-3 t öö t aj a t; er i ne v a d a 3 0 m in ut i t
as u p a ig a d j a te e nus e d )
Teenuse saajad Kestvus
1. G r up i i nt er vj uu ( as u tus e es i nd aj a v õ i b K un i 4 5 m i nu t it
j uur es v i i b id a)
Teised huvigrupid Kestvus
1. Ko os t ö öp ar tn er i d ( 1 - 2 p ar t n er it K un i 4 5 m i nu t it
as u t us e va l ik u l)
2. R a has taj a 30 m in ut i t
4. Asutuse külastuse ajakava
11 . 05 .2 0 15 P äev 1
Ae g T egev us ( l üh ik e k irj e l dus )
8. 3 0- 8 .4 5 A v ak oos o lek ( A. W ei zen b er gi 20 b)
8. 4 5- 1 1. 4 5 Dok um en ta ts io o ni ül e v aa t us , vorm i de t ä itm i n e
11 . 45- 1 2. 1 5 In ter vj u u k v a l it ee d ij u h i ga – Me rl e T om berg
12 . 15- 1 2. 4 5 Lõ u na p aus
12 . 45- 1 3. 1 5 In ter vj u u p er s o n al i g a - M a ar is K am ene v a (t e ge v us j uh e nd aj a,
k oguk on n at ö ö m ees k o nd ; t ea b et oa nõ us t aj a) , A nu R a hu
( te e nus te ar e n dus j u ht) , Le i l a Rä n i (t eg e v us j u he n daj a,
k oguk on n at ö ö m ees k o nd ; t öök es k k onn a s pe t s i al is t), Ir e ne K ad u
( r e ha b i li t ats i oo n im ees k onn a j uh t)
13 . 15- 1 3. 3 0 Dok um en ta ts io o ni ül e v aa t us , vorm i de t ä itm i n e
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13 . 30- 1 4. 1 5 In ter vj u u k o os t öö p art n er it eg a - Zs o lt B ug ars zk i (T a l l i nn a
Ül ik o ol i So ts ia a lt ö ö In s ti t uu d i s ots i a al p o l ii t ik a l ek tor, r ää g i b
i ng l is e k ee l es ) j a M ar g e V onk , P E RH Ps ü h h i aa tr ia k l i in ik
14 . 15- 1 4. 3 0 Dok um en ta ts io o ni ül e v aa t us , vorm i de t ä itm i n e
14 . 30- 1 5. 1 5 In ter vj u u te e nus e s a aj at e ga - T im o, Ma l l, Ma rk o, T oom as , Mik ,
In dr ek , Aa d u, M ak s im
15 . 15- 1 5. 3 0 Dok um en ta ts io o ni ül e v aa t us , vorm i de t ä itm i n e
15 . 30- 1 6. 0 0 In ter vj u u r a has taj a ga - Airi Nõmm (Sotsiaalkindlustusameti
sotsiaalteenuste üksuse nõunik) ja Marina Runno (Tallinna
Sotsiaal -ja Tervishoiuameti peaspetsialist)
16 . 00- 1 6. 3 0 Dok um en ta ts io o ni ül e v aa t us , vorm i de t ä itm i n e
12 . 05 .2 0 15 P äev 2
Ae g T egev us ( l üh ik e k irj e l dus )
9. 0 0- 1 0. 3 0 Ha a ber s t i Kl u b im aj a k ü las tus j a in t er vj u u p e rs on a l i ga (Õ is m äe
te e 1 05 a)
10 . 30- 1 0. 4 5 T r ans p or t P e lg ur an d a
10 . 45- 1 2. 1 5 P el g ur an n a T er a ap i ak es k us e n i ng t u g ik es k us e k ü las t us j a
i nt er vj u u p er s on a l ig a ( P el g ur an n a 31 )
12 . 15- 1 3. 1 5 Lõ u na
13 . 15- 1 3. 3 0 T r ans p or t K ad r i or gu ( A. W eize nb er g i 2 0b)
13 . 30- 1 4. 1 5 In ter vj u u d ir ek t or ig a – M er ik e O te p a lu
14 . 15- 1 6. 3 0 Dok um en ta ts io o ni ül e v aa t us , vorm i de t ä itm i n e
16 . 30- 1 7. 0 0 Lõ p uk oos o lek
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EQUASS ASSURANCE
AUDIT REPORT
Site visit: 11.-12.05.2015
Tallinna Vaimse Tervise Keskus
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 Tallinna Vaimse Ter vise Keskus (Tallinn
service provider Mental Health Centre) (hereinafter TMHC)
Address: A. W eizenbergi 20b, 10150 Tallinn
Post box: N/A
Person responsible Mer ike Otepalu, director
(CEO):
Contact person: Mer le Tomberg , quality manager
Phone: (+372) 6276640
Fax: -
E-mail: talllinn@vaimnete r vis.ee
Web site: www. vaimneter vis.ee
Name of Auditor: Mar iliis Männik -Sepp
Dates of audit: 11.-12.05.2015
Clients: 720
Staff: 51
Services: Support in ever yday lif e,
supported living,
employm ent support,
rehabilitat ion ser vices and programs
2
2. Audit program
11.05.2015 Day 1
Time Acti vit y
8.30-8.45 Opening meeting (A. Weizenbergi 20b)
8.45-11. 45 Documentation review
11.45-12.15 Interview with qualit y manager of TMHC Mer le Tomberg
12.15-12.45 Documentation review, up -dat ing f iles
12.45-13.15 Interview with staff :
Maar is Kameneva (communit y car e team),
Anu Rahu (ser vices’ development manager),
Leila Räni (community care team),
Irene Kadu (rehabilitation team)
13.15-13.30 Documentation review, up -dat ing f iles
13.30-14.15 Interview with c ooperation partners :
Zsolt Bugarszki ( Institute of Social W ork , Tallinn
Universit y),
Marge Vonk, Psychiatry Clinic, North Estonia Medical
Centre (PERH)
14.15-14.30 Documentation review, up -dat ing f iles
14.30-15.15 Interview with persons ser ved :
Timo, Mall, Marko, Toomas, Mik, Indrek, Aadu, Maksim
15.15-15.30 Documentation review, up -dat ing f iles
15.30-16.00 Interview with f inancing body –
Air i Nõmm ( Estonian National Social Insurance Board ),
Mar ina Runno ( Social Welf are and Healt h Care
Department )
16.00-16.30 Documentation review, up -dat ing f iles
12.05.2015 Day 2
Time Acti vit y
9.00-10.30 Visit to the Haaberst i Club House and interview with
staff (Õismäe tee 105a)
10.30-10.45 Transport to Pelguranna
10.45-12.15 Pelguranna Ther apy Center and Support Home and
inter view with staff (Pelguranna 31)
12.15-13.15 Lunch break
13.15-13.30 Transport to Kadriorg (A. Weizenbergi 20b)
3
13.30-14.15 Interview with direct or Mer ike Otepalu
14.15-16.30 Documentation review, up -dat ing f iles
16.30-17.30 Closing meeting
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 are
stated in the development plan f or
2012-2017 of TMHC and on T MHC’s
website http:// www. vaimneter vis.ee/ ,
which is available in three
languages: Est onian, Russian and
English.
The mission of TMHC is to support
the recover y pr ocess, off ering
mental health ser vices with the
highest qualit y and sharing
knowledge about mental health.
The employees of TMHC
demonstrated through inter views
that they ar e aware of the
organizat ion’s mission, vision and
core values and they implement the
vision and mission values on ser vice
provision.
2. The social servi ce provider defines, documents, and implement s its
qualit y policy by determining long term qualit y goals, and its
commitment to continuous improvement.
4
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
The qualit y standard , long -term
goals and commitment to continuous
improvement are stated in the in the
development plan for 2012 -2017 of
TMHC.
The long -term goals of TMHC ar e
descr ibed in the organizat ion’s
development plan. The main
strategic goals are to support the
recover y pr ocess and raise the
qualit y of lif e of persons ser ved; and
to ensure the sustainabilit y of the
organizat ion.
It appeared f rom the inter views that
the staff of TMHC is knowledgeable
of the qualit y standa rd and long term
goals of the organizat ion. Also, the
staff seemed to be devoted to deliver
qualit y ser vices and pursue f or
continuous improvement.
TMHC gained the certif ication of
EQUASS Assurance in 2011 f or the
f irst time.
3. Persons served, famil y m embers 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
this cr iterion of the EQUASS Assurance cer tif ication program
5
Strengths Improvem ent & developments
TMHC has developed diff erent
methods to ask and receive f eedback
f rom persons served, staff and
stakeholders. The procedure has
been descr ibed in the qualit y manual
of TMHC. A system of f eedback h as
been developed.
For example f rom f unding bodies
f eedback is received though audits
(f.e Social Insurance Board audits) .
Questionnaires are used to receive
f eedback f rom persons ser ved.
Employees have a chance to give
f eedback on ongoing basis and also
f eedback is asked during staff
perf ormance reviews . Regular staff
motivat ion and sat isf action sur veys
are conducted as well.
Results of sur veys are analyzed and
summarized in the annual act ivit y
reports.
4. The social service provider i nforms all stakeho lders about the
offered programmes and services avai lable.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
TMHC has inf ormed a ll possible The services of TMHC could be
stakeholders about its services using better descr ibed on the home page
6
a variet y of methods and of TMHC. On the page f or services
approaches. (http://www. vaimnet ervis.ee/teenuse
d/) the off ered services are listed
The home page of TMHC is ver y and also inf ormation is provided,
inf ormative, giving a lot of which units provides what ser vices
inf ormation about TMHC. Also f .e and what steps to take to get the
brochures in three languages are ser vices. For better communication it
available. would be advisable to add
inf ormation there, what are the goals
Inf orming staff is descr ibe d in t he
of these ser vices , what do these
training procedur e. Also var ious
ser vices consist of .
measures have been developed f or
the participation of staff , f .e TMHC kodulehel võiks pakutavaid
trainings, meetings, methodological teenuseid paremini kirjeldada.
instruct ion, super vision, Teenuste lehel
questionnaires etc. ((http://www. vaimnet ervis.ee/teenuse
d/) on esitatud loet elu pakutavatest
Stakeholders are aware of the
teenustest, teenuseid pakkuvatest
ser vices of TMHC, which was
üksustest ja kuidas t eenusele saada.
ver if ied imple mented through
Parema kommunik atsiooni nim el
inter views wit h persons ser ved, staff
oleks soovitatav lisada lehele
and partners.
vastavate teenuste eesmärgid ja
sisukirjeldused.
5. The social service provider management establishes and
documents an annual planning a nd review process.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
The annual planning and review
process is integrated into the
management process of the
organizat ion. The planning procedure
has been documented, including
strategic planning, annual planning
7
and also including development and
innovat ion projects. The process is
reviewed regular ly.
There are annual action plans , which
are reviewed regularly during
“reporting meetings”. Minutes of the
meeting are dr awn up to document
the current state of the
implementation of the action plan.
6. The plan includes:
annual outcomes / targets
the acti vities to be undertaken in ac hieving 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 th e EQUASS Assurance certif ication program
Strengths Improvem ent & developments
The annual planning process of
TMHC has a cyclic character.
The annual work plan includes
objectives, measur es and act ivit ies,
tangible results and deadlines.
The annual plan is approved by the
management .
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 t he EQUASS Assurance certif ication program
8
Strengths Improvem ent & developments
TMHC is ver y act ive, when it comes
to satisf ying the needs and
expectat ions of the societ y and
demonstrat ing social responsibilit y
contributing to the societ y.
TMHC has contr ibut ed to amending
the mental health ser vices related
legislat ion. It organized the Mental
Health Week, wit h open doors days
in all its locat ions and inf ormation
seminars.
Var ious projects and activit ies are
organized by T MHC and also with its
cooper ation partners .
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 EQUASS Assura nce certif ication program
Strengths Improvem ent & developments
TMHC has demonstrated social
responsibilit y through diff erent
activities contr ibut ing to the societ y.
F.e innovat ion p roject "The
development of exper ience
advisers"; project "Risk assessme nt
and management training program",
project "The communit y support f or
people with special needs" etc.
9
9. The social servi ce provider has a staff recruitment and retention
policy that promot es the selection of qualified personnel based on
required know ledge, skills and compet ences.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
TMHC has a well-tr ained, committed
and competent staff – social workers,
psychologists, activit y leaders,
nurses etc. Staff is highly valued by
the management.
Recruitment and selection procedure
f or staff has been developed. This
also includes the principles f or
equalit y and non -discrimination.
Perf ormance indicators of TMHC
have been worked out, procedures of
training activities have been
descr ibed.
All employees have individual job
descr iptions, which include required
knowledge, skills and competences.
It appeared f rom the inter views wit h
the personnel that t hey all are well
aware of their roles, r ights and
duties. It also came out that the
employees are highly mot ivat ed, like
their jobs and are devoted to
delivering high qualit y ser vice.
10
10. The social service provider operates in compli ance w it h
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 documentation of TMHC meets The risk analysis (health and saf ety
legal r equirements and is reviewed evaluat ion) is conducted by the
to do this. The staff level is kept at trained staff of TMHC (the activit y is
optimum and this is reviewed also managed by t he health and saf et y
regularly. representat ive). Even though it has
been done comprehensively, it could
Rules of the organization have been ser ve usef ul to conduct this activi t y
established. The working condit ions by an outside expert once in a while.
are evaluated (r isk assessments are
carried out by TMHC staff ) and Töökeskkonna riskianalüüsi viib läbi
necessar y act ion plans are drawn up TMHC väljaõppe saanud personal
and amendments are made. (töökeskkonna voliniku juhtimisel).
Kuig i see on tehtud suur e
Even though there are no volunteers, põhjalikkkusega, võib aeg -ajalt
the rules of procedure f or voluntar y osutuda kasulikuks vastava töö
activities have been developed. läbiviimine välisekspe rdi poolt.
The principles f or showing
recognit ion to employees are
descr ibed in staff motivat ion and
remunerat ion policy. Employees ar e
given recognitions f or outstanding
perf ormance and incentive pay f or
personal achievements.
11. The social service provider trains all staff based on a plan for
leaning and development and evaluates the effecti veness of the
training.
11
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
Staff development and training needs
are assessed annually and are
descr ibed in the Training Needs f or
the Year. Annual t raining plan is
created, that includes inf ormation
about the names and amounts of
trainings.
The staff of TMHC is trained based
on their needs and expectat ions. A ll
the inter viewed em ployees showed
high appr eciation concerning the
trainings received.
Feedback on trainings is collected
and training inf ormation is gathered.
The eff ectiveness of the trainings is
then evaluated and descr ibed in the
annual activit y report.
12. The social servi ce provi der applies requirements for competence
in the identified roles and functions of staff and evaluates them on
annual basis.
Remark from the auditor: The ser vices of the social ser vice pr oviders 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
12
annually.
The perf ormance of staff is reviewed
in many var ious ways. Regular
perf ormance reviews , super visions,
methodological instructions and work
guidance are carr ied out with staff
member, during which the y are
instructed and super vised to do their
work eff ectively and eff iciently and
their compet ences are evaluated.
Also their f eedback is collect ed
during these reviews.
Inf ormation about t he work load of
staff is collected.
13. The social servi ce provi der recognizes the staff as a resource for
feedback on organizational perf ormance, service development and
staff development
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
The involvement of staff in the
planning and evaluation of services
is descr ibed in var ious procedures of
TMHC. F.e annual planning
procedure, qualit y manual, measures
f or involvement staff . F.e strategy
days are organized f or t he whole
organizat ion.
TMHC recognizes staff as a usef ul
tool f or gaining inf ormation. It has
regular staff meetings, perf ormance
13
reviews, super visions etc.
A register of obstacles in client work
has been developed to gather
inf ormation about possible inc idents
and to learn f rom them.
Staff satisf action sur veys are carried
out in T MHC.
14. The social service provi der has mechanisms in place to enhance
satisfaction and motivation of staff
Remark from the auditor: The ser vices of the social ser vice pr ov iders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
Staff evaluations, staff
questionnaires and employees’
sur veys are used to gain f eedback
on satisf action and motivat ion.
Mechanisms to provide satisf action
and mot ivat ion are described in staff
motivat ion and remuneration policy.
Special events f or showing
recognit ion to staff have been
organized, as T MHC values highly its
personnel and demonstrates concer n
f or them.
F.e team of the year, empl oyee of the
year are elected and rewarded.
14
15. The social servi ce provi der assures the rights of persons served
outlined in a Chart er of Rights w hich is based on the EU Charter of
Fundamental Rights , the European Convention for the Protection of
Human Rights and Fundamental Freedoms of the Council of Europe
and other int ernati onal human ri ghts conventions, especiall y those
elaborat ed under the United Nations.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of t he EQUASS Assurance certif ication program
Strengths Improvem ent & developments
TMHC has developed the rights and
duties of persons ser ved, which
conf orm to international human
rights convent ions.
The rights and duties are added to
the ser vice deliver y procedures.
They ar e introduced to persons
ser ved by staff and are available on
the walls of centers (in all locat ions).
The persons ser ved conf irm their
understanding of the rights and
duties by signing the service
contract.
Also procedures f or abuse
prevent ion have been developed.
The staff demonstrated their
knowledge of the rights and dut ies
through the inter views.
16. The soci al service provider informs the person served about
his/her rights and duties especiall y to equal treatment on grounds of
age, disabilit y, gender, race, religion or belief and sexual orientation
before recei ving the services.
15
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 The rights and dut ies are explained
to persons ser ved by staff and are to the clients and they sign the
available on the walls of centers (in contract conf irming they have got
all locat ions). acquaint ed to them. Still, i t could
ser ve usef ul to make the rights and
The persons ser ved conf irm their duties available also in easy to read
understanding of the rights and language or using visual
duties by signing the service components, that would help the
contract. persons ser ved to unde rstand and
adapt them better. Also, disclosing
They have also been introduced and
the rights and dut ies of persons
discussed dur ing the meetings of
ser ved would be a step t o more
client representations (minutes of
opened communicat ion.
meetings were provided).
Teenuse saajate õig usi ja kohustusi
The clients demonstrated their
selgitatakse klientidele ning need on
knowledge of the rights and dut ies
lisatud kliendiga sõlmitavasse
through the inter views.
lepingusse, tõenda maks, et teenuse
saaja on nendega tutvunud. Siiski
oleks soovitatav klientide õigused ja
kohustused teha kättesaadavaks ka
lihtsamas sõnastuses või
visualiseerit ud kujul, mis võimaldaks
teenuse saajatel neid parem ini
mõista ja omaks võtta. Samuti oleks
teenuse saajat e õiguste ja
kohustuste avaldamine asutuse
kodulehel samm avatum a
kommunikatsiooni poole.
16
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
TMHC has developed a procedure f or
handling compl aints.
The various ways on complaining
include sending an e -mail, oral
inter view, written complaint.
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 complaints are dealt with and
answered.
A register f or complaints and
proposals has been drawn up, which
also gives input t o improving the
procedures of TMHC.
The complaint management system
proves to be transparent.
18. The social service provider respects th e fundamental right to
self-determination of the person served. They freel y det ermine their
political status and freel y pursue their economic, soci al and cultural
development.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
17
Strengths Improvem ent & developments
The self -determination supporting
related pr inciples are descr ibed in
the qualit y manual of TMHC and in
the ser vice deliver y procedures
Feedback is collected though clients’
sur veys and also through client
representat ion.
It became evident through the
inter views that the staff supported
the right to self -determinat ions of
clients and that the persons ser ved
were handled wit h respect.
19. The social servic e 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 meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
The process of f acilitating the
persons ser ved in choosing and
having access to advocates and/or
support ing persons in described in
the service deliver y processes of
TMHC (supporting ser vices and
rehabilitat ion ser vices) pr ocedur es.
The descr iption of the support
person ser vice was presented to
Tallinn Cit y author ities.
Recommendat ions were given to t he
18
persons ser ved f or using the
ser vices of supporting persons.
The perf ormance in f acilitating
persons ser ved in having acces s to
advocates and/or supporting persons
is evaluat ed annually and reported in
the annual activit y r eport of TMHC.
20. The social service provi der defines and documents its policy on
ethics that respects and assures the dignit y of the persons served,
protects them from undue risk and promotes soci al justice
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
The code of ethics of TMHC has To be more open to the publicit y, it
been developed and made available would be advisable to disclose the
to the staff . Member s of staff showed ethical pr inciples of TMHC on its
awareness about the related ethic home page.
principles.
Et olla rohkem avalikkusele avatud,
The policy respects and assures the oleks soovitatav avaldada T MHC
dignit y of the persons ser ved, eetilised põhimõtt ed asutuse
protects them f rom undue r isk and kodulehel.
promotes social justice.
New staff members are introduced
the ethical principles .
21. The social service provider operat es mechanisms w hich prevent
the physi cal, mental and financial abuse of users.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
19
Strengths Improvem ent & developments
The code of ethics for the personnel
of TMHC has been developed and
made available to the staff . Mem bers
of staff showed awareness about the
related ethic principles.
The policy includes princi ples to
prevent physical, mental and
f inancial abuse of persons ser ved.
Also procedures f or abuse
prevent ion have been developed.
The same principles are also
ref lected in the ser vice deliver y
processes of TMHC (support ing
ser vices and rehabilitation ser vi ces)
procedures.
TMHC evaluates its prevention
activities, draws up a summary and
ref lects the results in the annual
activit y report.
22. The social servi ce provi der provides services in a safe system of
w orking w ithin a safe environment to ensure the p hysical securit y of
persons served, their families and caretakers.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
TMHC provides services in a saf e The risk analysis (health and saf ety
system of working within a saf e evaluat ion) is conducted by the staff
environment. Risk assessments of of TMHC (the activit y is managed by
the work place have been conducted the health and saf ety
representat ive). Even though it has
20
and related action plans created. been done comprehensively, it could
ser ve usef ul to conduct this act ivit y
Health and saf ety system and saf e by an outside expert once in a while.
working procedures f or staff have This would enable to review the
been dr awn up. current methodology as well.
The physical secu rit y of persons Töökeskkonna riskianalüüsi viib läbi
ser ved and employees has been TMHC personal (väljaõ ppe saanud
ensured through these activit ies. töökeskkonna voliniku juhtimisel). Kuigi
see on tehtud suure põhjalikkusega,
võib aeg -ajalt osutuda kasulikuks
vastava töö läbiv iimine välise eksperdi
poolt. See annaks võimaluse ka
olemasoleva metoodika üle vaadata.
23. The social service provider defines, documents, monito rs and
evaluat es a set of principles, values and procedures that govern
behavi our in servi ce deli ver y containing aspects of confidentialit y,
accuracy, pri vacy and integrit y.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
The principles, values and
procedures in ser vice deliver y are
descr ibed in t he qualit y manual and
code of ethics.
It was demonstrated through the
inter views of staff that they ar e
aware of 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 t o them.
21
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
There is a policy regulating the
processing of delicate personal data.
Also special security requirements
have been established.
The principles are over viewed
regularly.
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 necessar y roles and
responsibilities are descr ibed in the
statue of TMHC, job descr iptions of
employees and job prof iles .
The relat ed roles and responsibilit ies
are presented in detail in the in the
ser vice deliver y processes of TMHC
(support ing services and
rehabilitat ion ser vices) procedur es.
Relevant inf ormation is available
also on the web pag e of TMHC.
22
26. The social service provi der w orks in partnership w ith other
organisations in the provision of servi ce 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
TMHC works closely with the
medical, work and social
organizat ions, as well as
prof essional organizat ions,
universities and ot her e ducational
inst itutions. It organizes meetings
and inf ormation days in order to
support the partners in the work wit h
people with mental health problems.
It has made a list of its cooperation
partners (available on home page) ,
grouped them by the f ield of
partnership and drawn up a
cooper ation matrix, which dives an
over view of all the partners and
helps in planning and analyzing
partnership relat ions.
TMHC has contracts wit h f inancing
bodies.
W ith cooperation partners var ious
projects and activities are organized,
which also ser ve the ne eds and
expectat ions of society.
TMHC ser ves also as the tr aining
base f or students, mainly f rom
Tallinn Universit y and Tallinn Healt h
Care College.
TMHC evaluates the cooper ation
23
related to the services delivered by
contract partners. F.e discussions
with partners during annual planning
process, also discussions of joint
development/ innovat ion projects,
etc. Minutes of meetings are
prepared.
A good over view of the cooperat ion
relat ions and act ivities is given in
the ann ual activit y r eport.
27. The social service provider w orks in partnership w ith persons
served, purchasers and other stakeholders in the development of
services.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
The persons ser ved, purchasers and
other stakeholders are involved in
the development of services of
TMHC through meeting s and
sur veys.
F,e in 2014 the survey of f amily
member of clients served was
conducted to gain f eedback about
their needs, expectations and
f eedback.
Feedback is asked both orally and
in a wr itten f orm. F.e cli ents’
questionnaires and sur veys;
meetings with f unding bodies etc.
Minutes of meetings are pr epared.
24
The measures of involvement ar e
descr ibed in the qualit y manual of
TMHC. Relat ed activities are shown
in the development plan f or 2012 -
2017 of TMHC and in the annual
plan.
The creation of communication
specialist position enables to put
more emphas is on not just
communicating what TMHC does, but
also sharing its knowledge, best
practices and experiences to others.
The partners showed high
appreciat ion to what TMHC does.
28. The social service provi der includes persons served as acti ve
partici pants in planning and have set up appraisal made up of on-
going 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 principles and procedures f or
the involvement of persons ser ved in
the management of the service are
descr ibed in the ser vice deliver y
processes of TMHC (support ing
ser vices and rehabilitat ion ser vices
procedures). The topic is also
covered in the qualit y manual of
TMHC.
Clients are involved in the ser vice
25
planning, deliver y and appra isal
procedure.
There regular meetings of clients
representat ions. Ideas and proposals
that are made there, reach t he
management.
The criterion was ver if ied sat isf ied
also through exploring client work
documentat ion and through
inter views with staff 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 measures, activities and polic y
f or client participat ion ar e agreed
with the persons ser ved. The clients’
rights to be involved in the
management of the ser vice are
descr ibed in t he r ights and duties of
the persons ser ved.
The policy and procedures f or
involvement are reviewed annuall y
and documented in the minutes of
meetings of the client representation.
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.
26
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 & de velopments
Empowerment of persons ser ved is
an integral part of ser vice 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.
Empowerment is described in the
qualit y manual of TMHC. T MHC uses
CARe (Comprehensive Approach of
Rehabilitation) methodolog y. In
developing the ser vices best
practices and contemporar y
approaches f rom diff erent countries
are used.
TMHC also off ers support in
ever yday lif e in a day care center on
clubhouse model.
TMHC has developed perf ormance
indicators to measure the results in
strengthening the empowerment of
persons being ser ved.
The criterion was ver if ied sat isf ied
through exploring client work
documentat ion and through
inter views with staff and clients.
31. The social service provi der operates specific mechanisms for
establishing an empow ering environment.
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 pr ogram
Strengths Improvem ent & developments
Empowerment of persons ser ved is
an integral part of ser vice 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. F.e CARe methodolog y
training. The results of activities ar e
disclosed in the annual activit y
report of TMHC.
32. The social servi ce provider sel ects p rogrammes 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
TMHC has an over view of the needs
of the persons ser ved ( wait ing lists ,
meetings wit h cooperation partners ,
clients’ f eedback, minutes of
meetings of client representations,
individual plans of persons ser ved).
The units of TMHC are located all
over Tallinn and well accessible . On
the home page of TMHC the maps
28
were presented showing the
locations of diff erent units.
33. The social service provider offers programmes consistent w ith
the identified n eeds 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
TMHC does cooperation with the
f unding bodies and has ascertain ed
the needs and expectations of them.
Contracts have been signed with
f unding bodies .
The needs of diff erent stakeholders
been discussed during meetings and
during daily cooper ation (though e -
mails, telephone) .
The success and results of the
exist ing ser vices have been
determined and is descr ibed in
activities’ reports.
Long-term strategic goals are
descr ibed in the development plan of
TMHC f or 2012-2017.
Inf ormation about various projects is
available on the home page of
TMHC.
34. The social service provi der operates indi vidual processes that
are dri ven by the needs of the person served.
29
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif icati on program
Strengths Improvem ent & developments
All related inf ormation is documented
in the individual plan s of the persons
ser ved, which was ver if ied by
examples of client documentation
seen during the site visit.
The process itself is described in t he
ser vice deliver y processes of TMHC
(support ing services and
rehabilitat ion ser vices procedures).
35. The social service provider documents the planni ng of services
based on the ident ification of indi vi dual needs and expectations of
persons served i n an Indi vidual Plan.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
The clients’ individual needs and
expectat ions are wr itt en down in the
individual plan s.
The individual plans involve all the
inf ormation set by the criter ion and
are agreed by the persons ser ved.
This was ver if ied by examples of
client documentation seen during the
site visit.
30
36. The social service provid er identif ies, documents, and maintains
the key servi ce deli very processes to the persons served in line w ith
its vision, mission statement and quali t y policy.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of th e EQUASS Assurance certif ication program
Strengths Improvem ent & developments
The main ser vice deliver y pr ocesses
of TMHC are: supporting ser vices
procedure and rehabilitat ion ser vice
procedure.
The service deliver y process es are
descr ibed shortly also on the hom e
page of TMHC.
The main ser vice deliver y pr ocesses
are in line with TMHC’s vision,
mission and qualit y principles.
All processes are regularly reviewed
by the internal audit processes.
37. The social service provi der review s this delivery p rocess and
maintains control over the deli very of t he servi ce.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
TMHC reviews the ser vice deliver y
process es through the internal audit
processes. Corresponding audit
reports are composed.
Procedures f or conducting internal
audits have been developed.
31
The main processes are reviewed
periodically.
Regular meetings, checks, reviews
and controls are conducted to assur e
maintaining control over the deliver y
of services.
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
TMHC ensures that the person s
ser ved can access a cont inuum of
ser vices as n eeds of persons served
are evaluat ed and descr ibed in
individual plans. According to the
individual plans, necessar y ser vices
are provided.
The continuation of service deliver y
is monitored and evaluated regular ly.
The auditor evidenced examples of
individual plans, minutes of meetings
and reports.
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
32
Strengths Improvem ent & developments
Annual act ivit y reports are
composed, which address the
continuum of services .
A register of obstacles in client work
has been developed to gather
inf ormation about possible incidents
and to learn f rom them.
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.
40. The social service provi der operates servi ces from a holistic
approach based on the needs and 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 me et
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
TMHC uses client - centered holist ic
approach, which is aimed to improve
client ’s qualit y of lif e.
The qualit y of lif e init iat ive’s
eff ectiveness is mea sured and
reported in individual plans .
CARe methodoly is used T MHC,
which a helpf ul tool in measuring the
qualit y of lif e of persons ser ved.
The criterion was verif ied f ulf illed by
also explor ing the client work
33
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 m eet
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 and job prof iles of
TMHC. These ar e evaluated annually
during employees’ perf or mance
evaluat ions and also dur ing regular
super visions, wor k methodology
instruct ions etc.
Trainings are provided to employees,
which was evidenced by training
plans of TMHC and came out f rom
inter views.
42. The social service provider identifies its b usiness results and
provides formal periodic and independent revi ew and procedures 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
TMHC has developed perf ormance
indicators to measure the results of
34
its activit ies.
Results are repor ted in annual
activit y reports, which are disclosed
on the web page of TMHC.
External r eviews ar e made by the
f unding bodies.
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 basi s.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
TMHC gathers and documents
inf ormation regarding results of
providing ser vices (both on
individual and collective basis).
This inf ormation is available in
individual reports and a summar y is
presented also in the annual act ivit y
report of TMHC, which is disclosed
on the hom e page of the
organizat ion.
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 meet
this cr iterion of the EQUASS Assurance certif icat ion program
35
Strengths Improvem ent & developments
TMHC evaluat es t he results and
added value of its work during
meetings and through clients’ and
other stakeholders’ surveys .
Related inf ormation is also ref lected
in the individual plans and
summarized in the annual act ivit y
report.
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 se r vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
TMHC organizes regular sur veys to
receive f eedback f rom the persons
ser ved and their f amilies.
Also the satisf action of other
stakeholders is evaluated by using
diff erent means like meetings,
questionnaires etc.
Feedback is disclosed on the home
page of TMHC.
46. The social service provider provides accessible and easil y
understandable records on outcome, including personal perceptio n
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
36
Strengths Improvem ent & developments
The records on outcome are
communicated to stakeholders, st aff
and persons ser ved.
Annual activit y r eports include
personal perceptions and
achievements.
Annual act ivit y r eports are disclosed
on the home page of TMHC.
47. The soci al service provider acti vel y disseminates organization
performance among its staf f, 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 Assurance certif ication program
Strengths Improvem ent & developments
TMHC reports its perf ormance to
f unding bodies, staff and ser vice
users.
Related inf ormation is also available
on the home page of TMHC.
Inf ormation is disseminated through
home page, H-web reports, activit y
reports to f unding bodies, strateg y
days (staff ), client representation
meetings, etc.
48. The social service provider has a standard procedure for
continuous improvement on the basis of an improvement cycle.
37
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif icat ion program
Strengths Improvem ent & developments
The PDCA cycle is used and
descr ibed in the annual planning
procedure of TMHC. Annual plans
are drawn up and ar e reviewed.
All the process and activit ies are
reviewed regular ly.
The results and perf orma nce of
TMHC is measured and descr ibed in
annual activit y reports.
All qualit y improv ement projects ar e
document ed. Inf ormation about them
is also available on the home page
of TMHC.
There is electronic database
development plan 2014 -2015.
49. The social service provi der identifies performance i ndicators for
measuring the results of the improvement actions.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
38
All improvement programs are
document ed, they include goals and
respect ive perf ormance indicators.
This was verif ied through inspecting
f ew examples during site visit.
F.e Hamet methodology to evaluate
the working knowledge o f the clients,
Jobpicsi tests f or clients.
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 m eet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
TMHC f inds ways of being
innovat ive, taking into account the
needs and expectations of
stakeholders. Best practices and
contemporar y approaches f rom
diff erent countries are used in
developing ser vices.
TMHC participates in diff erent
projects both in local and
international level.
F.e innovat ion project "The
development of exper ience
advisers"; project "Risk assessment
and management training program",
project "The communit y support f or
people with special needs" etc.
39
All related inf ormation was verif ied
to be documented and inf ormation
about the projects is also available
on the home page of TMHC.
4. Agreed additional development / improvements
The applicant decided on the following improvement actions and/or
additional development for the period of two years:
Short descript ion of the actions
(including SMART objectives)
1. criterion 4 The services of TMHC could be better descr ibed on the
home page of TMHC. On the web page f or services
(http://www. vaimnet ervis.ee/teenused/ ) the off ered
ser vices ar e listed and also inf ormation is provided,
which units provides what ser vices and what steps to
take to get the services.
For better communication it would be advisable to add
inf ormation there, what are the goals of these ser vices,
what do these ser vices consist of .
TMHC kodulehel võiks pakutavaid teenuseid paremini
kirjeldada. Teenuste lehel
(http://www.vaimnetervis.ee/teenused/ ) on esitatud loetelu
pakutavatest teenust est, teenuseid pakkuvat est
üksustest ja kuidas teenusele saada.
Parema kommunikatsiooni nimel oleks soovitatav lisada
lehele vastavat e teenuste eesmärgid ja sisukirjeldused.
Person responsible / vastutaja: kvaliteedijuht / qualit y
manager
Due date / tähtaeg: 20.11.2015
2. criterion 16 The rights and duties are explained to the clients and
they sign the contract conf irming they have got
acquaint ed to them. Still, it could ser ve usef ul to make
the rights and dut ies available also in easy to read
language or using visual components, that would help
the persons ser ved to understand and adapt them better.
Also, disclosing the rights and dut ies of persons ser ved
40
would be a step to m ore opened communication.
Teenuse saajate õigusi ja kohustusi selgitatakse
klient idele ning need on lisatud kliendiga sõlm itavasse
lepingusse, tõendamaks, et teenuse saaj a on nendega
tutvunud. Siiski oleks soovitatav klient ide õigused ja
kohustused teha kättesaadavaks ka lihtsamas
sõnastuses või visualiseer itud kujul, mis võimaldaks
teenuse saajatel neid paremini mõista ja omaks võtta.
Samuti oleks teenuse saajate õiguste ja kohustuste
avaldam ine asutuse kodulehel samm avatuma
kommunikatsiooni poole.
Person responsible / vastutaja: kvaliteedijuht / qualit y
manager
Due date / tähtaeg: 20.11.2015
3. criterion 20 To be more open to t he publicit y, it would be advisable
to disclose the ethical pr inciples of TMHC on its home
page.
Et olla rohkem avalikkusele avatud, oleks soovitatav
avaldada T MHC eet ilised põhimõtted asut use kodulehel.
Person responsible / vast utaja: kvaliteedijuht / qualit y
manager
Due date / tähtaeg: 20.11.2015
4. criterion 22 The risk analysis (health a nd saf ety evaluation) is
conducted by the staff of TMHC (the activit y is managed
by the health and saf ety representat ive).
Even though it has been done compr ehensively, it could
ser ve usef ul to conduct this act ivit y by an outside expert
once in a while. T his would enable to review the current
methodolog y as well.
Töökeskkonna riskianalüüsi viib läbi T MHC personal
(väljaõppe saanud töökeskkonna voliniku juhtimisel).
Kuig i see on tehtud suure põhjalikkusega, võib aeg -ajalt
osutuda kasulikuks vastava töö läb iviim ine välise
eksperdi poolt. See annaks võimaluse ka olemasolev
metoodika üle vaadata.
Person responsible / vast utaja: kvaliteedijuht / qualit y
manager
Due date / tähtaeg: 20.11.2015
41
5. Closing remarks
Tallinn Mental Health Cent er (TMHC) is a Tallinn Cit y social welf are
inst itution, established in 2000, that provides and develops var ious mental
health ser vices f or adults wit h psychiat ric special needs and their f amilies.
Their mission is to support the recovery process of persons with mental
health problems by off ering mental health ser vices wit h the highest qualit y
and sharing our knowledge about mental healt h.
The service provider helps the person with mental health pr oblems to have
the best possible qualit y of lif e, purpose and meaning of lif e and to f eel
oneself as a valued member of societ y.
TMHC off ers its clients comprehensive support which is based on
psychosocial rehabilitation principles and CARe ( Comprehensive Approach of
Rehabilitation) methodolog y.
TMHC consists of six units that are located all over Tallinn. Their main
ser vices are support in ever yday lif e in a day care center as well as
individually, using case management method; supported living; employment
support and a var iet y of rehabilitation services and programs.
The organizat ion has social wor kers, pshycologists, psychiatrists,
occupat ional ther apists, psychiatric nurses, support persons and
peer workers working in its team. TMHC provides ser vices f or over 700
clients with mental health problems annually. Ser vices are provided in
Estonian and Russian language.
TMHC has once alr eady gained EQ UASS Qualit y Assurance certif icate ( in
2011). Even though the cert if ication expir ed after two years, TMHC continued
to implement EQUASS qualit y pr inciples and was able to show results and
evidence of doing so.
TMHC is a well-managed social ser vice provider, with a visionar y leader in
f ront of the organization . The principles of process management, including
PDCA cycle and systematic impr ovement of all processes are integral to the
f unctioning of the organizat ion. The documentation of the TMHC is well
organized, correct and comprehensive.
Strategic and annual planning is in place and well -f unctioning. Perf ormance
indicators have been developed to measure the results, which are presented
along with oth er inf ormative data in the annual act ivit y reports.
The staff of TMHC is prof essional and continuously trained. For supporting
staff , a methodology guidance, supervision and work guidance are
42
systematically used, which helps to ensure the client center ed approach of
the TMHC ser vices (CARe). Thanks to supportive leadership, f lat
organizat ional structure and diff erent possibilit ies to be involved in the
decision-making process , the staff is hig hly mot ivated and also valued by the
management .
Inf ormation about TMHC is available f or all stakehol ders t hrough diff erent
channels. The organizat ion pays a lot of attention to raising the awar eness
of publicit y about m ental health issues. It f unctions as a competence center
of mental health issues, shar es its experi ences and knowledge and trains
interest ed parties.
TMHC implements holist ic and person -centered appr oach in its ser vice
provision, taking into account pr esent and f uture needs of both service users
and the societ y in general. The persons ser ved are system aticall y
empowered and the aim is to raise the qualit y of their lives.
The service provider does intense and f ruitf ul co -operation with local
partners and also abroad. F.e it partners with local gover nment and NGOs (in
policy-making), wit h establishments of higher educat ion and hospitals in
research and development projects. There are numerous innovat ion projects
that ser ve the interests of the persons served and also the communit y and
wider societ y.
The audit or exper ienced on site that t he social ser vice provider T MHC
perf orms in compliance with t he EQUASS Assurance criter ia. The
inter viewed representatives of partners, f inancing bodies, employees of
TMHC and persons served conf irmed this, which was ref lected in their
satisf action. They were especially sa tisf ied with the person -centered
approach, wide range of activities, pleasant and car ing personnel and the
var iet y of locations.
During the audit the organization showed many examples of best pr actice,
especially in the f ield of person center ed approach , involvement of staff,
co-operat on with par t ners in Estonia and abroad and innovat ive thinking and
acting .
The whole staff was kind and cooperat ive in introducing the work of TMHC,
f inding necessar y evidential mater ials and shar ing inf ormation about f ulf ill ing
EQUASS cr iteria.
43
For the per iod of following two years, some improvement actions were
agreed that are brought out i n part 4 of the audit report. An over view of
suggestions f or improvement that are mentioned under the specif ic criter ia is
given as well in part 3.
The improvement areas included in general communicating diff erent
inf ormation through the web page of TMHC. An idea was given to present the
rights and duties of persons ser ved in easy language or using visual aid.
Also a suggestion was made t o outsource the health and saf ety r isk analysis
to get an external view.
After verif ication of the indicators by r eviewing documentation, conduct ing
inter views and performing site visit, the auditor was conf irmed that the
criteria f or qualit y assurance of the European Qualit y f or Social ser vices
were f ulf illed. The auditor was convinced that TMHC is devoted to qualit y
assurance and improvem ent in its work and delivers ser vices of high qualit y.
***
Tallinna Vaimse Tervise Keskus (TVTK) on 2000. aastal loodud Tallinna linna
sotsiaalhoolekandeasutus, mis pakub ja arendab vaimse tervise teenuseid
psüühilise erivajadusega inimest ele ja nende peredele. Nende missioon on
toetada psüühilise erivajadusega inimese taastumist, pakkudes kvaliteetseid
vaimse ter vise teen useid ja jagades teadmisi oma valdkonnast.
Teenuse osutaja aitab psüühiliste er ivajadustega inimest ele pakkuda parimat
võimalikku elukvaliteeti ning anda nende elule eesmärk ja tähendus, et nad
saaksid ennast tunda ühiskonna väärtuslike liikmetena.
TVTK pakub oma klient idele nende individuaalsetest vajadustest lähtuvat
igakülgset toetust. Asutuse töö põhineb kõikehõlmava psühhosotsiaalse
rehabilitatsiooni ehk CARe ( Comprehensive Approach of Rehabilitation )
metoodikal.
TVTK koosneb kuuest üksusest, mis asu vad üle Tallinna. Nad osutavad
järgmisi teenuseid: igapäevaelu toetamise, toetatud elam ise ja töötamise
toetamise teenus ning er inevaid rehabilitatsiooniteenus eid ja -programme.
Asutuse meeskonda kuuluvad sotsiaalt öötajad, psühholoogid, psühhiaatrid
tegevust erapeudid, psühhiaatriaõed, tegevusjuhendajad ning
kogemusnõustajad. TVTK pakub aastas teenuseid üle 700 -le psüühilise
erivajadusega inimesele. Teenuseid pakutakse nii eesti kui ka vene keeles.
TVTK on kord juba EQUASS Assurance sertif ikaadi saanud (2 011. aastal).
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Kuig i sert if ikaat aegus 2011. aastal, jätkas TVTK kvalit eedisüsteemi
põhimõtete rakendamist ning näitas ette sellkohaseid tõendeid ja tulemusi.
TVTK on häst i juhitud sotsiaalteenuse osutaja, mille eesotsas on visionä ärist
liider. Protsessijuh timise põhimõtted, sealhulgas PDC A tsükkel ja
süstemaat iline pare ndamine, on lahutamatud organisatsiooni t oimim ise osad.
TVTK dokumentatsioon on hästi organiseeritud, korrektne ja täielik.
Strateegiline ja iga -aastane planeer imine on paigas ja hästi toim i v.
Tulemuslikkuse mõõtmiseks on välja töötatud tulemuslikkuse näitajad, mis
esitatakse koos teiste inf ormatiivsete andmetega iga-aastases
tegevusaruandes.
TVTK töötajad on prof essionaals ed ja neid koolitatakse pidevalt. Personali
toetamiseks kasutatakse süstemaatiliselt metoodi list juhendamist,
super visiooni ja t öö juhendam ist, mis aitavad tagada kliendikeskse
lähenem isviisi TVTK teenuste osutamisel (CAR e). Tänu toetavale
juhtimisele, lamedale organisatsiooni struktuurile ja erinevatele
otsustusprotsessis k aasam ise võimalust ele on töötajad kõrgelt motiveer itud
ja ka hinnatud juhtkonna poolt.
Teave TVTK kohta on saadaval kõikide le sidusrühmade le eri kanalite kaudu.
Organisatsioon pöör ab suurt tähelepanu avalikkuse teadlikkuse tõstmis ele
vaimse ter vise teema valdkonnas. Asutus toimib vaimse ter vise
kompetentsikeskus ena, jagab oma kogemusi ja teadmisi ning koolitab
huvitatud isikuid .
TVTK rakendab terviklikku ja teenuse saaja keskset lähenemist oma
teenuste osutamise l, võttes ar vesse nii t eenuse saajate kui ka laiema
ühiskonna praegusi ja tulevasi vajadusi . Järjepidevalt tegeletakse teenuse
saajate jõustamisega ning eesmärk on tõsta nende elukvaliteeti.
Teenusepakkuja teeb intensiivset ja vilj akat koostööd kohalike partneritega
ja ka välispartneritega. Näiteks t eeb ta koostööd kohalike omavalitsuste ja
mittetulundusühingut ega (õigusloomes ), t eeb koos kõrgkoolide ja haiglate ga
teadus- ja arendusprojekte. TVTK-l on mitmeid innovatsioonipr ojekte , mis
teenivad nii teenuse saajate huve kui ka kogukonna ja laiema ühisk onna
huve.
Kohapeal koges audiitor, et sotsiaalteenuse osutaja TVTK tegutseb
vastavuses EQUASS Assurance kriteer iumit ega. Intervjuud huvigruppide ja
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rahastajate esindajatega, TVTK töötajatega ja teenuse saajatega samuti
kinnitasid seda, m is väljendus nende rahulolus. Er iti r ahul oldi isikukeskse
lähenem isega, tegevuste ar vukusega, meeldiva ja hoolitsev a personaliga
ning erinevat e asukohtadega.
Auditi käigus oli asutusel ette näidata mitmeid parimaid praktikaid ja
saavutusi EQ UASSi põhimõtete täitmisel , eelk õige isikukeskses
lähenem ises, personali kaasam ises , koostöös nii Eestis kui välismaal ning
innovaat ilises mõtlemises ja käitumises .
Kogu asutuse töötaj askond oli lahke ja koostööaldis TVTK töö tutvustam isel,
vaj aliku tõendusmat erjali leidmisel ning inf or matsiooni jagamisel EQUASS - i
kriteeriumit e täitmise kohta.
Järgnevaks kaheks aastaks lepiti kokku mõned parendustegevused, mis on
välja toodud aruande 4 -ndas osas. Ülevaade par endussoovit ustest
konkreetsete kriteeriumite lõikes on esitatud ka aruande 3- ndas osas.
Parendusvaldkonnad hõlmasid üldises plaanis erineva inf ormatsiooni
avaldam ist TVTK kodulehel. Anti edasi idee t eenuse saajate õigused ja
kohustused lihtsas sõnastuses ja visualiseeritud kujul esitada. Samuti t eht i
ettepanek tööter vishoiu - ja ohutuse risk ianalüüs sisse osta välise mõõtme
saamiseks.
Pärast indikaator itele vastam ise tõendamist, tutvudes dokumentatsiooniga
ning viies läbi inter vjuud, oli audiitor veendunud, et kriteeriumid Eur oopa
kvaliteedimärgi jaoks sotsiaalteenustes on täidetud. Audiitor sai
veendumuse, et TVTK on pühendunud oma töös k valit eedi tagamisele ja
täiustam isele ning osutab kõrge kvaliteediga teenuseid.
Tallinn, 19. 05.2015
Mar iliis Männik -Sepp
EQUASSi auditor / EQUASS auditor
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Maarika Aro
Saatja: Maarika Aro
Saatmisaeg: 22. mai 2015. a. 9:24
Adressaat: 'guusbeek'; 'Marie Dubost'
Koopia: Keiu Talve
Teema: Tallinna Vaimse Tervise Keskuse audit report
Manused: Additional_Information _Form_TVTK.doc; EQ_Audit Report_TVTK_2015.doc;
EQUASS_taotlusvorm_TVTK2015_.xlsx; Asutuse auditi külastuse
ettevalmistus_TVTK.docx
Dear Marie, Dear Guus,
Attached you’ll find an audit report and other documents of Tallinna Vaimse Tervise Keskus EE2015-004.
Please let Keiu to know in case there are some comments about the report.
Best regards,
Maarika Aro
Sotsiaalteenuste kvaliteedi keskus
Arendusspetsialist
Astangu Kutserehabilitatsiooni Keskus
tel +372 687 7223
mob +372 521 3563
[email protected]
Astangu 27 Tallinn 13519
www.equass.ee
www.astangu.ee
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