EQUASS ASSURANCE
AUDIT REPORT
Site visit: 15.-16.12.2014
Tartu Hiie Kool
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 Tartu Hiie Kool (her einafter THK)
service provider
Address: Hiie 11, Tartu 51006
Post box: N/A
Person responsible Helgi Klein, headmistress
(CEO):
Contact person: Hene Binsol, deput y director of studies
Phone: (+372) 7 422 293
Fax: (+372) 7 422 298
E-mail:
[email protected] .ee
Web site: http://www.hiie.tartu.ee
Name of Auditor: Mar iliis Männik -Sepp
Dates of audit: 15.-16.12. 2014
Clients: Number of person served: 105
As of (date): 24.11.2014
Staff: Number of Full t ime staff : 28 (rehabilitation
ser vice)
Number of Part time staff : 0
Number of Contracted staff : 0
Number of volunteer s : 0
Services: 1. Rehabilitation ser vice
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2. Audit program
21.11.2013 Day 1
Time Acti vit y
10.30-11.00 Opening meeting , documentation review
11.00-13.00 Documentation review
13.00-13.45 Lunch break
13.45-15.00 Documentation review, up -dat ing f iles
15.00-15.45 Interview with deput y director of studies - Hene Binsol
15.45-16.15 Documentation review, up -dat ing f iles
16.15-17.00 Interview with staff : Ulvi Raidla ( eripedagoog ), Reeli
Mišiniene ( speech therapist ), Janne Jehe
(psychologist )
17.00-18.30 Documentation review, up -dat ing f iles
16.15-17.00 Interview with persons ser ved by the r ehabilitation
unit.
22.11.2013 Day 2
Time Acti vit y
8.30-9.30 Interview with cooperation partners: Reet Veenpere
(speech therapist o f Tartu Universit y Hospital ),
Regina Paabo ( Viipekeeletõlkide OÜ member of the
board, sign language interpreter, sign language
lecturer of Tartu Univer sit y )
9.30-10.45 Documentation review, up-dat ing f iles
10.45-11.30 Interview with f inancing body – Air i Nõmm (Social
Insurance Board)
3
11.30-11.45 Documentation review, up -dat ing f iles
11.45-12.30 Interview with persons ser ved by the r ehabilitation
unit
12.30-12.45 Documentation revi ew, up-dat ing f iles
12.45-13.45 Lunch break
13.45-14.45 Documentation review, up -dat ing f iles
14.45-15.30 Interview with headmistress - Helgi Klein
15.30-16.00 Documentation review, up -dat ing f iles
16.00-16.30 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
THK are docum ented in the
organizat ion’s quality manual and on
its website http:// www. hiie.tartu.ee/ .
The employees of THK demonst rated
through inter views that they are
aware of the organizat ion’s mission,
vision and core values and they
implement the vision and m ission
values on ser vice pr ovision.
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2. The social servi ce provider defines, documents, and implements its
qualit y polic y by determining long term qualit y goals, and its
commitment to continuous improvement.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & deve lopments
The qualit y standard and
commitment to continuous
improvement of THK is documented
in the organizat ion’s qualit y manual.
The long -term goals of THK are
descr ibed in the organizat ion’s
development plan.
It appeared f rom the inter views that
the staff of THK is k nowledgeable of
the qualit y standar d 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.
Bef ore starting to implement
EQUASS, THK has been involved
with t he implementation of the
qualit y system for educat ional
establishments since 2006.
3. Persons served, famil y members and servi ce user organisations are
able to give feedback on their individual and collecti ve experience of
programmes and services .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
5
Strengths Improvem ent & developments
THK has developed ways t o ask and It would be advisable to make sure
receive f eedback f rom person s that the f eedback from stakeholder s
ser ved, their representatives, staff is always documented in a proper
and stakeholders. way so that this inf ormation could be
used f or improving the ser vices and
The organizat ion uses various f or making decisions on management
methods to achieve t his. level.
F.e childr en’s and parents’ Soovitatav on kindlustada, et
satisf action sur vey, employee huvigruppidelt saadud tagasiside on
satisf action sur vey. alat i korrektselt dokumenteer itud, et
saadud inf ormatsiooni saaks
Results of sur veys are analyzed and
kasutada teenust e täiustamiseks
summarized. Results of important
ning juhtim isotsuste tegemiseks.
meetings and gatherings are
recorded in wr itten minutes of the
meetings.
4. The social service provid er 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 & development s
THK has inf ormed all possible
stakeholders about its services using
a variet y of methods and
approaches. This is done through
important cooper ation partners,
brochures, homepag e of THK etc.
This was verif ied implemented
through inter views wit h per sons
ser ved, staff and partners.
The opportunit ies f or involvement
6
are descr ibed in the policies and
procedures qualit y policy of the
organizat ion.
5. The social service provider management establishes and
documents an annual planning and review process.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
The annual planning and review The process is exist ing and
process is integrated into the implemented, but a possibilit y f or
management process of the development would be descr ibing the
organizat ion. annual planning and review process
in a more detailed manner to depict
The process is described in the all the inf ormation that is taken into
qualit y manual and general work plan account in the planning process and
of THK. The process is reviewed all the related steps and personnel
annually as descr ibed in the qualit y involved.
manual.
Protsess on kirjeldatud ning seda
There are annual action plans and rakendatakse, kuid
annual r eport ing on the arenguvõimaluseks on aastase
implementation of the plans. planeer imise ja ülevaatuse protsessi
kirjeldamine detailsemal moel, nii et
see sisaldaks kogu planeer imisel
arvesse võetavat inf otmatsioon i ning
kõiki planeerim isega seotud etappe
ja seotud personali.
7
6. The plan includes:
annual outcomes / targets
the acti vities to be undertaken in achieving the annual targets
monitoring of the performance of the organisation in meeting its
annual targets
time-scales and procedures for revi ew and revi sion.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
The annual planning pr ocess of THK The criterion is f ulfilled, but as an
has a cyclic character. The annual improvement f or f uture it would be
work plan includes objectives, key advisable to review and to make sure
activities, tangible results and that the goals and objectives set in
targets. the development plan and in the
work plan are in correspondence wit h
The annual plan is approved by the each other and clearly related to
headm istress. measures and act ivities set in those
two documents.
Kriteer ium on täidet ud, kuid tulevi ku
mõttes on soovitatav üle vaadata ja
kindlustada, et arengukavas ja
asutuse tööplaanis esitatud
eesmärgid on omavahel selgelt
seotud ning vastavuses nimetatud
dokumentides esitatud meetmete ja
tegevust ega.
7. The social servi ce provider demonstrates or ganisation’s success
in satisf ying the needs and expectations of the societ y.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
8
Feedback f rom diff erent stakeholders
is collected and used to improve
ser vices.
THK does t ight cooperation with the
parents of children, Social Insurance
Board, social workers of local
government, organizations of
persons with hearing impairment
(Eesti Kurt ide Liit, Eest i
Vaegkuuljate Ühing, Kuulmispuudega
Laste Vanemate Liit ja
Implantaadilaste Selts, Eesti
Viipekeeletõlkide Ühing, Eest i
Pimekurtide Liit), Tartu Universit y
Hospital etc.
Var ious projects and activit ies are
organized with cooperation partn ers,
which also ser ve the needs and
expectat ions of societ y (f .e study
materials, trainings etc). THK ser ves
also as the training base f or the
students of Tartu Univer sit y.
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 services of the social ser vice providers meet this criter ion of the
EQUASS Assurance certif ication program
Strengths Improvem ent & developments
THK has demonstrated social
responsibilit y through diff erent
activities contr ibut ing to the societ y.
It has an active role in the raising of
9
awareness of societ y about the
opportunit ies and services related to
children with special needs of
hear ing and speech.
THK organizes all kind s of events, is
the training base f or the students of
Tartu Universit y and its specialists
have issued several study materials
meant f or teachers and childr en wit h
special needs of hearing and
speech.
9. The social servi ce provider has a staff recruitm ent 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 icati on program
Strengths Improvem ent & developments
Staff policy (including recruitment
and select ion procedures) has been
developed.
All employees have individual job
descr iptions, which include required
knowledge, skills and competences.
There is training policy and annual
training plans. Each year employees’
self -assessments are carried out.
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 mo t ivat ed, like
10
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 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 THK 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 recognit ion polic y
and employees are given
recognit ions f or example 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 Assurance certif ication program
11
Strengths Improvem ent & developments
Staff training policy regulates the
arrangement of trainings. Annual
training plans are dr awn up based on
the needs of the employees and
expectat ions of THK.
The staff of THK is trained regularl y
and all the inter viewed employees
showed high appreciation concer ning
the trainings received .
Feedback on trainings is collected
and training inf ormation is gathered
in special inf ormation system. The
eff ectiveness of the trainings is
evaluated.
12. The social servi ce provi der applies requirements for competence
in the identified roles and fu nctions 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 equiremen ts f or
employees are descr ibed in their job
descr iptions and qualit y manual and
are reviewed annually.
It was ver if ied by the inter views and
related documentation t hat
perf ormance reviews of staff
members who are directly involved in
12
ser vice deliver y, are carried out.
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 described in the qualit y manual.
THK recognizes staff as a usef ul tool
f or gaining inf ormatio n. It has regular
staff meeting s. Minutes of meetings
are prepared and are available f or all
staff . Also annual staff
questionnaires are used f or gaining
f eedback.
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’ e valuat ions are used to
gain f eedback on satisf action and
motivat ion.
13
Mechanisms to provide satisf action
and mot ivat ion are described in staff
recognit ion policy and qualit y
handbook.
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, especial l 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
THK has developed the rights and
duties of persons ser ved, which
conf orm to international human
rights convent ions. They ar e
introduced to childr en by staff .
The rights and duties of persons
ser ved are made available f or
publicit y on the web page of THK.
The staff and clients’ represent at ives
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, re ligion or belief and sexual orientation
before recei ving the services.
14
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
THK has developed the rights and
duties of persons served, which ar e
introduced to childr en by staff .
The staff and clients’ representat ives
demonstrated their knowledge of the
rights and duties through the
inter views.
17. The social service provider has acces sibl 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 ce rtif ication program
Strengths Improvem ent & developments
There is procedur e f or handling
complaints. So f ar, no complaints
have been made.
If was verif ied during the inte rviews
that the persons served and other
relevant stakeholder s were awar e of
the ways of making proposals and
complaining.
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
develo pment.
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
THK processes and procedure (also The criterion is f ulf illed, but in order
related f orms) have been prepared, to guarantee the a nnual evaluat ion,
taking into account the persons’ it would be advisable to add this
ser ved r ight to self -determinat ion. activit y in the qualit y manual or other
relevant document of THK.
It became evident through the
inter views that the staff was aware of Kriteer ium on täidet ud, kuid
this issue and the persons ser ved tagamaks iga-aastane
were handled wit h respect. enesemääratlusest lugupidamise
alane hindam istegevus, on
soovitatav see tegevus lisada
kvaliteedi käsiraamatusse või
muusse THK asjakohasesse
dokumenti.
19. The social service provi der facilitates the person served in
choosing and having access to advocates and/or supporting
persons.
Remark from the auditor: The ser vices of the social se r vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
The criterion is f ulf illed, but in order
The need f or a supporting person is to guarantee the annual evaluat ion
discussed with the persons ser ved inn f acilitat ing f inding supporting
(parents) and related inf ormation is persons, it would be advisable to a dd
presented in individual pl ans. this activit y in the qualit y manual or
other relevant document of THK.
The criterion was verif ied f ulf illed by
the evidence f ound in client work Kriteer ium on täidet ud, kuid
documentat ion and interviews. tagamaks iga-aastane tugiisiku
16
leidmise alane hindamistegevus, on
soovitatav see tegevus lisada
kvaliteedi käsiraamatusse või
muusse THK asjakohasesse
dokumenti.
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 soci al 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 THK has been developed and
made available to the staff . Mem bers
of staff showed awarenes s 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.
21. The social service provider operat es mechanisms w hich prevent
the physi cal, mental an d financial abuse of users.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
The code of ethics for the personnel
of THK has been developed and
made available to the staff . Mem bers
17
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.
22. The social servi ce provi der provide s 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 Assu rance certif ication program
Strengths Improvem ent & developments
THK provides ser vices 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.
The physical securit y of persons
ser ved and caretakers 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 aspec ts 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
18
The principles, values and
procedures in ser vice deliver y are
descr ibed in the qualit y policy 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 Assur ance certif ication program
Strengths Improvem ent & developments
There are principles f or processing The criterion is f ulf illed, but in order
delicate personal data. This to guarantee the regular analysis of
inf ormation is made available the pr inciples regarding
through the home page of THK. conf ident ialit y of data , it would be
advisable to add this activit y in the
The principles are over viewed qualit y manual or other relevant
regularly accor ding to the qualit y document of THK.
manual of the organizat ion.
Kriteer ium on täidet ud, kuid
tagamaks regulaarne andmete
konf identsiaalsuse põhimõtete
analüüs, on soovitatav see tegevus
lisada kvaliteedi käsiraamat usse või
muusse THK asjakohasesse
dokumenti.
19
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 THK, job descript ions of
employees and quality manual .
26. The social service provi der w orks in part nership 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
THK does a lot of cooper ation wit h
its partners. It has made a list of its
cooper ation partners. THK has
contracts with f inancing bodies and
major cooperat ion partners.
THK does cooper ation wit h the
parents of children, Social Insurance
Board, social workers of local
government, organizations of
persons with hearing impairment
(Eesti Kurt ide Liit, Eest i
Vaegkuuljate Ühing, Kuulmispuudega
Laste Vanemate Liit ja
Implantaadilaste Selts, Eesti
Viipekeeletõlkide Ühing, Eest i
20
Pimekurtide Liit), Tartu Universit y
Hospital etc.
W ith cooperation partners var ious
projects and activities are organized,
which also ser ve the needs and
expectat ions of societ y (f .e study
materials, trainings etc). THK ser ves
also as the training base f or the
students of Tartu Univer sit y.
THK evaluates the cooper ation
related to the services delivered by
contract partners.
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 t he 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 ser vices of THK
through meeting s and sur veys.
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
21
Strengths Improvem ent & devel opments
Children and their parents are
involved in the service planning,
deliver y and appraisal procedur e.
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 s ervice 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 progr am
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 are descr ibed in the qualit y
manual of THK.
30. The social service pro vi der operates specific instruments f or
users to improve their personal empow er ment and personal situation
and that of their communit y.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certi f ication program
Strengths Improvem ent & developments
Empowerment of persons ser ved is
an integral part of ser vice deliver y.
22
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 def ined in the
qualit y policy of THK.
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 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.
32. The social servi ce provider sel ects programmes w hich are based
on a needs assessment at the location w hich is most convenient for
the person served, famil y and care takers
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
23
THK has an over view of the needs of
the persons served (queues,
meetings with cooperation partners ).
The locat ion of THK is pleasant and
well accessible . All the ser vices ar e
delivered at the same complex,
which is convenient f or children and
parents.
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 ica tion program
Strengths Improvem ent & developments
THK does cooper ation wit h the
f unding bod y (Social Insurance
Board, SBI) and has ascertained the
needs and expectations of them
(recently SIB conduct ed state
sur veillance in THK) . The needs of
other stakeholders have also 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.
34. The social service provi der operates indi vidual processes that
are dri ven by the needs of 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
24
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 th e 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 icatio n program
Strengths Improvem ent & developments
The clients’ individual needs and
expectat ions are wr itten 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
(childre n/parents) .
This was ver if ied by examples of
client documentation seen during the
site visit.
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.
25
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 The criter ion is f ulf illed, but it is
descr ibed in the qualit y policy. The advisable to review the part of the
rehabilitat ion ser vice process rehabilitat ion ser vice procedure,
descr iption is also available on the which concerns assessment of
home page of THK. results.
The key ser vice deliver y pr ocesses Kriteer ium on täidetud, kuid on
are in line with THK’s vision, mission soovitatav üle vaadata
and qualit y pr inciples. rehabilitatsiooni teenuse pr otseduuri
osa, mis puudutab teenuste
All processes are regularly reviewed. tulemuslikkuse hindamist.
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 Assur ance certif ication program
Strengths Improvem ent & developments
THK reviews the ser vice deliver y
process es. Perf ormance reports are
composed.
The processes t hemselves are
reviewed per iodically.
The processes and the deliver y of
ser vices are subj ect to internal
control (audit).
26
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
THK ensures that the person ser ved
can access a cont inuum of services
as needs of persons ser ved ar e
evaluated 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.
39. The social service provi der develops a seamless continuum of
services and reduces barriers in a multi -disciplinary or multi -agenc y
setting.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
If barriers exist, they are discussed
in meetings and reported as
necessar y.
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.
27
40. The social service provi der operate s 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
THK uses client -centered holist ic The criterion is f ulf illed, but it is
approach, which is aimed to improve advisable to review the part of
client ’s qualit y of lif e. individual plans, wh ich concerns
assessment of individual results.
The qualit y of lif e init iat ive’s
eff ectiveness is measured and Kriteerium on täidetud, kuid on
reported in individual plans soovitatav üle vaadata individuaalse
plaani osa, mis puudutab teenuste
The criterion was verif ied f ulf illed by tulemuslikkuse hindamist indiviidi
also explor ing the client work tasandi l.
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 comp etences,
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 & deve lopments
28
The necessar y competences and
skills are described in job
descr iptions and in the qualit y
manual of THK. These are evaluated
annually dur ing employees’
perf ormance assessments .
Trainings are provided to employees,
which was evidenced by training
plans of THK 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 & developments
Targeted results are measured and
reported in annual reports, which ar e
disclosed on the web page of THK.
External review was recentl y
conducted by the Social Insurance
Board, which f ound no violations or
major deviations.
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
29
Strengths Improvem ent & developments
THK 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 summary is disclosed
also in the annual reports of THK.
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 EQUA SS Assurance certif ication program
Strengths Improvem ent & developments
THK evaluat es the r esults and added
value of its work during meetings.
This is also ref lected in related
individual and summarized reports.
45. The social service provider eval uates 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 icati on program
Strengths Improvem ent & developments
30
THK 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 EQUA SS Assurance certif ication program
Strengths Improvem ent & developments
The records on outcome are
communicated to stakeholders, staff
and persons ser ved.
The content and f ormat depends on
the target group. Related inf ormation
is also available on the home page
of THK.
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
31
THK reports its perf ormance 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 THK.
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 t he EQUASS Assurance certif ication program
Strengths Improvem ent & developments
The PDCA cycle is used and
descr ibed in the qualit y manual of
THK.
All the process and activit ies are
reviewed regular ly. The results and
perf ormance of THK is measur ed and
descr ibed in related 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 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
32
All improvement programs are
document ed, include goals and
respect ive perf ormance indicators.
This was verif ied through inspectin g
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
THK f inds ways of being innovat ive,
taking into account the needs and
expectat ions of stakeholders. THK
participates in diff erent projects both
in local and in ternat ional level.
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 3 More attention should be turned to
recording /document ing f eedback f rom stakeholders so
that this inf ormation could be used f or improving the
ser vices and f or making decisions on management level.
Rohem tähelepanu tuleks pöör ata huvigruppidelt saadud
tagasiside dokument eeri m isele, et saadud inf ormatsiooni
33
saaks kasutada teenuste täiustamiseks ning
juhtimisotsuste tegemiseks.
Person responsible / vast utaja: headm istr ess / direktor
Due date / tähtaeg: 31.12.2015
2. criterion 5 The annual planning and review process should be
descr ibed in a more detailed manner to depict all the
inf ormation that is taken into account in the planning
process and all the r elated steps and per sonnel
involved.
Aastase planeer imise ja ülevaatuse protsessi tuleks
kirjeldada detailsem alt, nii et see sisaldaks kogu
planeer imisel ar vesse võetavat inf otmatsiooni ning kõiki
planeer imisega seot ud etappe ja seotud personali.
Person responsible / vast utaja: headm istr ess / dir ektor
Due date / tähtaeg: 31.12.2015
3. criterion 6 The goals and object ives set in the development plan
and in the work plan should be in correspondence with
each other and clearly related to measur es and activities
set in those t wo documents.
Arengukavas ja asut use tööplaanis esitat ud eesmärgid
peavad olema omavahel selgelt seot ud ning vastavuses
nimetatud dokumentides esitatud meetmete ja
tegevust ega.
Person responsible / vast utaja: headm istr ess / direktor
Due date / tähtaeg: 31.12.2015
4. criterion 36 The part of the rehabilitat ion ser vice procedure, whic h
concerns assessment of result, should be described
more clearly.
Rehabilitatsiooni teenuse protseduur i osa, mis puudutab
teenuste tulemuslikkuse hindamist, tuleks detailsemalt
kirja panna.
Person responsible / vast utaja: headm istr ess / direktor
Due date / tähtaeg: 31.12.2015
5. criterion 40 In individual plans, t he assessments of results should be
descr ibed in more detail .
Individuaalset es plaanides tuleks tulemuslikkuse
hindamise osa detailsemalt ki rjeldada.
34
5. Closing remarks
Tartu Hiie School is a school f or children with special needs of hearing and
speech. Pupils with hear ing disabilities and deaf pupils whose parents want
to provide their children an oral education study in the department of
children with special needs of hearing. Pupils with normal hear ing and
primarily undamaged intellect who have reading and writing diff icult ies,
under-speech and sever e pronunciat ion disabilities that hinder them studying
in a normal school, study in the depa rt ment of children wit h special speech
needs.
THK has been involved with the implementation of the quality system for
educational establishments since 2006 . It started to implement EQUASS Assurance
quality system in 2012. The preparations for EQUASS enab led to improve the
quality management system of the organization from the aspect of the
requirements set to social sector service provider s. The existing functio ning
quality system was used as much as possible, adding the specific elements arising
from EQUASS quality principles. The corresponding additio ns were added to the
procedures and guidance notes of the o rganization and the activities of the
organizatio n were improved in order to respond to the ten quality principles of
EQUASS.
The auditor exper ience d on sit e that the social ser vice provider THK
perf orms in compliance with t he EUQASS Assurance criter ia. The
inter viewed r epresentatives of partners, f inancing bodies, employees of THK
and representatives of persons served conf irmed this , which was ref lec ted in
their sat isf action .
During the audit the organization showed many examples of good pract ice,
especially in the f ield of person cent ered appr oach and involvement of
personnel. The whole staff was kind and cooperat ive in introducing the work
of THK, f inding necessar y evident ial mat erials and shar ing inf ormation about
f ulf illing EQUASS cr iteria.
For the period of f ollowing two years, some improvement actions 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 included in general improving the procedures of THK
(rehabilitation ser vice procedure and annual planni ng pr ocedur e), more
comprehensive documentation of f eedback received f rom stakeholders and
also more comprehensive documentation of results of services used in
individual plans.
After verif ication of the indicators by r eviewing documentation, conduct ing
35
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 THK is devoted to qualit y
assurance and improvem ent in its work and delivers ser vices of high qualit y.
***
Tartu Hiie Kool on HEV laste kool, kus on võimalik kuulmis- ja kõnepuudega lastel omandada
põhikooli haridus ning kuulmispuudega koolieelikutel saada koolieelset ettevalmistust. T
egemist on hariduslike erivajadustega õpilaste kooliga, mille õppe-kasvatustööd iseloomustab
korrigeeriv ja kaasav suunitlus kaasaegse õppevara, otstarbeka näitvahendite ja ruumikasutuse
kaasabil. Kooli ülesandeks on leevendada lapse probleeme logopeedilise ja eripedagoogilise abi
ning interdistsiplinaarsete tugiteenustega sedavõrd, et laps suudaks võimaluse korral minna
(tagasi) oma elukohajärgsesse kooli. Oluline on õigel ajal kasutusel võtta parimad meetmed, et
olemasolev puue või probleem ei süveneks.
Koolis toimub õpilaste kõne ja üldise arengu taseme igakülgne korrigeerimine,
kommunikatsioonioskuse arendamine, artikulatsiooniaparaadi töö arendamine, hääle- ja häälikute
seadmine, suultlugemise õpetamine, kuuldetaju arendamine, keeleliste väljendusvahendite
kujundamine, sõnavara laiendamine, õige ja teadliku lugemise õpetamine, jutustamisoskuse
arendamine ning võimalikult veatu kirjutamisoskuse kujundamine. Oluline on harjutamine ja õpitu
kinnistamine ning arengut toetavad tegevused pärast ainetunde. Õppeperioodil on kaugemal
elavatel õpilastel võimalus elada kooli õpilaskodus.
Arvestades Tartu Hiie Kooli professionaalse (eri)pedagoogilise personaliga varustatust, personali
pikaajalisi töökogemusi kuulmis- ja kõnepuudega laste õpetamisel, laialdast kompetentsi ja kooli
logistiliselt head asukohta Eestis, osutatakse kõigile kuulmis- ja kõnepuudega lastele kogu
Eestis rehabilitatsiooni- ja õppenõustamisteenuseid. Kõik spetsialistid, kes nõustavad ja probleeme
lahendavad, on ise aktiivsed praktikud. Koolil on suhtevõrgustik ja kontaktid, mille kaasabil on
võimalik abivajajate murede lahendamisel tuge pakkuda.
Käesoleval õppeaastal õpib koolis 342 õpilast ja ettevalmistusrühmas 10 koolieelikut. Avatud on 30
klassikomplekti ja 1 kooliks ettevalmistusrühm.
THK on rakendanud haridusasutustele suunitletud kvaliteedisüsteemi
alates 2006. Aastast. EQUASS Assurance kvaliteedisüsteemi hakati
rakendama aastal 2012. EQ UASSi rakendamiseks etteva lm istamine
võimaldas täiustada asutuse kvaliteedij uhtim ise süsteemi sotsiaalvaldkonna
teenuseid osutavatele asutusteele esitat ud nõuetest lähtuvalt. Olemasolevat
toimivat kvaliteedisüsteemi kasutati võimalikult palju ära, lisades sinna
EQUASSi kvaliteedi p rintsiipidest tulenevat eripär a. Vastavad täiendused
viidi sisse asut use protseduuridesse ja juhenditesse ning täiustati oma
tegevust, et see vastaks EQUASSi kümnele kvaliteedi põhimõt tele.
Kohapeal koges audiitor, et sotsiaalteenuse osutaja tegutseb vasta vuses
EQUASS Assurance kriteeriumitega. Intervjueer itud huvigruppide ja
rahastajate esindaj atega, THK töötajatega ja teenuse saajatega samut i
kinnitasid seda, mis väljendus nende rahulolus.
36
Auditi käigus oli asutusel ette näidata mitmeid häid näiteid ja s aavutusi
EQUASS- i põhimõt ete täitmisel, mis on hea praktika näideteks. Kogu
asutuse töötajaskond oli lahke ja koostööaldis THK töö tutvustamisel,
vaj aliku tõendusmat erjali leidmisel ning inf ormatsiooni jagamisel EQUASS - 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 hõlma sid üldises plaanis THK
protseduur ide täiustamist (rehabilitatsiooniteenuse protseduur ja aastase
planeer imise pr otseduur), huvigruppidelt saadava tagasiside
kõikehõlmavamat dokumenteerim ist ning individuaalsetes plaanides
saadavate teenuste t ulemuste ulat uslikum at kirjeldamist.
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 THK on pühendunud kvaliteedi tagamisele ja täiustamisele
oma töös ning osutab kõrge kvaliteediga teenuseid.
Tallinn, 19. 12.2014
Mar iliis Männik -Sepp
EQUASSi audiitor
37
Maarika Aro
Saatja: Keiu Talve
Saatmisaeg: 8. jaanuar 2015. a. 10:19
Adressaat:
[email protected]
Koopia: Maarika Aro
Teema: audit report EST2014-005 Tartu Hiie Kool
Manused: EQ_Audit Report_Tartu_Hiie_Kool.doc; Tartu Hiie Kooli audit_loplik.xlsx
Olekulipp: Lipuga märgitud
Tere Hiie kooli pere,
Mul on rõõm teatada, et Tartu Hiie Kooli rehabilitatsiooniüksus on hinnatud vastavaks EQUASS Assurance
põhimõtetele ja seega on teile antud EQUASS Assurance sertifikaat. Palju õnne!
Sertifikaadi saadab teile Marie Dubost Brüsselist koos EQUASS logo kasutamise juhistega.
Sertifikaat kehtib 2 aastat, misjärel on uuesti tarvis läbida lõppaudit, kui soovite, et sertifikaadi kehtivus kestaks.
Olete endiselt oodatud osalema kõikidele EQUASS kohaliku esinduse poolt korraldatud teenuste kvaliteedi
teemalistele koolitustele, seminaridele ja küsimuste korral võtke meiega julgelt ühendust!
Lisast leiate auditi raporti ning auditi taotluse koos audiitori märgetega. Kui auditi raportis jääb midagi segaseks-
palun võtke ühendust minu ja ka audiitoriga.
Kõikide sertifitseeritud asutuste nimed avaldatakse www.equass.be ja www.equass.ee veebilehtedel.
Soovin edu ja jaksu ja järejepidevust järkuval kvaliteedinõuete rakendamisel!
Tervitustega Tallinnast,
Keiu
EQUASS Eesti
Astangu KRK
Tel: +372 5682 9104
www.equass.ee
www.astangu.ee
From: Guus van Beek [mailto:
[email protected]]
Sent: Thursday, January 08, 2015 10:00 AM
To: Keiu Talve
Cc: Marie Dubost; Maarika Aro; Mariliis Männik-Sepp
Subject: Re: audit report EST2014-005 Tartu Hiie Kool
Importance: High
Dear Keiu,
I h a ve r e vi e w e d t h e a u d i t r e p o r t f r o m Tartu Hiie Kool (r e f e r e n c e n u m b e r EST2014-005) a n d I c o n c l u d e
t h a t t h e s e r vi c e s (w i t h i n t h e s c o p e o f t h e a p p l i c a ti o n ) o f t h i s o r g a n i z a t i o n m e e t a l l t h e E Q U AS S
a s s u r a n c e c r i t e r i a . B a s e d o n t h e delegated power, which is described in the EQU ASS internal
procedures and approved by the I nternational EQU ASS Awarding Commi ttee, th e s e r vi c e s (w i t h i n t h e
s c o p e o f t h e a p p l i c a t i o n ) o f Tartu Hiie Kool (r e f e r e n c e n u mb e r EST2014-005) w i l l b e c e r t i f i e d w i t h
E Q U AS S As s u r a n c e i n S o c i a l S e r vi c e s .
1
Ac c o r d i n g t h e a g r e e d c o m m u n i c a t i o n p r o c e d u r e , I k i n d l y a s k y o u t o d i s s e mi n a t e t h e d e c i s i o n t o
c e r t i f y t h e s e r vi c e s (w i t h i n t h e s c o p e o f t h e a p p l i c a t i o n ) o f T a r t u H i i e K o o l (r e f e r e n c e
n u mb e r E S T2 0 1 4 - 0 0 5 ) w i t h E Q U AS S As s u r a n c e i n S o c i a l S e r vi c e s .
M a r i e D u b o s t w i l l s e n d t h e c e r t i f i c a t e (a n d g u i d e l i n e s f o r u s i n g t h e E Q U AS S As s u r a n c e l o g o )
d i r e c t l y t o T a r t u H i i e K o o l (r e f e r e n c e n u m b e r E S T 2 0 1 4 - 0 0 5 ) .
Kind regards,
Guus van Beek
European Quality in Social Services (EQUASS)
c/o EPR, 15, Rue de Spa , B-1000 Brussels
Belgium
Phone: +31653770121
Email:
[email protected] / website: www.equass.be
2