EQUASS ASSURANCE APPLICATION
ADDITIONAL INFORMATION
1. Short information about the organisation in the nati ve language
S A H aa ps al u N eu r o l oo g il i n e Re h ab i l it a ts i o on ik es k us (H NR K) on ra hu l ik us
l oo d us k au nis üm br us k on n as p aik n e v ta as tus ra v ih a i gl a , m is pak u b t aas t us ra v i- j a
reh a b i li t ats i oo n it e en us e id . HN R K o n s uu n an u d e nd a t eg e v us e k olm e le p õ h il is e l e
s i ht gru p i l e: p e aaj uk ahj us t us eg a i n im es e d, s e lj a aj uk ahj us t us e g a i n i m es ed n i ng
ne ur o lo o g il is te pr o b l e em id eg a l a ps e d .
HN RK - l on k aas a egs et e te a dm is te g a n i ng e n tus i as t l ik m ees k on d, t än a pä e v as e d
v ah e nd i d j a r u um id n i n g r o hk em k ui p o ol e s aj an d i p ik k us ed k o g em us ed , m i da
k lie n ti d eg a t eg e l em is e l k as ut at ak s e. H NR K p eam is ek s e es m ärg ik s on k v al i te e ts e
tõ e nd us põ h is e k l ie n d i k es k s e j a t er v ik l ik u t e en us e p ak k um ine .
L is ak s ig a pä e v a s e l e r a v it öö l e o n HN R K us al dus v ä ärs ek s prak t ik ab aas ik s n o ort e l e
s pe ts ia l is ti d e le ni n g h eak s par tn er ik s er i n e v at es t ea d us - j a ar en d u s proj ek ti d es .
2. Short information about the organisation in English (acti vities,
clients, etc.)
Ha a ps a l u Ne ur o lo g ic a l R eh a b i l i ta t io n C e ntr e is a re h ab i l it a ti o n h os p it a l l oc a te d i n
na t ura l l y b e au t if u l s ur r ou n d in gs . T h e hos p it a l pr o v id es re h ab i l i ta t io n s er v ic es f or
c h il dr e n an d a d ul ts s u f f er in g f r om v ar ie t y of ne ur o lo g ic al c on d it i o n s . T h e m aj or
tar g et gr o up is p eo p l e wi t h s p in a l c or d i nj ur y or br a in inj ur y, a l it t le l es s er am o un t
ha v e pr o gr es s i v e n er v e - c o n d it i ons , m u lt i p le tra um as , a nd c on g en i t a l de v e l opm en t al
d is or d ers .
Ha a ps a l u Ne ur o lo g ic a l R eh a b il i ta t io n C e ntr e has k no wl e d ge a b le a n d e nt hus i as t ic
s taf f , m od er n f ac i l it i es a n d l on g- term ex p er ie nc es . T h e m a in aim of t he hos p it a l is
to pr o v i de e vi d enc e - b as e d p at i e nt - c e ntr e d r eh a b il i ta t io n wi th h i g h qu a l it y.
In a d d it i on t o e v er yd a y wo r k wit h p at i en ts t h e h os p i ta l is a trus t wo rth y p rac t ic a l
s et t in g f or yo u n g s p ec i al is ts a nd a go o d p ar t ner in dif f er e nt s c i e nc e - a nd
de v e l opm en t pr oj ec ts .
Num ber of p er s ons s er v ed : 25 7 0 i n - p a ti e nt c as es an d 1 49 6 o ut - p at i en t c as es
dur i n g th e ye ar 2 0 14 .
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Num ber of s t af f : 1 3 8
3. Name of the organisation as you w ould w ant it to appear on the
EQU ASS Assurance certificate
Ha a ps a l u N e ur o l o o g il i n e R e ha b i li t ats i o on ik es k us (H a aps a l u N e uro l o gic a l
Re h ab i l it at i o n Ce n tr e)
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 certific ate:
Neuro-rehabilitat ion
5. Organisation’s logo
(At t ac h e d)
Information to be published on EQUASS website:
Na me of th e o rg an is a t ion: Ha a ps a l u N eur o l og ic a l Re h ab i l it a ti o n Ce ntr e
Po st ad dr e ss: S ad am a 1 6 Ha a ps a l u 9 05 0 2 Es t o n ia
Di re cto r: Pr i it E e lm äe
Cont ac t p e rs on: K a dr i E n gl as
E- m a il (c ont act p e rso ns) : k adr i. e ng l as @ hnr k .ee
W eb: www. h nr k .e e
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EQUASS ASSURANCE
ASUTUSE KÜLASTUSE
ETTEVALMISTAMISE VORM
Asutuse külastus: 17-18. märts 2015
Haapsalu Neuroloogiline Rehabilitatsioonikeskus
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 a lus t at i EQ U A S S i r ak en d am is e ga ja m i da on k va l it e e d i s üs t e 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 te i n ud t ee n us t e k v a l it ee d i t ag am i s ek s j a t õs tm is ek s om a as u t us es
pär as t ee lm is t EQ UA S S i a ud i ti t ?
3. M il l is e d on as u tus e h u v i gr u p i d? Ke l l eg a j a m il l is t k oos t ö öd as u tus t eh ak s e n in g
k uid as o n v ä lj a s e l g i t a tu d h u v igr u pp i d e oo t u s ed ?
4. K ui d as s a a va d er i n e va d h u vi gr u pi d os a le d a t ee n us t e ar e nd am is e l ?
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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
As ut us e ju h t
Huv i gr up i d
P er s o n a l
Juht im in e 1. K ir j e l d ag e Teie as ut us e j u h tim is e
k or ral d us t j a a as t as e p l an e er im is e x
k or ral 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 ui da s o le te x x
ne n des t t ea d a s aa n u d ?
5. K as T e i lt o n k üs it u d j a k ui d as o n T e i l
v õ im al ik a n 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 o gu 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
x
üh is k o nn a v aj a d us t e le / k og uk on na l e
s uu n at u d te g e vus i o l et e k orr a ld a nu 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 )?
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2. K ui d as k a as a t ak s e p er s on a l i
te e nus te pl a ne er im is s e, ar e nd am is s e x x
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 ?
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4. Ku i das i nf orm eer it a k s e te e nus e
s aaj at õi g us es t s a a da ees tk os tj at võ i
x x
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
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 ?
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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
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 ?
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2. K ui d as o l et e r a hu l t e e nus e pak k uj a x
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 er s 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 l um e a u di i t or i j aok s va lm is p an na t a ot l us d ok um end is m ärgi t ud
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
J uh a tus e es im ees : Pr i i t E elm ä e 45 m in ut i t
Personal Kestvus
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Ar en d us - j a k v a l it e ed ij uh t : Ka dr i E n g las 60 m in ut i t
P ers o n a l: K ok k u in te r vj u ud 60 m i nu t it
A ndr es K uk k - s ots i a al tö öt aj a
A in a T õn ut ar e - v an em õd e
Ri i n a M õim - f üs i ot er a pe u t
Teenuse saajad Kestvus
G ru pi i nt er vj uu (3-5 er in e v a t ee n us e K un i 4 5 m i nu t it
s aaj at ; as u tus e es in d a j a võ i b v aj a dus e l
j uur es v i i b id a)
Teised huvigrupid Kestvus
K oos tö ö p ar t ne r i d : K un i 4 5 m i nu t it
T rii n L a as i - T al l i nn a Ül ik o ol i Ha a ps a l u
K ol l e d ži d ir ek to r
Mo n ik a H auk a nõm m - Ees t i Pu u et eg a
In im es t e K oj a ( E PI K) j uh t ( v i a Sk yp e )
Ra h as t aj a : 30 m in ut i t
K alj o Po l d o v, Ees t i H a ig ek as s a P ärn u
os ak o nn a j u ht
4. Asutuse külastuse ajakava
17 . 03 .2 0 15 P äev 1
Ae g T egev us ( l üh ik e k irj e l dus )
10 . 00- 1 0. 1 5 A v ak oos o lek
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10 . 15- 1 3. 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 , r in gk ä ik
13 . 45- 1 4. 4 5 In ter vj u u ar en d us - j a k v a li t ee d ij u h i ga
14 . 45- 1 5. 0 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 . 00- 1 5. 3 0 In ter vj u u r a has taj a ga
15 . 30- 1 6. 3 0 In ter vj u u p er s o n al i g a
16 . 30- 1 7. 0 0 Dok um en ta ts io o ni ül e v aa t us , vorm i de t ä itm i n e
18 . 03 .2 0 15 P äev 2
Ae g T egev us ( l üh ik e k irj e l dus )
9: 0 0- 9 .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
9. 3 0- 1 0. 1 5 In ter vj u u k o os t öö p art n er it eg a
10 . 15- 1 1. 0 0 Dok um en ta ts io o ni ül e v aa t us , vorm i de t ä itm i n e
11 . 00- 1 2. 0 0 In ter vj u u te e nus e s a aj at e ga
12 . 00- 1 3. 0 0 Lõ u na p aus
13 . 00- 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
13 . 30- 1 4. 1 5 In ter vj u u j uh a tus e es i m eheg a
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: 17.-18.03.2015
Haapsalu Neuroloogiline Rehabilitatsioonikeskus
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 Haapsalu Neuroloogiline
service provider Rehabilitatsioonikeskus (Haapsalu
Neurological Rehabilitation Centre)
(hereinafter HNRK)
Address: Sadama 16, Haapsalu 90502
Post box: N/A
Person responsible Priit Eelmäe, Chairman of the Board
(CEO):
Contact person: Kadr i Englas, qualit y manager
Phone: (+372) 47 25 400
Fax: (+372) 47 25 401
E-mail: inf
[email protected]
Web site: http://www.hnrk.ee/
Name of Auditor: Mar iliis Männik -Sepp
Dates of audit: 17.-18.03. 2015
Clients: Number of person served: 2570 in-patient
cases and 1496 out -patient cases dur i ng the
year 2014
Staff: Number of staff : 139
including 21 part time and 14 contracted
Services: Rehabilitation ser vice
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2. Audit program
17.03.2015 Day 1
Time Acti vit y
10.00-10.15 Opening meeting
10.15-13.45 Documentation review
13.45-14.45 Interview with qualit y manager of HNRK – Kadr i
Englas
14.45-15.00 Documentation review, up -dat ing f iles
15.00-15.30 Interview with f inancing body – Kaljo Poldov, head of
Eesti Haigekassa (Estonian Health Insur ance Fund)
Pärnu department
15.30-16.30 Interview with staff :
Andres Kukk – social worker
Aina Tõnutare - senior nurse
Riina Mõim - physiot herapist
16.30-17.00 Documentation review, up -dat ing f iles
18.03.2015 Day 2
Time Acti vit y
9.00-10.00 Interview with cooperation partners:
Triin Laasi – direct or of Tallinna Ülikooli Haapsalu
Kolledž (Tallinn Universit y Haapsalu College)
Monika Haukanõmm – chairman of the board of Eesti
Puuet ega Inimeste Koda (The Estonian Chamber of
Disabled People)
10.00-11.00 Documentation review, up -dat ing f iles
11.00-12.00 Interview with persons ser ved - Tõnis Lepik, Katrin
Heli, Kalle Saar ja Raili Rosenberg
3
12.00-13.00 Lunch break
13.00-13.30 Documentation review, up -dat ing f iles
13.30-14.15 Interview with the chairman of the board – Priit
Eelm äe
14.15-16.30 Documentation rev iew, up-dat ing f iles
16.30-17.00 Interview with qualit y manager of HNRK - Kadri
Englas
17.00-17.30 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 of
HNRK are stated in the employees’
manual and on HNRK’s website
http://www.hnrk.ee/ .
The employees of HNRK
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 missio n values on ser vice
provision.
4
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 socia l ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
The qualit y standard and
commitment to continuous
improvement of HNRK are stated in
the employees’ manual .
The long -term goals of HNRK are
descr ibed in the organizat ion’s
development plan.
It appeared f rom the inter views that
the staff of HNRK is knowledgeable
of the qualit y standard 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.
HNRK gained the certif ication of
EQUASS Assurance in 2011 f or the
f irst time.
3. Persons served, famil y members and servi ce user organisations are
able to give feedback on their individual and collecti ve exp erience of
programmes and services.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
5
HNRK has developed diff erent
methods to ask and receive f eedback
f rom persons served, staff and
stakeholders.
For example f rom f unding bodies
f eedback is received though audits
(f.e Estonian Health Insurance Fun
and 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
(annual) staff satisf action sur veys
are conducted as well.
Results of sur veys are analyzed and
summarized.
4. The social service provider i nforms all stakeholders about the
offered programmes and services avai lable.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
HNRK has inf ormed all possible
stakeholders about its services using
a variet y of methods and
approaches.
This is done thr ough important
cooper ation partners, brochures,
webpage of HNRK et c.
6
F.e the development plan, annual
reports and inf ormation about the
ser vices of HNRK is available on t he
webpage. The annual act ivity plans
are presented to the staff. For staff
most important inf ormation has been
gathered inf o “employees’ manual”,
which is available f or all staff
members.
The persons ser ved can review most
important inf ormation f rom “client ’s
inf ormation booklet”, which they f ind
in their room and f rom inf ormation
screens in the rooms of HNRK.
Quarterly magazine “ Keskustelu” is
issued, which is distr ibuted to
cooper ation par tners, staff and
persons ser ved.
Stakeholders are aware of the
ser vices of HNRK, which was ver if ied
implemented through inter views wit h
persons ser ved, staff and partners.
5. The social service provider management establishes and
documents an annual pl anning and review process.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
The annual planning and review
process is integrat ed into the
management process of the
organizat ion.
7
The process has been descr ibed in
the employees’ manual . The process
is reviewed regularly.
There are annual action plans , which
are reviewed quarterly dur ing
“improvement meetings”. Minutes of
the meeti ng are made 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 achieving the annual targets
monitoring of the performance of the organisation in me eting 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 planning process of The criterion is f ulf illed, but there is
HNRK has a cyclic character. The slight room f or improvem ent in the
annual work plan includes wording of goals and object ives –
objectives, key act ivities, tangible they should always express the
results and targets. desired change / expected situation
and not be expressed as activit ies.
The annual plan is approved by the The def iciency was not all-per vading ,
board. but appeared randomly.
Kriteer ium on täidet ud, kuid
eesmärkide sõnasta mise osas on
natuke arenguruumi – eesmärgid
tuleks alati sõnastada soovitava
muutusena / oodatava olukorrana,
mitte sõnastatuna tegevustena.
8
Puudus ei olnud läbiv, vaid esines
pisteliselt.
7. The social servi ce provider demonstrates organisation’s succes s
in satisf ying the needs and expectations of the societ y.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
Feedback f rom diff e rent stakeholders
is collected and used to improve
HNRK’s ser vices. HNRK has dr awn
up the scheme of feedback system
and wr itten down related act ivit ies.
Communicat ion strategy has been
developed and is descr ibed in the
employees’ manual.
HNRK collects inf o rmation about the
media r eleases concerning its
activities.
The waiting list f or rehabilitation
ser vices shows the high demand f or
the treatments delivered by HNRK.
HNRK does tight cooperat ion with its
f unding bodies, educat ional
inst itutions, Estonian Cha mber of
Disabled People etc.
Var ious projects and activit ies are
organized with cooperation partners ,
which also ser ve the ne eds and
expectat ions of society.
9
8. The social service provider demonstrates organisati on’s social
responsibilit y t hrough acti vi ties contri buting to the societ y.
Remark from the auditor:
The services of the social ser vice providers meet this criter ion of the
EQUASS Assurance certif ication program
Strengths Improvem ent & developments
HNRK has demonstrated social
responsibilit y through diff erent
activities contr ibut ing to the societ y.
F.e it has opened The Center of
Adapt ive Devices in its prem ises,
off ers rehabilitation ser vices to
inhabitants of Hiium aa (island), does
tight cooperation with Haapsalu
College to teach students an d to
ser ve as a training base f or the
students.
HNRK in cooperation with its
partners has conducted sever al
sur veys, f .e a study about young
athlet es, also a study about the
possibilit y to move in Haapsalu wit h
wheel-chair.
HNRK has org anized several
train ings (f .e NDT training) and has
taught the caregivers of Haapsalu
Kutsehar iduskeskuse (Haapsalu
Vocat ional Education Centre ).
HNR has been involved with the
establishment of Terviseedenduse ja
Rehabilitatsiooni Kompetentsikeskus
(Centre of Excellence of H ealth
10
Promotion and Rehabilitat ion).
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
Staff policy (including staff
recruitment and retention
procedures) has been developed.
All employees have indi vidual job
descr iptions, which include required
knowledge, skills and competences.
Staff development and training
principles have been developed and
annual training plans are drawn up.
It appeared f rom the inter views wit h
the personnel that t hey all are w ell
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. The social service provider operates in compli ance w ith
mandator y national le gislation, 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 EQU ASS Assurance certif ication program
11
Strengths Improvem ent & developments
The documentat ion of HNRK meets
legal r equirements and is reviewed
to do this. The staff level is kept at
optimum and this is reviewed also
regularly.
The working condit ions are evaluated
(risk assessments are carried out)
and necessar y amendments are
made.
The principles f or showing
recognit ion to employees are
descr ibed in staff motivat ions and
recognit ion policy and employees are
given recognitions f or outstanding
perf ormance.
11. The social service provider trains all staff based on a plan for
leaning and development and evaluates the effecti veness of the
training.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assur ance certif ication program
Strengths Improvem ent & developments
Staff development and training
principles have been developed,
which are described in the
employees’ manual.
Annual training plan s are drawn up
based on the needs of the
employees and expe ctat ions of
12
HNRK.
The staff of HNRK is trained
regularly and all the inter viewed
employees showed high appreciat ion
concerning the trainings received.
Feedback on trainings is collected
and training inf ormation is gathered.
The eff ectiveness of the traini ngs is
then evaluated.
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
annually.
Regular perf ormance reviews are
carried out wit h staff member, during
which their competences ar e
evaluated.
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
13
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 se rvices
is described in the employees’
manual.
HNRK recognizes staff as a usef ul
tool f or gaining inf ormation. It has
regular staff meetings.
Sur veys concer ning the movement of
inf ormation and sat isf action of staff
have been carried out in HNRK.
Feedback has also been collected
through staff perf ormance reviews.
14. The social service provi der has mechanisms in place to enhance
satisfaction and motivation of staff
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
Staff evaluations, staff
questionnaires and annual
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 recog nit ion policy.
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 the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
HNRK has developed the rights and
duties of persons ser ved, which
conf orm to international human
rights convent ions. They ar e
introduced t o persons ser ved by staff
(nurse) and are available in the
client ’s inf ormation booklet.
The staff and persons ser ved
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 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
HNRK has developed the rights and
duties of persons served, which ar e
introduced to clients by staff (nurse).
They are wr itten down in client ’s
15
inf ormation bookle t. Clients sign a
document conf irming that they are
aware of their r ights and dut ies.
The staff and clients demonstrated
their knowledge of the rights and
duties through the interviews.
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
HNRK has developed a procedure f or
handling praises and complaints.
This part of the f eedback system.
If was verif ied during the inte rviews
that the persons served and other
relevant stakeholder s were awar e of
the ways of praising and
complaining.
It is possible to give related
f eedback f.e thought the webpage of
HNRK. All complaints are dealt wit h
and answered (if they include
names).
18. The social service provider respects the fundamental right to
self-determination of the person served. They freel y det ermine their
political status and freel y pursue their economic, soci al and cultural
development.
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
Related pr inciples are part of the
code of ethics and are also
descr ibed in “the general pr inciples
of the treatment of patients ”.
HNRK pr ocesses and procedure have
been prepared, taking into account
the persons’ ser ved right to self -
determination.
Feedback is collected though clients’
sur veys.
It became evident through the
inter views that the staff was aware of
this issue and the persons ser ved
were handled wit h respect.
19. The social service pr ovi 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 need f or a supporting person is
discussed with the persons ser ved
by the social wor ker and related
inf ormation is presented in individual
plans.
17
The criterion was verif ied f ulf illed by
the evidence f ound in client work
documentat ion and interviews.
The work of social workers is
evaluated dur ing annual perf ormance
reviews.
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 fr om 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 for the personnel
of HNRK has been developed and
made available to the staff . Mem bers
of staff showed awareness about the
related ethic principles.
The policy respects and assures the
dignit y of the persons ser ved,
protects them f rom undue r isk and
promotes social justice.
New staff members are introduced
the ethical pr inciples during the
induction training and they give their
signature conf irming that they have
read and understood the code of
ethics.
21. The social service provider operat es mechanisms w hich prevent
the physi cal, mental and financial abuse of users.
18
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 for the pers onnel
of HNRK has been developed and
made available to the staff . Mem bers
of staff showed awareness about the
related ethic principles.
The policy includes principles to
prevent physical, mental and
f inancial abuse of persons ser ved.
Feedback concerning th is issue is
collect ed dur ing the clients’ sur veys.
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 social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
HNRK provides services in a saf e
system of working within a saf e
environment. Risk assessments of
the work place have been conducted
and related action plans created.
Health and saf ety plan and
procedures to ensure a saf e
environment and physical secur it y of
persons ser ved have been drawn up.
The physical securit y of persons
19
ser ved and employees has been
ensured through these activit ies.
23. The social service provider defines, documents, monitors and
evaluat es a set of principles, values and procedures that govern
behavi our in servi ce deli ver y containing aspects of confidentialit y,
accuracy, pri vacy and integrit y.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
The principles, values and
procedures in ser vice deliver y are
descr ibed in the employees’ 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 to them.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
There is a policy regulating the
processing of delicat e personal data.
The principles are over viewed
20
regularly.
25. The social service provider defines the roles and
responsibilities, authorities and the interrelatio n 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
Strengt hs Improvem ent & developments
The necessar y roles and
responsibilities are descr ibed in the
statue of HNRK, job descriptions of
employees and employees’ manual .
Relevant inf ormation is available on
the web page of HNRK.
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
HNRK does a lot of cooper ation wit h
its partners. It has made a list of its
cooper ation partner s (available on
the webpage) .
HNRK has contracts with f inancing
bodies and maj or cooperation
partners.
W ith cooperation partners var ious
21
projects and activities are organized,
which also ser ve the ne eds and
expectat ions of society.
F.e project “back to work” with
Töötukassa, (applying f or adaptive
devices), cooperation with Tartu
Universit y Hospital Children’s Fund,
etc.
HNRK ser ves also as the training
base f or the students of Tallinn
Universit y Haapsalu College.
HNRK evaluates the cooperat ion
related to the services delivered by
contract partners. F.e discussions
with partners during annual planning
process, also discussions of joint
development/ innovat ion proj ects,
etc.
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 EQUA SS Assurance certif ication program
Strengths Improvem ent & developments
The persons ser ved, purchasers and
other stakeholders are involved in
the development of services of
HNRK thr ough meeting s and
sur veys. Feedback is asked both
orally and in a writt en f orm. F.e
clinets’ questionnair es and sur veys;
22
meetings with f unding bodies etc.
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 dialog ue 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 E QUASS Assurance certif ication program
Strengths Improvem ent & developments
HNRK has f or exam ple the f ollowing
procedures, that cover the
involvement of person s ser ved :
general principles of treatment of
patients, policy f or inpatient
treatment, f eedback system.
There is also a special policy
concerning the inf orming and
involvement of persons ser ved.
Clients are involved in the ser vice
planning, deliver y and appraisal
procedure.
The criterion was ver if ied sat isf ied
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.
23
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 served or
representat ives of persons ser ved.
They ar e descr ibed in the
employees’ manual of HNRK.
On site the auditor was able to read
the minutes of “improvement
meetings” and also to see the results
of several audits / checks / reviews,
which covered this t opic.
30. The social service provi der operat es 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 oviders meet
this cr iterion of the EQUASS Assurance certif ication pro gram
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.
Empowerment is described in the
employees’ manual of HNRK. It is an
integral part of the client work, which
is also descr ibed in the “g ener al
principles of treatment of patients ”
24
and in “the policy f or inpatient
treatment”.
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.
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 integral part of ser vice deliver y.
Related act ivities were evidenced in
ser vices’ deliver y pr ocess es 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 FI M tr ainings f or staff.
32. The social servi ce provider sel ects program mes 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 icatio n program
Strengths Improvem ent & developments
HNRK has an over view of the needs
of the persons ser ved ( wait ing lists ,
25
meetings wit h cooperation partners ,
clients’ f eedback, individual plans ).
The locat ion of HNRK is ver y
pleasant and well accessible . All the
ser vices are delivere d at the sam e
complex, which is very convenient.
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
HNRK does coo peration with the
f unding bodies and has ascertain ed
the needs and expectations of them.
Contracts ha ve been signed with
f unding bodies; st udents' pract ice
needs have been ascertained, etc.
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.
34. The social service provi der operates indi vidual processes that
are dri ven by the needs of the person served.
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 & 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 the
organizat ion’s policies and
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 in an Indi vidual Plan.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
The clients’ individual needs and The criterion is f ulf illed, but there is
expectat ions are wr itten d own in the slight room f or improvement in the
individual plan s. wording of specif ic measurable
objectives The def iciency was not
The individual plans involve all the all-per vading , but appeared
inf ormation set by the criter ion and random ly.
are agreed by the persons ser ved.
Kriteer ium on täidet ud, kuid
This was ver if ied by examples of spetsiif iliste mõõdetavate
client documentation seen during the eesmärkide sõnastamise osas on
site visit. pisut arenguruumi. Puudus ei olnud
läbiv, vaid esines pisteliselt.
27
36. The social service provider identif ies, documents, and maintains
the key servi ce deli very processes to the persons served in line w ith
its vision, mission statement and quali t y policy.
Remark from the auditor : The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
The service deliver y processes are
descr ibed in the em ployees’ manual:
general principles of treatment of
patients, policy f or inpatient
treatment and policy f or outpatient
treatment.
The service deliver y process es are
descr ibed also f or the f or the clients
on the home page of HNRK, which is
assured by the organization’s qualit y
standard.
The key ser vice d eliver y pr ocesses
are in line wit h HNRK’s vision,
mission and qualit y principles.
All processes are regularly reviewed
through the internal control
processes.
37. The social service provi der review s this delivery process and
maintains control over the deli very of t he servi ce.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
HNRK reviews the ser vice deliver y The criter ion is fulf illed. Further
process es through t he inter nal developing the internal control
28
control pr ocesses . Perf ormance system to ensure r egular control of
reports are composed. the treatment of patients.
The processes t hemselves are Kriteer ium on täidetud . Edasine
reviewed per iodically. sisekontrolli süsteemi edasi
arendam ine, et tagada ravit öö
Regular meetings, checks, reviews sisuline kontroll.
and controls are conducted to assur e
maintaining control over the deliver y
of services.
38. The social service prov ider 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
HNRK ensures that the person s
ser ved can access a continuum 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 studied examples of
individual plans, minutes of meetings
and quarter ly reports on site to verif y
the indicator.
39. The social service provi der develops a seamless continuum of
services and reduces barriers in a multi -disciplinary or multi -agenc y
setting.
29
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance ce rtif ication program
Strengths Improvem ent & developments
Annual act ivit y reports are
composed, which address the issue.
The criterion was verif ied f ulf illed by
also explor ing the client work
documentat ion, where evidence was
f ound about multidisciplina r 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 meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
HNRK uses client - centered holist ic
approach, which is aimed to improve
client ’s qualit y of lif e.
The qualit y of lif e init iat ive’s
eff ectiveness is measured and
reported in individual plans .
FI M system is used HNRK, 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
documentat ion, where evidence was
f ound about measur ing the qualit y of
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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 meet
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 in the employees’
manual of HNRK. These are
evaluated annually during
employees’ perf ormance evaluations.
Trainings are provided to employees,
which was evidenced by training
plans of HNRK and came out f rom
inter views.
42. The social service provider identifies its business 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 & devel opments
Targeted results are measured and
reported in annual reports, which ar e
disclosed on the web page of HNRK.
External audits are conducted and
also var ious checks, audits and
31
reviews ar e made by the f unding
bodies.
43. The social servi ce provi de r 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 icat ion program
Strengths Improvem ent & developments
HNRK 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
disclosed a lso in the annual reports
of HNRK.
Inf ormation is also collected through
the client ’s sur veys and
questionnaires.
FI M database also ser ves a usef ul
inf ormation base f or this kind of
inf ormation.
44. The social service provider evaluates its business res ults 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 me et
this cr iterion of the EQUASS Assurance certif ication program
32
Strengths Improvem ent & developments
HNRK evaluates the 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 activit y reports.
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 oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
HNRK organizes regular sur veys t o
receive f eedback f rom the persons
ser ved and their par ents.
Also the satisf action of other
stakeholders is evaluated 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
33
The records on outcome are
communicated to stakeholders, staff
and persons ser ved. The content and
f ormat depends on t he target group.
Annual activit y repor ts are drawn up.
Related inf ormation is also available
on the home page of HNRK.
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 Assurance certif ication program
Strengths Improvem ent & developments
HNRK reports its perf orman ce to
f unding bodies, staff and ser vice
users using diff erent methods.
The content and f ormat depends on
the target group. Related inf ormation
is also available on the home page
of HNRK.
Inf ormation is disseminated through
home page, meetings, magazine,
inf ormation screens 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 meet
this cr iterion of the EQUASS As surance certif ication program
Strengths Improvem ent & developments
34
The PDCA cycle is used and
descr ibed in the employees’ manual
of HNRK (annual planning process;
qualit y standard).
All the process and activit ies are
reviewed regular ly (improvement
meetings). The results and
perf ormance of HNRK is measured
and described in act ivit y reports.
All qualit y improv ement projects ar e
document ed.
49. The social service provi der identifies performance i ndicators for
measuring the results of the improvement a ctions.
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
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.
50. The servi ce provider introduces and manages innovative w ays of
w orking that have been identified based on the needs of
stakeholders.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
35
HNRK f inds ways of being
innovat ive, taking into account the
needs and expectations of
stakeholders. HNRK participates in
diff erent projects both in local and
international level.
F.e Centre of Excellence of Health
Promotion and Rehabilitation ; HUR
gym, The Center of Adaptive
Devices; Kõnnilabor etc.
All related inf ormation was verif ied
to be docum ented.
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 6 The criterion is f ulfilled, but there is slight room f or
improvement in the wording of goals and objectives –
they should always express the desired change /
expected sit uation and not be expr essed as act ivities.
The def iciency was not all -per vading, but a ppeared
random ly.
Kriteer ium on täidetud, kuid eesmärkide sõnastamise
osas on natuke arenguruumi – eesmär gid tuleks alati
sõnastada soovitava muutusena / oodatava olukorrana,
mitte sõnastatuna tegevustena.
Person responsible / vastutaja: kvaliteedijuht / q ualit y
manager
Due date / tähtaeg: 20.03.2017
36
2. criterion 35 The criterion is f ulfilled, but there is slight room f or
improvement in the wording of specif ic measurable
objectives. The def iciency was not all -per vading, but
appeared randomly.
Kriteer ium on täidet ud, kuid spetsiif ilist e mõõdetavate
eesmärkide sõnastamise osas on pisut arenguruumi.
Puudus ei olnud läbiv, vaid esines pisteliselt.
Person responsible / vastutaja: kvaliteedijuht / qualit y
manager
Due date / tähtaeg: 20.03.2017
3. criterion 37 The criterion is f ulf illed . Further developing the internal
control system to ensure regular control of the treatment
of patients.
Kriteer ium on täidetud . Edasine sisekontrolli süsteem i
edasi arendamine, et tagada ravitöö sisuline kontroll.
Person responsibl e / vastutaja: kvaliteedijuht / qualit y
manager
Due date / tähtaeg: 20.03.2017
5. Closing remarks
Haapsalu Neurological Rehabilitation Centre is a rehabilitat ion hospital
located in naturally beautif ul surroundings. The hospital provides
rehabilitat ion ser v ices f or childr en and adults suff ering f rom variet y of
neurological condit ions. The major target group is people with spinal cord
injur y or brain inj ur y, a litt le lesser amount have progressive ner ve -
conditions, mult iple t raumas, and congenital development al disorders.
Haapsalu Neurolog ical Rehabilitation Centre has knowledgeable and
enthusiast ic staff , modern f acilities and long -term experiences. The main aim
of the hospital is t o provide evidence - based patient -centred rehabilitation
with high qualit y.
In addition to ever yday work with pat ients the hospital is a trust worthy
practical sett ing f or young specialists and a good partner in diff erent
science- and development projects.
HNRK has been involved with the implem entation of EQUASS qualit y system
since 2010. The preparat ions f or EQUASS enabled to improve the
management system of the organizat ion. The procedures and manuals of the
37
organizat ion and the activit ies of HNRK were impr oved in or der to respond to
the ten qualit y pr inciples of EQUASS.
HNRK has once alr eady gained EQUASS Qualit y Assur ance certif icate (in
2011). Even though the certif icat ion expir ed after two years, HNRK continued
to implement EQUASS qualit y pr inciples and was able to show results and
evidence of doing so.
The auditor exper ienced on site that the social ser vice provider HNRK
perf orms in compliance with t he EQUASS Assurance criter ia. The
inter viewed representatives of partners, f inancing bodies, employees of
HNRK and persons served conf irmed this, which was reflected in their
satisf action. They were especially sat isf ied with the personnel of HNRK
(client work) and wit h the ser vices and pleasant environment .
During the audit the organization showed many examples of good pract ice,
especially in the f ield of person cent ered appr oach and i nvolvement of
personnel. The whole staff was kind and cooperat ive in introducing the work
of HNRK, f inding necessar y evidential materials and sharing inf ormation
about f ulf illing EQUASS crit eria.
For the period of f ollowing two years, some improvement act ions and
additional developm ents were agreed that are brought out in part 4 of the
audit report. A more detailed over view of suggestions f or improvement that
are ment ioned under the specif ic criter ia is given in detail in part 3. The
improvement areas incl uded in general improving the expr ession of goals
and specif ic measur able objectives; also improving the system of internal
controls.
After verif ication of the indicators by r eviewing documentation, conduct ing
inter views and performing site visit, the audi tor 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 HNRK is devot ed to qualit y
assurance and improvem ent in its work and delivers ser vices of high qualit y.
***
SA Haapsalu Neuroloogiline Rehabilitatsioonikeskus (HNRK) on rahulikus
looduskaunis ümbruskonnas paiknev taastusravihaigla, mis pakub
taastusravi- ja rehabilitatsiooniteenuseid. HNRK on suunanud enda tegevuse
kolmele põhilisele sihtgrupile: peaajukahjustu sega inimesed,
38
seljaajukahjustusega inimesed ning neuroloogiliste probleemidega lapsed.
HNRK- l on kaasaegsete teadmist ega ning entusiastlik meeskond,
tänapäevased vahendid ja ruumid ning rohkem kui poole sajandi pikkused
kogemused, mida klient idega tegelem isel kasutatakse. HNRK peamiseks
eesmärgiks on kvalit eetse tõenduspõhise kliendikeskse ja tervikliku teenuse
pakkumine.
Lisaks igapäevasele ravitööle on HNRK usaldusväärseks praktikabaasiks
noortele spetsialistidele ning heaks partneriks erinevat es teadus - ja
arendusprojektides.
HNRK-s hakati EQ UASS Assurance kvaliteedisüsteem i rakendama aastal
2010. EQUASSi r akendamiseks ettevalm istamine võim aldas täiustada
asutuse juhtim ise süsteem i sotsiaalvaldkonna teenuseid osutavatele
asutuste le esitatud nõuetest läh tuvalt. Täiendat i asutuse protseduure ja
juhend eid ning täiustati oma t egevust, et see vastaks EQUASSi kümnele
kvaliteedi põhimõttele.
HNRK on kord juba EQUASS Assur ance sertif ikaadi saanud (2011. aastal).
Kuig i sertif ikaat aegus 2011. aastal, jätkas HNRK kvaliteedisüsteem i
põhimõtete rakendamist ning näitas ette sell ekohaseid tõendeid ja tulemusi.
Kohapeal koges audiitor, et sotsiaalteenuse osutaja HNRK tegutseb
vastavuses EQUASS Assurance kriteeriumitega. Intervju ud huvigruppide ja
rahastajate esindajateg a, HNRK töötajatega ja teenuse saajatega samuti
kinnitasid seda, mis väljendus nende rahulolus. Er iti rahul oldi HNRK
personaliga (klienditöö) ja osutatavat e teenustega ning meeldiva
keskkonnaga.
Auditi käigus oli asutusel ette näidata mitmeid häid näiteid ja saavutusi
EQUASS- i põhimõtete täitmisel, mis on hea praktika näideteks, eelkõige
isikukeskses lähenemises ja personali kaasamises. Kogu asutuse
töötajaskond oli lahke ja koostööaldis HNRK töö tut vustamisel, vajaliku
tõendusmaterjali leidm isel ning inf o rmatsiooni jagamisel EQ UASS - i
kriteeriumit e täitmise kohta.
Järgnevaks kaheks aastaks lepit i kokku mõned parendustegevused ja
täiendavad arendused, mis on välja toodud aruande 4 -ndas osas. Detailsem
ülevaade parendussoovitustest konkreetsete kriteeriumite lõikes on esitatud
aruande 3-ndas osas. Parendusvaldkonnad hõlmasid üldises plaanis siht ide
39
ja spetsiif iliste mõõ detavate eesmärkide sõnastamist; samuti sisekontrollide
süsteem i täiustamine.
Peale indikaator itele vastamise tõendamist, tut vudes dokumentatsiooniga
ning viies läbi inter vjuud, oli audiitor veendunud, et kriteeriumid Eur oopa
kvaliteedimärgi jaoks sotsiaalteenustes on täidetud. Audiitor sai
veendumuse, et HNRK on pühendunud kvalitee di tagamisele ja täiustamisele
oma töös ning osutab kõrge kvaliteediga teenuseid.
Tallinn, 20. 03.2015
Mar iliis Männik -Sepp
EQUASS- i auditor / EQUASS auditor
40
Maarika Aro
Saatja: Maarika Aro
Saatmisaeg: 23. märts 2015. a. 11:48
Adressaat: 'Marie Dubost'; 'Guus van Beek'
Koopia: Keiu Talve
Teema: Audit report Haapsalu NRK EST2015-002
Manused: Additional Information Form_Haapsalu NRK.doc; Asutuse auditi külastuse
ettevalmistuse vorm_uus.pdf; EQ_Audit Report_HNRK.doc; EQUASS_taotlusvorm_
2015_Haapsalu NRK.xlsx; HNRK_logo_sinine.cdr
Dear Marie, Dear Guus,
Attached you’ll find an audit report and other documents of Haapsalu Neuroloogiline Rehabilitatsioonikeskus
(Haapsalu Neurological Rehabilitation Centre) EST2015-002.
Please let Keiu to know in case there are some comments about the report.
Maarika Aro
Sotsiaalteenuste Kvaliteedi Keskus
Arendusspetsialist
Astangu Kutserehabilitatsiooni Keskus
tel +372 687 7223
mob +372 521 3563
[email protected]
Astangu 27 Tallinn 13519
www.astangu.ee
Liitu Astangu uudiskirjaga
1