Kiri välja EIT Tugiliisu auditi raport Brüssellisse

EQUASS ASSURANCE APPLICATION ADDITIONAL INFORMATION 1. Short information about the organisation in the native language Erivajadustega Inimeste Toetusühing Tugiliisu ( EIT Tugiliisu ) osutab mitte institutsionaalseid ( avahooldus ) teenused täiskasvanud in imestele. Osutame teenuseid Tallinna linnale ja riigile näiteks: toetatud elamise teenus, igapäevaelu toetamise teenus, toetatud töötamise teenus ning lisaks Tegevusi ja Projekte mis aitavad vaimupuudega inimestel toime tulla iseseisva eluga tavapärases ühiskonnas. 2. Short information about the organisation in English (activities, clients, etc.) Support center for people with special needs tugiliisu was established at 2000. Since year 2002 we provide special welfare and social services for people with spec ial needs. Support center for people with special needs tugiliisu is a non - profit organization that seeks to develop communit y services for people with intellectual disabilities. We develop these services because we believe that every person has the right to live independentl y living and as well to organize their lives independently. Target group Severe and moderately disabled adults, who want to liv eas independentl y as possible in a normal environment. Our service users are working in open labor markets, based on activit y supervisors assistance. Our service users are mothers, whom we support in raising children. Our service users live in a normal environment, with the same rights and responsibilities as all other people. Goal Support for people with intel lectual disabilit y living independentl y. Working with the service user and his or her loved ones, providing a comprehensive, individuall y tailored support in everyday life and help support people with intellectual disabilities to find their place in societ y. Vision Be sustainable, progressive organization that has the best supporter for people with intellectual disablement who want to live independentl y in open societ y. 1 Services 1. Assistance in everyday life Everyday life support services are designe d to be man's best self -sufficiency and the development of psychosocial support, managing skills for everyday life and managing skills for work through counseling. 2. Supported living service Supported living services are dealing with people's social integra tion and support him, the possibilit y of creating a residential use. Peoples guide household and everyday life in the organization to ensure a reasonabl y self - sufficiency while living independentl y. 3. Supported work service Employment support services are d esigned to guide and advise people to support their self -sufficiency and improve the qualit y of life of his abilities suitable job searching and working time. 4. Support Person Śupport person for intellectuall y disabled adult is tailor made service to support person integration to societ y, dealing with difficult situat ions personal, help person to link to different services. Guidance targeting diff erent aspects of lif e bef ore person will be directed to the supported living ser vice or other ser vices. This ser v ice is ver y f lexible. 3. Name of the organisation as you would want it to appear on the EQUASS Assurance certificate Erivajadustega Inimeste Toetusühing Tugiliisu 4. Name of services / departments of the organisation in the scope of the application as you would want it to appear on the EQUASS Assurance certificate: Assistance in everyday life Supported living service Supported work service Support person service 2 5. Organisation’s logo Information to be published on EQUASS website: Name of the organisation : Erivajadustega Inimeste Toetusühing Tugiliisu Post address: Maleva 16, Tallinn 11711 Director: Agne Raudmees, [email protected] Contact person : Margarita Razorjonova, service coordinator, [email protected] Email: [email protected] Web: www.vaimukad.ee 3 EQUASS ASSURANCE ASUTUSE KÜLASTUSE ETTEVALMISTAMISE VORM Asutuse külastus: 14.-15.11.2013 Erivajadustega Inimeste Toetusühing Tugiliisu Mariliis Männik-Sepp © 2012 by European Quality for Social Services (EQUASS)Tõrge! Järjehoidja nime pole antud. Kõik õigused kaitstud. Antud dokumendi elemente ei tohi paljundada, kopeerida ega muul elektroonilisel moel salvestada ilma EQUASS kirjaliku loata.  Asutuse külastuse ettevalmistamise küsimused EQUASS Assurance taotlusvormile ja antud lisainformatsioonile põhinedes palume teil ettevalmistuseks vastata järgnevatele selgitust nõudvatele küsimustele: Üldised teemad (max. 10 küsimust) 1. Mida olete teinud teenuste kvaliteedi tagamiseks ja tõstmiseks oma asutuses? 2. Kuidas olete taganud asutuse personali pädevuse ja arendamise? 3. Kuidas olete asutuses korraldanud teenuse saajate õiguste kaitsmise? 4. Millised on asutuse eetilised põhimõtted? 5. Kellega ja millist koostööd asutus teeb ning millist lisaväärtust seeläbi on saavutatud? 6. Kuidas saavad teenuse seejad osaleda teenuste arendamisel? 7. Kuidas selgitatakse välja teenuse saajate vajadused ja kuidas neid arvestatakse asutuse tegevuste täiustamisel? 8. Kirjeldage asutuse teenuste osutamise protsessi ja holistilist lähenemist teenuse kasutajale? 9. Kirjeldage kestva arengu tsükli rak endamist oma asutuses. 10. Tooge näiteid innovaatilistest lahendustest oma asutuses. Version 1.0 2  1. Kvaliteedi põhimõtetele ja EQ U ASS Assurance kriteeriumitele vastavuse küsimused/ teemad: Teenusesaaja koordinaator Huvigrupid ja juhataja Teenuste Personal d Juht im in e 1. Kas olete teadlikud asutuse missioonist, visioonist ja x väärtushinnangutest? Palun sõnastage. 2. Milliseid on asutuse x x kvaliteedipõhimõtted? 3. Kuidas on Teil võimalik anda tagasisidet pakutavate teenuste x x kohta? 4. Kirjeldage, milliseid asut use teenuseid teate ning kuidas olete x x nendest teada saanud? 5. Milliseid kogukonnale suunatud tegevusi olete teinu d ja kuidas annate lisandväärtust x kogukonnapõhistesse tegevustesse? 6. Milliseid ühiskonna vajadustele vastavaid mõõdetavaid tulemus i x olete kogukonnapõhiste tegevuste kaudu saavutanud? P er so na l 1. Kuidas jälgitakse teenuse pakkumisega otseselt tegelevate x x töötajate tegevust (perioodiliselt)? Version 1.0 3  2. Kuidas kaasatakse personali teenuste planeerimisse, x x arendamisse ja hindamisse? 3. Kuidas on tagatud personalipoliitika kooskõla x tööseadusandlusega? 4. Kuidas hinnatakse juhtkonna, personali ja vabatahtlike x x töötingimusi? 5. Kuidas toimub töötajate x x tunnustamine? Õ igu se d 1A. Selgitage, kuidas Teid on informeeritud ja kuidas tunnete „klientide õigus ja kohustusi“, tuues mõned näited? x x 1B. Kas olete teadlik (Teid on informeeritud) oma õigustest ja kohustustest teenuse saajana ning olete andud vastava kinnitava allkirja? 2A. Kuidas on korraldatud ettepanekute ja kaebuste menetlemise kord ning tagatud selle asjakohasus ja läbipaistvus ? x x 2B. Kuidas teenuse saajad saate esitada ettepanekuid või kaebusi? 3A. Kuidas aitab teenuse osutaja kaasa patsientide enesemääratlemisele ja kuidas seda x x iga-aastaselt hinnatakse ? 3B. Kuidas teenuse osutaja aitab Version 1.0 4  kaasa teie enesemääratlemisele ? 4. Kuidas informeeritakse teenuse saajat õigusest saada eestkostjat või x x tugiisikut ja kuidas seda iga -aastaselt hinnatakse? 5. Kas teid on koheldud austusega? x E et i k a 1. Kuidas Teid on informeeritud eetikakoodeksist ja kuidas tunnete x vastavaid põhimõtteid (tooge näiteid)? 2. Kui sageli vaadatakse üle ja analüüsitakse (koos personaliga) konfidentsiaalsusega seotud x x nõuded ning milliseid muudatusi viimati tehti? 3. Kui hästi tunnete teenuste osutamise põhimõtteid ning x väärtushinnanguid (tooge näiteid)? 4. Kuidas pääsete ligi oma isiklikele x andmetele? (klienditoimik) 5. Kus on kirjeldatud ja k as teate oma x rolli ja vastutusulatust? Koo st öö 1. Kellega ja millist koostööd tehakse (selgitage näidete varal, sh x x sotsiaalvaldkonna partnerid, rahastajad, teenuse kasutajad)? 2. Kuidas kaasatakse teenuste x x x arendamisse teenuse saajaid (nende esindajaid), teenuse ostjaid ja hankijaid? 3. Kuidas kaasatakse (nende) x x Version 1.0 5  vajaduste väljaselgitamise protsessi huvigruppe? 4. Kuidas analüüsite ja hindate x x koostööst tulenevat lisandväärtust? 5. Kuidas olete rahul koostööga? x x O s alu s 1. Kuidas osalevad kliendid vajaduste x x x väljaselgitamisel, teenuste planeerimisel ja a nalüüsimisel? 2. Kas ja kuidas on personali x x x koolitatud teenuse saajate jõustamise teemal ning kuidas see toimu igapäevases elus? 3. Kuidas aitab teenuse osutaja x kaasa teenuse saajate jõustamisele ja milliseid mõõdetavaid tulemusi on saavutatud? 4. Kas ja kuidas on teenuse saajate x x x osalemiseks vajalikud meetmed, tegevused ja kord kooskõlastatud teenuse saajatega või nende esindajatega? 5. Kui sageli vaadatakse üle teenuse x x saajate või nende esindajate osalemisega seotud meetmed ning millised on olnud viimased muudatused? Is ik uk e sk su s 1. Kuidas on kindlaks tehtud x x rahastajate vajadused ning teiste oluliste organisatsioonide huvigruppide vajadused ja kuidas Version 1.0 6  nendega arvestatakse? 2. Kuidas olete rahul teenusepakkuja x asukohaga? 3A. Kuidas on tagatud, et teenuse x x osutaja pakub oma teenuseid vastavalt teenuse saaja vajadustele? 3B. Kas individuaalne tegevusplaan vastab Teie vajadustele ja ootustele? 4. Kuidas vaadatakse asutuse poolt x pakutavaid teenuseid üle, arvestades samas teenuse saajate oodatava te tulemustega? 5. Kas individuaalne tegevusplaan on x x kooskõlastatud ja seda on korrigeeritud vastavalt teenuse saaja tagasisidele? Lai ah a ar de li su s 1. Kuidas asutus tagab, et personalil x x on ühtne arusaam peamistest teenuse osutamise protsessidest ja enda vastutusest nendes? 2. Kuidas asutus hindab teenuse x osutamise protsessi, et tagada teenuse saajate vajadustele ja huvidele vastavalt sujuvust üleminekul? 3. Kuidas asutus kasutab x x multidistsiplinaarset lähenemist kliendile individuaalse tegevusplaani koostamisel ja rakendamisel? 4. Kuidas asutus tagab, et teenuse x x saaja elukvaliteet on Version 1.0 7  individuaalselt määratletud teenuse saaja või tema perekonna poolt? 5. Kas ja kuidas teenuse jätkuvust x x hinnatakse iga -aastaselt? 6. Kuidas on tagatud teenuste ja x x programmide osutamisel üleminekute sujuvus? T ulemu st el e 1. Kuidas võrreldakse kliendi x ori en t e e rit u s individuaalse tegevusplaani tulemusi osutatud teenuste tulemustega ehk kuidas iga individuaalne plaan panus tab üldisesse teenuse tulemuslikkusesse? 2. Kuidas mõõdetakse teenuse x x hankijate / tellijate ja rahastajate rahulolu? 3. Kuidas on tagatud asutuse x tegevuse kooskõla seadusandlusega? 4. Kellele ja millist ülevaadet antakse x x asutuse tegevusest nin g kas see on sihtrühmadele arusaadavas keeles? 5. Kuidas kogutakse huvigruppidelt x x tagasisidet aastaaruandes kajastatud tulemuste kohta? Pi dev a r eng 1. Kirjeldage PDCA tsükli toimimist x x oma asutuses? 2. Kuidas ollakse kursis huvigruppide x uute ja muutuvate vajadustega? Version 1.0 8  Tooge näiteid huvigruppide esilekerkinud vajadustest 3. Tooge näiteid innovaatilistest x x töömeetoditest? 4. Tooge näiteid x innovatsiooniprojektidest? 5. Millised olid viimase kvaliteedi x parendamise projekti tulemused? 2. Nõutav dokumentatsioon EQUASS Assurance taotlusesse märgitud infole ja lisadele põhinedes palume vaatluseks ette valmistada järgnev dokumentatsioon: 1. käsiraamat 2. kliendi toimik 3. kaust Koosolekute protokollid 4. kaust Töökord 5. kaust Personal 6. kaust Koostöö 7. kaust Statistika 8. kaust Kaebused, Kiitused, Ettepanekud 9. kaust Kliendid 10. kaust Koolitus 11. kaust Sponsorid 12. kaust Lepingud 13. kaust Järjekord teenustele 14. kaust Suunamised teenustele 15. majandusaasta aruanne, väljatr ükk Version 1.0 9  3. Personali, teenuse saajate ja teiste oluliste huvi gruppide intervjueerimine EQUASS Assurance taotluses antud vastustele ja tõenditele põhinedes palume korraldada intervjuud järgmiste inimestega (funktsioon ja kestvus): Juhtkond Kestvus 1. juhataja 45 minutit Personal Kestvus 1. teenuste koordinaator 45 minutit 2. tegevusjuhendaja 45 minutit 3. tugiisik 45 minutit Teenuse saajad Kestvus 1. grupis 2-5 teenuse saajat 30 minutit 1. grupis 2-5 teenuse saajat 30 minutit Teised huvigrupid Kestvus 1. Koostööpartner 45 minutit 2. Rahastaja 45 minutit Version 1.0 10  4. Asutuse kül astuse ajakava 14.11.2013 Päev 1 Aeg Tegevus (lühike kirjeldus) 9.00-12.00 Avakoosolek, dokumentatsiooni ülevaat us 12.00-13.00 Lõunapaus 13.00-13.45 Dokumentatsiooni ülevaatus, vorm ide täit mine 13.45-14.30 Intervjuu teenust e koordinaatoriga 14.30-15.30 Dokumentatsiooni ülevaatus, vormide täit mine 15.30-16.15 Intervjuu tegevusjuhendajaga 16.15-17.00 Intervjuu tugiisikuga 15.11.2013 Päev 2 Aeg Tegevus (lühike kirjeldus) 9.00-10.45 Dokumentatsiooni ülevaatus, vormide täit mine 10.45-11.45 Intervjuu teenuse saajatega 11.45-12.45 Lõunapaus 12.45-13.30 Intervjuu koostööpartneriga 13.30-14.15 Intervjuu rahastajaga 14.15-15.15 Dokumentatsiooni ülevaatus, vormide täit mine 15.15-16.00 Intervjuu juhatajaga 16.00-16.45 Dokumentatsiooni ülevaatus, vormide täit mine 16.45-17.00 Lõpukoosolek Version 1.0 11 EQUASS ASSURANCE AUDIT REPORT Site visit: 14.-15. 11. 2013 Erivajadustega Inimeste Toetusühing Tugiliisu Mar iliis 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 Erivajadustega Inim este Toetusühing Tugiliisu service provider (EIT Tugiliisu) Address: Maleva 16, Tallinn Post box: N/A Person responsible Agne Raudmees, manager (CEO): Contact person: Agne Raudmees, manager Phone: 6605067 Fax: N/A E-mail: tugiliisu@vaimukad. ee Web site: www. vaimukad.ee , www.tugiliisu.ee Name of Auditor: Mar iliis Männik -Sepp Dates of audit: 14.-15.11.2013 Clients: Number of person served: 70 As of (date): 15.11 .2013 Staff: Number of Full time staff : 16 Number of Part time staff : N/A Number of Contracted staff : 3 Number of volunt eer s: 1 Services: 1. Assistance in everyday lif e 2. Supported work 3. Supported living 2  2. Audit program 14.11.2013 Day 1 Time Acti vit y 9.00-12.00 Opening meeting, documentation review 12.00-13.00 Lunch break 13.00-13.45 Documentation r eview, up-dat ing f iles 13.45-14.30 Interview w ith financing body - Mar i-Ly Soomer, Social Insurance Board 14.30-15.30 Documentation review, up -dat ing f iles 15.30-16.15 Interview w ith personnel - Eve Sõrmus, activit y super visor 16.15-17.00 Interview w i th personnel - Ar vo Raudm ees, support person 15.11.2013 Day 2 Time Acti vit y 9.00-10.45 Documentation review, up -dat ing f iles 10.45-11.45 Interview w ith a group of persons served (Ken Pääsuke, Oliver Puusepp, Albert Altmäe, Juhan Varik, Jaana Kütt, Mar ika Varik, Üllar King, Aivar Kaasik) 11.45-12.45 Lunch break 12.45-13.30 Interview w ith cooperation partner - Kerttu Rakke, MTÜ Vaimupuu 13.30-14.15 Interview w ith personnel – Margarita Razorjonova, coordinator of ser vices 3  14.15-15.15 Documentation r eview, up-dat ing f iles 15.15-16.00 Interview w ith manager Agne Raudmees 16.00-16.45 Documentation review, up -dat ing f iles 16.45-17.00 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 Tugiliisu are documented in the handbook of the organization. It was demonstrat ed through the inter views that the employees are well aware of the organization’s mission, vision and values. 2. The social servi ce provider defines, documents, and imple ments its qualit y policy by determining long term qualit y goals, and its commitment to continuous improvement. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The qualit y policy or main values and The long term goals of the 4 qualit y goals are described in the organizat ion are expressed ver y handbook of the organization. generally. It appeared f rom the inter views with the manager that in It appeared f rom the inter views that realit y the goals are much more the staff is well inf ormed of the specif ic, but have not been qualit y pr inciples. expressed in a wr itten f orm at. As there is no other strateg y document in Tugiliisu, then it woul d be advisable to think thoroughly through the long -term goals and perhaps conduct a SW OT analysis with the personnel (f .e during strategy day) and to compile a strategy document that would include the long term goals and pr ior ities . Asutuse pikaajalised e smärgid on esitatud üldises sõnastuses. Intervjuust juhatajaga ilmnes, et tegelikuses on eesmärgid palju spetsiif ilismad, kuid neid ei ole kirjalikult sõnastatud. Kuna asut uses ei ole muud strateegiadokumenti, oleks soovitatav põhjalikult läbi mõelda asutuse pika-ajalised eesmärgid ja prior iteedid ning võib-olla viia läbi ka SW OT analüüs koostöös personaliga (nt strateegia päeval) ning vorm istada need kirj alikult. 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 Person ser ved, f amilies and ser vice As asking f eedback is today not done user organizations have the always on regular basis, it would be opportunit y to give f eedback through advisable t o deve lop regular ways t o client inter views (once a year), also receive f eedback. F.e regular written through Facebook and guestbook. questionnaires, regular meetings There are also meetings organized in with stakeholders (partners, Tugiliisu. f inancing bodies, similar organizat ions etc). Also, it would be A policy f or handling complaints, advisable to descr ibe this procedure compliments and suggestions has in the handbook of the organization . been developed. Twice a year the manager conducts phone inter views Seoses sellega, et tagaside küsimine with persons ser ved (and/or their ei ole korraldatud tänasel päeval f amilies) in order to gain f eedback. regulaarselt, on soovitatav välj a töötada viisid regulaarse tagasiside saamiseks. Nt kirjalikud küsimustikud, korralised koosolekud huvigruppidega ( partnereid, rahastajad, sarnased organisatsioonid jne). Samuti on soovitatav kirjeldada tagasiside saamise protseduur asut use käsiraamatus. 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 do not meet this crit erion of the EQUASS Assurance certif icat ion program. Strengths Improvem ent & developments Tugiliisu has inf ormed its The processes and procedur es of stakeholders about ser vices off ered. Tugiliisu ’s ser vices are lacking at This is done by using internet, this point of time . Tugiliisu is 6 organizing mee ting s, taking activel y planning to compile the procedur es part in the work of the prof essional and procedur es f or implement ing its associat ion. This was also ver if ied ser vices, but this exercise is still implemented through inter views. unf inished. Tugiliisu relies on the inf ormation disclosed on the web sit e Inf ormation about services is of Social Insurance Board's web site available on the homepage of and on the “activities’ super visor Tugiliisu and on its Facebook manual” available f rom the web site account. There are also brochur es of the Ministr y of Social Aff airs. available. At the moment the home page www.tug iliisu.ee is under construct ion, includes outda ted inf ormation and is not ver y inf ormative. Part ially inf ormation about Tugiliisu is available under the web site of the prof essional associat ion ( www. vaimukad.ee ). For ensur ing better inf ormation and communication, it would be advisable to complement t he home page wit h necessar y inf ormation as soon as possible. Tugiliisu teenuste protsessid ja protseduur id tänasel päeval puuduvad. Tugiliisu planeerib koostada inf o oma teen uste osutamise protsesside ja protseduur ide kohta, kuid tänaseks ei ole seda ülesannet veel täidetud. Tugiliisu tugineb inf ormatsioonile Sotsiaalkindlustusameti kodu lehel ning “Tegevusjuhendaj a käsiraamatule”, mis on kättesaadav Sotsiaalministeerium i kodul ehelt. Praegusel ajahetkel on koduleht www.tug iliisu.ee valmimisel, sisaldab 7  vananenud inf ormatsiooni ja pole väga inf ormatiivne. Osaliselt on inf ormatsioon Tugiliisu kohta kättesaadav prof essionaalse eriala organisatsiooni kodulehelt (www. vaimukad.ee ). Parema inf ormatsiooni ja kommunikatsiooni tagamiseks on soovitatav t äiendada koduleht e vaj aliku inf ormatsiooniga niipea kui võimalik. 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 for annual planning process is descr ibed in the handbook and the format of annual plan itself of the organization , which is has a lot of room f or development. available to all of the staff . A thorough analysis of the procedur e The annual plan f or Tugiliisu was and the plan itself is strongl y compiled f or the f irst time in 2013 . It recommended. As a result the policy includes also an action plan f or and the plan are expected to become 2013. much more systemat ic and associated. As it is the f irst cycle f or Tugiliisu, it has not reached the analysis phase Aastaplaani koostamise protseduur i (of the plan and the procedure) yet, ning aastaplaani f ormaadil endal on but will analyze the procedure at the palju arenguruumi. beginning of 2014. Tungivalt soovitatav on läbi viia põhjalik aasta planeerimise protsessi ja aastaplaani vormi analüüs. Selle 8  tulemusena peaks poliitika ja plaan muutuma palju enam süsteemsemaks ja omavahel seostatavamaks. 6. The plan includes:  annual outcomes / targets  the acti vities to be undertaken in achieving the annual targets  monitoring of the performance of the organization in meeting its annual targets time-scales and procedures for revi ew and revi sion. Remark from the auditor: The ser vices of the soci al ser vice pr oviders do not meet this crit erion of the EQUASS Assurance certif icat ion program. Strengths Improvem ent & developments The annual planning process of The annual plan of Tugiliisu is Tugiliisu is planned to have a cyclic expected to become mor e character. The annual act ion plan inf ormative and detailed. The includes objectiv es. objectives should be SMART. The annual plan is approved by the The goals descr ibed in the text part manager of Tugiliisu. of the annual plan and in the action plan (which is in table f ormat) do not correspond to each other ent irely and they are presented in random order, not grouped by any goal or sub-object ive. The expect ed results are not always tangible or m easurable and indicators have been developed onl y to some of the goals/measures. It would be advisable to describe general goals in the text part of the plan and detailed activities in the action plan. 9  Tugiliisu aastaplaan peaks olem a inf ormatiivsem ja detailsem. Eesmärgid peaksid olema SMART. Aastaplaani tekst iosas ja tegevuskavas (tabeli f ormaadis) kirjeldatud eesmärgid ei ole omavahel täiest i kokku viidav ad ning on esitatud juh uslikus järjekorras, mitte grupeerit ult m õne eesmärgi või alaeesmärgi lõikes. Soovitatav on kirjeldada eesmärke üldisemalt aastaplaani tekstiosas ning detailsemalt tegevuskavas. 7. The social servi ce provider demonstrates organization’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 Feedback f rom staff , client s and In order to better demonstrate its stakeholders is collected, as ver if ied success in the sat isf act ion of the through inter views. Also the minutes needs of the societ y and the results of meetings of Tugiliisu and in meeting the needs and summaries of var ious event s, that expectat ions of the societ y, the y they have organized, have proved should be summar ized in the annual that the needs and expectat ions of activit y report of Tugiliisu. the societ y are being satisf ied. Selleks, et paremini väljendada oma edukust ühiskonna ootuste ja vaj aduste rahuldamises ning vastavaid tulemusi, tuleks vasta v inf ormatsioon kokkuvõt likult esitada asutuse aasta tegevusaruandes. 10  8. The social service provider demonstrates organisati on’s social responsibilit y t hrough acti vities contri buting to the societ y. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUA SS Assurance certif ication program Strengths Improvem ent & developments Tugiliisu has contributed to the It would be advisable to use societ y. It is devoted to the questionnaires/ sur veys to receive development and improvement of f eedback f rom stakeholders. ser vices meant f or mentally disabled people. Huvigruppidelt tagasiside saam iseks on soovitatav kasutada küsimust ikke/ Tugiliisu has been active in inf orming uuringuid. the societ y about the problems and developments in the services f or the mentally disabled people. Also it has been active in def ending the rights of mentally disabled people. Tugiliisu takes part in the activities of Estonian Mentally Disabled People Support Organization. Tugiliisu also issued magazine called “Vaimukad” ( “The W itts” in English) . 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 11 Tugiliisu has developed its s taff The principles of equalit y and non - policy. All employees have job discr imination should be better descr iptions, which include required pointed out in the staff policy. knowledge, skills and competences. Võrdsuse ja diskrimineer imise It appeared f rom the inter views wit h vastasuse poliit ika peaks olema the personnel that they are awar e of selgemini kirjeldatud their roles, rights and dut ies. It also personalipoliitikas. came out that the employees are motivated, like their jobs and are devoted to delivering qualit y ser vice. 10. The social service provider operates in compli ance w ith mandator y national legisla tion, 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 A ssurance certif ication program Strengths Improvem ent & developments The staff documentation meets legal requirements and is reviewed to do this. Staff level is kept at optimum and this is reviewed annually. The principles f or showing recognit ion to em ployees are descr ibed in staff recognition policy. Award trips and trainings are an example of showing recognition. From 2013 onwards also best employees of the year are elected. 12  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 Strengths Improvem ent & developments Employees’ training policy has been Drawing up annual training plan drawn up. Annual training plan is should be descr ibed in the staff f ormulated based on the needs of the policy. employees and expectat ions of Tugiliisu. The process of gaining f eedback after trainings and the evaluation Staff is trained on needs bases and scale of trainings should be all the inter viewed employees descr ibed in the staff policy. showed satisf action concerning the Prepar ing a wr itten summary of the trainings receive d. training (including its eff iciency in ver bal expression) would be a good Training needs are discussed during idea. annual staff evaluations. Feedback f rom passed training is collected . Koolituskava koostamise pr otsessi tuleks kirjeldada koolit us poliit ikas. Koolituste jär gselt tagasiside kogumine ja koolit uste hindamise skaala tuleks lahti selgitada koolituspoliit ikas. Koolitusest kirjaliku kokkuvõtte (sh verbaalne väljendus ef ektiivsuse kohta) koostamine oleks hea idee. 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 13  Strengths Improvem ent & developments The competence r equirements f or During internal control procedures employees are described in their job several weaknesses in the written descr iptions. reports (compiled by act ivit y super visors) have been discovered. Annual staff evaluat ions are carried out, as descr ibed in the staff policy, Tugilii su should continuously carr y where the before mentioned out internal control procedures and requirements are assessed. consult more employees to ensure the qualit y of the reports and through Internal control p rocedures are also this also the qualit y of services . used to review the perf ormance of staff members, who are direct ly Sisekontrolli protseduur ide käigus involved in ser vice deliver y. tuvastati mitmeid puuduseid (tegevusjuhendajate koostatud) kirjalikus aruandluses. Tugiliisu peaks jätkuvalt läbi viim a sisekontrolli pr otseduure ja nõustama töötajaid, et tagada aruannete ja seeläbi teenust e kvaliteet. 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 Tugilii su recognizes staff as a usef ul Employees’ partici pation (gaining tool f or gaining inf ormation. Staff f eedback and using it concerning the meetings are organized regular ly, planning and evaluation of services) where important questions ar e should be more clearly descr ibed in discussed and f eedback f rom staff is 14 received. Minutes of meetings are the handbook of the organizat ion . prepared. Also, the f eedback gained, should be document ed more pr ecisely. Töötajate kaasamist (tagasiside saamine ja kasutamine t eenuste planeer imise ja hindamise osas) tuleks selgemalt kir jeldada asutuse käsiraamatus. Samuti t uleks saadud tagasisidet täpsemalt dokumenteerida. 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 Annual employees’ evaluat ions are used to gain f eedback on satisf action and motivation. The results of evaluat ions are document ed. Also, recognit ion policy f or staff has been developed. Best employees have been given awards. Interviews with staff proved high motivat ion and satisf action of staff . 15  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 ona l 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 & developmen ts Tugiilisu has developed the rights and duties of persons ser ved, which conf orm to international human rights convent ions. They are introduced to the persons ser ved by staff . The rights of persons are part of the contract signed wit h the persons ser ved . The rights and duties are also introduced dur ing meetings of staff and meet ings wit h clients. The staff and clients demonstrated their knowledge of their rights and duties through the interviews. 16. The soci al service provider informs the person ser ved 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 m eet this cr iterion of the EQUASS Assurance certif ication program 16  Strengths Improvem ent & developments The rights and duties of persons ser ved are introduced to the persons ser ved by the activit y super visors of Tugiliisu. Clients sign the documentat ion concerning their rights and duties (service contract). The staff and persons ser ved demonstrated their knowledge of the rights and duties through the inter views. 17. The social service provider has accessibl e complai nt management s ystem w hich registe rs 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 Tugiliisu has developed a policy f or In order to make the system better handling complaints, praises and accessible and transparent, it would proposals. be advisable to add inf ormation about making proposals and If was verif ied during the interviews complaining on the organizat ion ’s that the persons served were awar e web page. of the ways of making proposals and complaining. The policy should pay also more attention to receiving related f eedback from f inancing bodies and other relevant stakeho lders. Süsteem i kättesaadavamaks ja läbipaist vamaks muutmiseks on 17  soovitatav lisada inf ormatsioon kaebuste ja ettepanekute kohta asutuse kodulehele. Samuti peaks poliitika ena m tähelepanu pöö r ama vastava tagasiside saam isel e rahastajatelt ja teistelt seotu d osapooltelt. 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. Remark from the aud itor: 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 It is described in the ethical Tugiliisu should am end its policies principles of Tugiliisu that staff with the description, how its should respect the fundamental r ight perf ormance in respecting the right to self -determinat ion of the persons to self -determination of the person ser ved. ser ved is evaluated with the persons ser ved. Also, how the results of the Also the rights and duties of persons evaluat ion ar e documented. ser ved include this principle. Tugiliisu peaks täiendama om a It became evident through the poliitikaid kirjeldusega, kuidas koos inter views that the staff was aware of teenuse saajatega hinnatakse this issue and the persons ser ved Tugiliisu käitumist teenuse saajat e were handled wit h respect. enesemääramisest lugup idamise osas. Samuti, k uidas vastava Tugiliisu evaluates its perf ormance hindamise tulemused in respect ing the right to self - dokumenteeritakse. determination of the person ser ved during its meetings . 18  19. The social service provi der facilitates the person served in choosing and having access to advocates and/or supporting persons. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Person ser ved are inf ormed about Tugiliisu could do better in the right to receive inf ormation evaluat ion of its perf ormance in the concerning advocates and/or f acilitat ion of choosing/accessing to support ing persons by the staff of advocates/support ing persons. This Tugiliisu. activit y should be carried out This was proved through inter views annually and should be descr ibed in with clients and staff. Tugiliisu’s policies. Also inf ormation, how the results of the evaluation are document ed. Tugiliisu saaks parendada oma tegevust iga-aastases hindamises, kuidas on abistatud teenuse saajaid leidmaks eestkostja ja/või tugiisik. Seda tegevust tuleks teostada iga - aastaselt ning kirjeldada asutuse poliitikates. Samuti inf ot, kuidas vastava hindamise tulemused dokumenteeritakse. 20. The social service provi der defines and documents its policy on ethics that respects and assures the dignit y of the persons served, protects them from undue risk and promotes soci al justice Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & de velopments 19 The ethical pr inciples of Tugiliisu ar e document ed and include respect ing and assur ing the dignit y of the persons ser ved. These principles have been introduced to employees , which was ver if ied through the interviews. 21. The social service provider operat es mechanisms w hich prevent the physi cal, mental and financial abuse of users. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The ethical pr inciples of Tugiliisu Tugiliisu could do better in include its ways to prevent the evaluat ion of its perf orma nce in physical, mental and f inancial abuse prevent ing the physical, mental and of service users. f inancial abuse of service users. Tugiliisu evaluat es its related This activit y should be carried out perf ormance during meetings. annually and described in Tugiliisu’s policies. Also inf ormation, how the results of the evaluat ion are document ed. Tugiliisu saaks parendada oma tegevust iga-aastases hindamises, kui ef ektiivne ollakse oma tegevuses teenuse saajate f üüsilise, vaimse j a majandusliku ärakasutamise ennetamisel. Nimetatud tegevust tuleks läbi viia iga-aastaselt ning kirjeldada asutuse poliitikates. Samuti inf o, kui das hindamise tulemusi 20  dokumenteeritakse. 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 Working conditions are evaluated It would be advisable to do thorough (risk assessment) and necessar y risk analysis on regular basis and t o amendments are made. descr ibe necessar y amendments in action plans of the organizat ion also The measures and activities f or in f uture. ensur ing saf e system of working and saf e environment are described in Põhjalikke r iskianalüüse tuleks teha Tugiliisu’s manual f or saf e working . teatava regulaar susega ning analüüsist tulenevad The activit ies related to health and parendustegevused ka edaspidi saf ety plan are described in the kirjeldada asutuse tegevuskavas. action plan of Tugiliisu. 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 t he ethical pr inciples of 21 Tugiliisu. It was demonstrated through the inter views of staff that they ar e aware of the ethic principles related to their work. 24. The social service provider defines, documents, monitors and evaluat es procedures for assuring confiden tialit 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 Tugiliisu has docum ented policy f or In order to guarantee the review and the protect ion of personal data. The analysis of the policy once in ever y policy is introduced to all of the staff two years, this should be laid down and is reviewed. in the policy (f or employees) . The policy has been translated also Tagamaks poliit ika ülevaatus ja into “ easy to read” language f or the analüüsim ine vähemalt kord kahe clients. aasta tagant, tuleks see r eguleer ida vastavas (töötajatele mõeldud) Tugiliisu has analyzed this policy. poliitikas. 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 22 The necessar y roles and Even though the cr iterion is met, it is responsibilities are descr ibed in the suggested to consider disclosing the job descr ipt ions of employees. The roles and responsibilities of roles and responsibilit ies of the employees on the or ganizat ion’s web management are described in the page. statue of the organization. Kuig i kriteeriumiga ollakse It was ver if ied through inter views vastavuses, oleks soovitatav kaaluda that the persons served were awar e töötajate rollide ja vastutuse of the roles and responsibilities of avaldam ist asutuse kodulehel. the staff and management . 26. The social service provi der w orks in partnership w ith other organizations 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 Tugiliisu does cooperation with its It would be good to make a list of partners. It does str ong cooperation Tugiliisu’s partners and group them with the prof essional organizat ion of by the f ield of partnership. disabled people – Estonian Mentally Disabled People Support Besides asking oral f eedback, it Organization. would be advisable to ask written f eedback (f . e questionnair es) f rom Partnership and its added value is partners concerning their sat isf action discussed and evaluated dur ing (also the value that they see in the meetings. partnership with Tugiliisu and how to make partnership even more From partner ’s inter view it appear ed eff ective). that the cooperation has pr oved successf ul. Evaluat ing the added value of partnerships on r egular basis should be descr ibed in Tugiliisu’s policies. Also, how the results of evaluation are documented. 23  Oleks hea teha nimekiri Tugiliisu partneritest ning grupeer ida need partnerluse valdkonna alusel. Lisaks suulisele tagasisidele partneritelt , oleks soovitatav küsida kirjalikku tagasisidet ( nt küsimustikud) part nerite lt nende rahulolu kohta (samuti partnerit e rahulolu koostööst saadava lisaväärtuse kohta ning kuidas partnerlust veel ef ektiivsemaks muuta). Koostöösuhetest tuleneva lisaväärtuse hi ndast tuleks kirjeldada Tugiliisu dokumentatsioonis, samut i kuidas hindamise tulemusi dokumenteeritakse. 27. The social service provider w orks in partnership w ith persons served, purchasers and other stakeholders in the development of services. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The persons ser ved, purchasers and More attent ion should be paid to other stakeholders are welcome to receiving f eedback f rom f inancing participate in the development of bodies. ser vices of Tugiliisu through meeting s. Also, other important stakeholders should be more systemat ically involved in t he identif icat ion of (their) needs. Enam tähe lepanu peaks pöörama 24  tagasiside saam isele rahastajatelt. Samuti t uleks kaasata teisi olulisi väliseid huvigruppe süsteemsemalt (nende vajaduste väljaselgitamisse ). 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 aud itor: 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 criterion was ver if ied sat isf ied The policy and procedures f or the through exploring client work involvement of clients (act ive documentat ion and through participation in service planning, inter views with staff and clients. implementation and management) should be descr ibed in more detail. Besides, Tugiliisu has trained some of its members to be self -advocates. Teenuse saajate osalem ist (aktiivne kaasamine teenust e planeer imisse, läbiviimisse ja juhtimisse) tuleks kirjeldada detailsemalt poliit ikates ja protseduur ides. 29. The social service provi der institutes an annual evaluation of partici pation of persons served bot h on indi vidual and/or group basis. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments 25 The measures, activ ities and polic y The policy of client participat ion f or client participation is introduced should be wr itten down in mor e and discussed during clients’ detail and also the f act of analyzing meetings and is reviewed. this policy annually is better guaranteed, if added to the corresponding policy. Klientide osalem ine teenustele kaasarääkimises tuleks kirjalikult esitada üksikasjalikuimalt ning samuti on vastava poliit ika iga - aastane analüüs paremini tagatud, kui see on lisatud vastavasse poliitikasse. 30. The social service provi der operates specific instruments f or users to improve their personal empow erment 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 E QUASS Assurance certif ication program Strengths Improvem ent & developments The criterion was ver if ied sat isf ied Empowerment and t he f acilitation of through exploring client work empowerment of the persons ser ved documentat ion and through should be def ined and described in inter views with staff and clients. wr itten f ormat in the handbook of the organizat ion. Empowerment is an important part of the work of activit y super visors. It is advisable to bring out more clearly t he tangible results achieved in strengthening the empowerment of persons being served in the organizat ion’s annual activit y report. Jõustamine ja jõustamise tugevdamine tuleks def ineerida ja laht i selgitada kirjalikus vormis 26  asutuse käsiraamatus. Soovitatav on välja tuua selgemalt mõõdetavad tulem used teenuste saajate jõustam ise tugevdamises asutuse aasta-aruandes. 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 The criterion was ver if ied sat isf ied The measures f or creating an through exploring client work empowering environment should be documentat ion and through more clear ly described in the inter views with staff and clients. organizat ion’s documentation. The employees ar e tra ined about Jõustava keskkonna loom ise empowerment . meetmeid tuleks täpsemalt kirjeldada asutuse dokumentatsioonis. 32. The social se rvi 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 Tugiliisu is off ering services based on the needs of persons ser ved . The ser vices are delivered in Tallinn. Recently new prem ises were opened 27 f or better service deliver y. The persons ser ved expressed satisf action with t he locat ion of ser vice deliver y. 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 Cooperation meet ings have taken It would be advisabl e to conduct place to discuss the needs and more comprehensive sur veys to expectat ions of stakeholders . ascertain the needs and expectations of various stakeholders. Soovitatav on korraldada laiaulatuslikumaid uuringuid, et selgitada välja huvigruppide vaj adused ja ootused. 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 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. 28 The process itself is described in the policies of the organizat ion. 35. The social servic e 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 During the internal control expectat ions are wr itten down in the procedures some shortcomings wer e individual plan s. identif ied in the client work documentat ion. More attent ion The individual plans involve all the should be paid to the qualit y of cl ient inf ormation set by the criter ion and work documentation. are agreed by the persons ser ved, which was verif ied by examples of Also, more attention should be paid client documentation seen during the to the wording of specif ic site visit. measurable objectives. Sisekontrolli protseduur ide käigus tuvastati puudujääke kllienditöö dokumentatsioonis. Seega tuleb klienditöö dokumentatsiooni kvaliteedile edasi pidi enam tähelepanu pöörata. Samuti tuleb enam tähelepanu panna mõõdetavate eesmär kide sõnastam isele. 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. 29 Remark from the auditor: The ser vices of the social ser vice pr ovider do not meet this crit erion of the EQUASS Assurance certif icat ion program. Strengths Improvem ent & developments Tugiliisu uses t he ser vice delive r y The service deliver y pr ocesses of processes descr ibed on the web Tugiliisu should be descr ibed in the page www.ensib.ee and in handbook handbook of the organizat ion. The “Tegevusjuhendaja käsiraamat” processes should be in line with (activit y super visor ’s manual) . Tugiliisu’s vision, mission and qualit y principles. It has initiated the process of descr ibing its processes in the The processes should be regular ly organizat ion’s handbook. reviewed. Tugiliisu teenust e osut amise protseduur id peaksid olema kirjeldatud asutuse käsiraamatus. Protsessid peaksid olema kooskõlas asutuse visiooni, missiooni ja kvaliteedi põhimõtet ega. Protseduure peaks regulaarselt üle vaatama. 37. The social service provi der review s this deliver y 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 The ser vice delivery is r eviewed during the internal control process es. The processes t hemselves are discussed per iodically during 30 meetings. 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 Needs of persons ser ved ar e Even though the cr iterion is met, it is evaluated annually and accor dingly suggested to report the results of the necessar y ser vices are provided. evaluat ion of service cont inuation more precisely. Kuig i kriteeriumiga ollakse vastavuse s, oleks soovitatav esitada katkematu teenuseahela hindam ise tulemused aruandluses selgemalt. 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 t he auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The barriers are discussed in Even though the cr iterion is met, it is meetings and reported in annual suggested to report the about the plans. barriers more precisely. The criterion was veri f ied f ulf illed by Kuig i kriteeriumiga ollakse also explor ing the client work vastavuses, oleks soovitatav documentat ion, where evidence was inf ormatsioon takistustest f ound about multidisciplinar y aruandluses selgemalt. 31 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 f or 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 Tugiliisu uses client -centered holistic approach, which is aimed to improve client ’s qualit y of lif e. This is descr ibed in the handbook of the organizat ion. The qualit y of life is measured annually and reported in client work documentat ion. 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. These are evaluated and analyzed during annual employees’ perf ormance reviews. 32  42. The social service provider identifies its business results and provides formal periodic and inde pendent revi ew and procedures t o achieve the targeted results. Remark from the auditor: The ser vices of the social ser vice pr ovider do not meet this crit erion of the EQUASS Assurance certif icat ion program. Strengths Improvem ent & developments Starting f rom 2013 Tugiliisu draws up It was diff icult to measure Tugiliisu’s annual plans in standard wr itten perf ormance against objectives at f ormat. The achievements and the beginning of 2013, as the goals results of 2012 we re summed up also f or 2012 were not clearly set. in the same document. In order to better be able to measure The results of the previous year were organizat ion’s annual activit ies/ communicated both, to the staff and perf ormance outcom es, the activit ies to the persons ser ved. and goals need to be more clear l y presented in the an nual act ion plan The annual (f inancial) report is also with corresponding indicators. composed and audited by an ext ernal body (audit or). It would also be advisable to compile an annual act ivit y report. The action of Tugiliisu has been controlled also by t he Social Keeruline oli mõõta Tugil iisu Insurance Board. Respect ive control eesmärkide t äitmist 2013. a asta reports have been composed. alguses, kuna 2012. aasta eesmärke ei olnud selgelt määr atletud. Oma tegevuste/ soorituste tulem uste paremaks hindamiseks tuleb tegevused ja eesm ärgid selgemalt esitada aastases tegevusplaanis koos vastavate indikaatoritega. Samuti on soovitatav koostada iga - aastane tegevusaruanne. 33  43. The social servi ce provi der identifies and regis ters 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 Strengt hs Improvem ent & developments Tugiliisu gathers and documents The procedure f or measuring inf ormation (also statistics) achieved results of the received regarding results of providing ser vices on collective basis and also ser vices (bot h on individual and benef its f or persons ser ved of collect ive basis), which was received ser vices on collective basis evidenced in client work should be document ed in the policies documentat ion. of Tugiliisu. In f uture it would be advisable to present the benef its f or persons ser ved of received ser vices on collect ive basis more clearly ( in annual activit y report) . Tugiliisu poliit ikates tuleks kirjeldada protseduur id, kuidas mõõdetakse teenuste tulemusi kollek tiivsel tasandil ja ka kuidas mõõdetakse teenuse saajate kasutegurit kollektiivsel tasandil. Edaspidi on soovitatav täpsem alt välja tuua inf ormatsioon teenuse saajate poolsete kasutegurite kohta kollektiivsel tasandil (tegevusaruandes) . 34 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 EQ UASS Assurance certif ication program Strengths Improvem ent & developments Tugiliisu evaluates the results and It would be advisable to set more added value of its work during its clearly in the organizat ion’s policies , meetings. The added value to clients how and when the added value of the is evaluated while conducting lif e ser vices f or qualit y of lif e of persons qualit y tests to per sons ser ved. ser ved, is discussed and reported. Soovitatav on asutuse poliit ikates selgemalt välj a tuua, kuidas ja millal arutatakse teenuse saaja lisaväärtust teenuse saaja elukvaliteedile ning kuidas tulemustest r aporteer itakse . 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 Tugiliisu collects f eedback f rom its It would be advisable to start using clients and other s takeholders. This regular sur veys to r eceive f eedback is done through meetings and f rom the persons served and (phone) inter views. stakeholders. The received inf ormation needs to be analyzed and necessar y improvement activit ies ref lected in 35  the annual action plans. Soovitatav on alustada regulaarset e tagasiside küsitlustega, et saada tagasisidet klient idelt ja teistelt huvigruppidelt. Saadavat inf ormatsiooni tuleb analüüsida ja vajalikud parandustegevused kajastada aastaplaanis. 46. The social service provider provides accessible and easil y understandable records on outcome, including personal perception and achievements Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The outcomes of 2012 were summed In f uture it would be advisable to up in the annual plan f or 2013. This start f ormulating annual activit y included inf ormation on what the reports, which are communicated t o organizat ion had achieved during the staff , stakeholders an d disclosed on year. the organization’s web page. The report included inf ormat ion on These reports should include among personal perceptions and other inf ormation the value and achievements. added value of services. Inf ormation on personal perceptions and It was orally comm unicated to the achievements should be more clearl y staff and persons served (in brought out. understandable way) . Tulevikus on soovitatav alusta da tegevusaruannete koostamist, mis edastatakse personalile, huvigruppidele ning avalikustatakse asutuse kodulehel. 36  Aruanded peaksid muuhulgas sisaldama inf ormatsiooni teenuste väärtuse ja lisaväärtuse kohta. Samuti tuleks selgemalt välja tuua inf ormatsioon personaalsete hinnangute ja saavut uste kohta. 47. The social service provider activel y disseminates organisation performance among its staff, service users and external stakeholders. Remark from the auditor: The ser vices of the social ser vice pr ovider s meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Tugiliisu compiles monthly reports to In f uture it would be advisable to Social Insurance Board and has start f ormulating annual activit y summed up its act ivities of 2012 in reports, which are communicated t o the annual plan f or 2013. staff , stakeholders and disclosed on the organization’s web page. The inf ormation was orally communicated to the staff and Tulevikus on soovitatav alustada persons. tegevusaruannete koostamist, mis edastatakse personalile, huvigruppidele ning avalikustatakse asutuse kodulehel. 48. The social service provider has a standard procedure for continuous improvement on the basis of an improvement cycle. Remark from the audi tor: The ser vices of the social ser vice pr oviders do not meet this crit erion of the EQUASS Assurance certif icat ion program Strengths Improvem ent & developments The PDCA cycle was taken into use As cont inuous impr ovement cycle is recently and is ver y generall y a new concept f or Tugiliisu, the y descr ibed in the handbook of the have just recently started 37 organizat ion. implement ing it. The goals and activit ies are Though, the whole process needs to descr ibed in the annual plan . be analyzed after the f irst year of usage, descr ibed in the policy of the The process and activities will be organizat ion and amend ed, wher e reviewed and the results and necessar y. perf ormance of Tugiliisu will be analyzed starting f rom the next year. In order to guarantee successf ul implementation of PDCA cycle in Qualit y improv ement projects have f uture, attention has to be paid to: been documented. a. measuring the results of the actions and b. implement ing corrective actions. Pideva par enduse tsükkel on Tugiliisu jaoks uus kont septsioon, mida on hiljut i hakatud juurutama. Seega, kogu protsessi tuleb analüüsida peale aastat kasutamist, kirjeldatud s aama asutuse poliitikates ja mu udetud, kus vajalik. Selleks, et tagada PDCA tsükli edukas rakendamine edaspidi, tuleb tähelepanu pöör ata: a. tegevuste tulemuse hindamisele; b. parendavate tegevust e ellurakendamisele. 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 soci al ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program 38  Strengths Improvem ent & developments All improvement programs are More attent ion should be paid to the document ed, include goals and measurabilit y of perf ormance perf ormance targets. indicators. This was verif ied through inspecting Enam tähelepanu tuleks pöörata f ew examples during site visit. indikaator ite mõõdetavusele. 50. The servi ce provider introduces and manages innovative w ays of w orking that have been id entified 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 Tugiliisu f inds ways of being innovat ive, taking into account the needs and expectations of stakeholders. 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 description of the actions (including SM ART objecti ves) 1. (Criteria 4, Compile the service delivery processes of Tugiliisu 36) - draw up the procedures of the services delivered by Tugiliisu (f.e in the handbook of the organization); - ensure that the processes are in line with Tugiliisu’s vision, mission and 39  quality principles; - review the processes regularly, f.e by the internal control processes; - complement the home page of Tugiliisu with services related information for ensuring better information and communication. - the whole process has to be analyzed after the first year of usage and amended, where necessary. Koostada Tugiliisu teenuste osutamise protseduurid - välja töötada Tugiliisu teenuste osutamise protseduurid (nt asutuse käsiraamatus); - tagada, et protseduurid on kooskõlas asutuse visiooni, missiooni ja kvaliteedi põhimõtetega; - vaadata protseduure regulaarselt üle, nt sisekontrolli protsesside käigus; - peale esimest kasutusaastat analüüsida protsessi ning muuta, mis on vajalik. Vastutaja/ person responsible: Tugiliisu juhataja/ manager Tähtaeg/ deadline: 15.05.2014 2. (Criteria 5, 6, Develop a thorough procedure for annual planning and compile a thorough annual plan 42, 48) - analyze the existing procedure and action plan format for improvements; - make necessary amendments in the procedure and the format of the action plan; - review the process regularly; - compile detailed annual plans with SMART objectives and tangible / measurable expected results and indicators; - ensure the measuring of the results of actions (of previous period) and the implementation of corrective actions (for successful implementation of PDCA cycle). Töötada välja põhjalik aasta planeerimise protsess, koostada põhjalik aasta tegevusplaan - läbi viia põhjalik aasta planeerimise protsessi ja aastaplaani formaadi 40  analüüs; - teha vajalikud muudatused protseduuris ja aasta plaani formaadis; - vaadata üle protsessi regulaarselt; - koostada detailsed aasta plaanid SMART eesmärkidega ning reaalsete/ mõõdetavate oodatavate tulemuste ja indikaatoritega; - tagada (eelmise perioodi) tegevuste tulemuste hindamine ja parendavate tegevuste ellurakendamine (PDCA tsükli edukas rakendamiseks). Vastutaja/person responsible: Tugiliisu juhataja/ manager Tähtaeg/deadline: 15.05.2014 3. (Criteria 3, 8, Develop ways and begin asking feedback on regular basis 27, 33, 45) - compile questionnaires/ surveys (to be used orally or in writing) to receive on regular basis feedback from persons served, staff and stakeholders (partners, financing bodies, similar organizations etc); - ask regular feedback, summarize and analyze it; - describe this procedure in the handbook of the organization. Töötada välja tagasiside küsimise viisid ning küsida regulaarset tagasisidet - koostada kirjalikud küsimustikud/ uuringud (suuliselt või kirjalikult kasutamiseks) regulaarse tagasiside saamiseks klientidelt, töötajatelt ja huvigruppidelt (partnered, rahastajad, sarnased organisatioonid jne); - küsida regulaarselt tagasisidet, koostada kokkuvõtted ja analüüsida seda; - kirjeldada tagasiside saamise protseduuri asutuse käsiraamatus. Vastutaja/ person responsible: Tugiliisu juhataja/ manager Tähtaeg/deadline: 15.05.2014 41 4. (Criter ion 2) Express the long term goals of the organization in writing. - consider conducting a SWOT analysis; - think thoroughly through the long-term goals (f.e during strategy day); - compile a strategy document that would include the long term goals. Esitada asutuse pikaajalised esmärgid kirjalikus vormis. - kaaluda SWOT analüüsi läbiviimist; - mõelda põhjalikult läbi asutuse pika-ajalised eesmärgid (nt strateegia päeval); - koostada strateegia dokument, mis sisaldab pika-ajalisi eesmärke. Vastutaja/ person responsible: Tugiliisu juhataja/ manager Tähtaeg/deadline: 15.11.2015 5. (Criter ia 12, Pay more attention to the quality of client work documentation 35) - client work documentation (including individual plans and related reports) need to be thorough and include all demanded information; - individual objectives need to be specific and measurable; - continue to carry out internal control procedures and consult employees about the expectations related to the quality of the client work documentation. Pöörata enam tähelepanu klienditöö dokumentatsiooni kvaliteedile - kllienditöö dokumentatsioon peab olema täielik ning sisaldama kogu nõutavat informatsiooni (sh individuaalsed plaanid ja seotud aruanded); - individuaalsed eesmärgid peavad olema sprtsiifilised ja mõõdetavad; - jätkuvalt tuleb läbi viia sisekontrolli protseduure ja nõustada töötajaid klienditöö dokumentatsioonile esitatavatest ootustest. Vastutaja/ person responsible: Tugiliisu juhataja/ manager Tähtaeg/deadline: 15.11.2015 6. (Criter ia 46, Formulate and disclose annual activity reports 47, 30) These reports should include among other information (that was weak in 42  the summary of 2012): - overview of performance and related statistics; the value and added value of services; - information on personal perceptions and achievements; - tangible results achieved in strengthening the empowerment of persons being served; - benefits for persons served of received services on collective basis. Reports need to be communicated to staff, stakeholders and disclosed (f.e on the organization’s web page). Koostada ja avaldada iga-aastased tegevusaruanded Aruanded peaksid muuhulgas sisaldama (mis oli nõrk 2012. aasta kokkuvõttes): - ülevaade tegevustest ja seotud statistika; - informatsiooni teenuste väärtuse ja lisaväärtuse kohta; - informatsiooni personaalsete hinnangute ja saavutuste kohta; - mõõdetavad tulemused teenuste saajate jõustamise tugevdamises; - informatsioon teenuse saajate poolsete kasutegurite kohta kollektiivsel tasandil. Teavitada aruannetest personali, huvigruppe ning avalikustada need (nt asutuse kodulehel). Vastutaja/ person responsible: Tugiliisu juhataja/ manager Tähtaeg/ deadline: 15.11.2015 7. The handbook of the organization and the policies and procedures need to become more precise and reviewed regularly. F.e the following needs to be more clearly described: Criterion 13. employees’ participation (gaining feedback and using it concerning the planning and evaluation of services); 43 18. how performance in respecting the right to self-determination of the person served is evaluated with the persons served; 19. performance in the facilitation of choosing/ accessing to advocates/ supporting persons; 21. evaluation of performance in preventing the physical, mental and financial abuse of service users: 28. involvement of clients (active participation in service planning, implementation and management); 29. policy of client participation (in the delivery and improvement services); 30. empowerment and the facilitation of empowerment of the persons served; 31. measures for creating an empowering environment; 43. measuring the achieved results of the received services on collective basis and benefits for persons served of received services on collective basis; 44. how and when the added value of the services for quality of life of persons served, is discussed and reported. Information should also be available on how the processes are reviewed. Nt selgemalt tuleks kirjeldada järgmist: Kriteerium 13. töötajate kaasamine (tagasiside saamine ja kasutamine teenuste planeerimise ja hindmise osas); 18. kuidas koos teenuse saajatega hinnatakse Tugiliisu käitumist teenuse saajate enesemääratlemisest lugupidamise osas; 19. iga-aastane hindamine, kuidas on abistatud teenuse saajaid leidmaks eestkostja ja/või tugiisik; 21. iga-aastane hindamine, kui efektiivne ollakse oma tegevuses teenuse saajate füüsilise, vaimse ja majandusliku ärakasutamise ennetamisel; 28. teenuse saajate osalemine (aktiivne kaasamine teenuste 44  planeerimisse, läbiviimisse ja juhtimisse); 29. klientide osalemine teenustele kaasarääkimises; 30. jõustamine ja jõustamise tugevdamine (defineerida ja lahti selgitada); 31. jõustava keskkonna loomise meetmeid; 43. kuidas mõõdetakse teenuste tulemusi kollektiivsel tasandil ja kuidas mõõdetakse teenuse saajate kasutegurit kollektiivsel tasandil; 44. kuidas ja millal arutatakse teenuse saaja lisaväärtust teenuse saaja elukvaliteedile ning kuidas tulemustest raporteeritakse; Info peaks olema ka selle kohta, kuidas protseduure üle vaadatakse. Vastutaja/ person responsible: Tugiliisu juhataja/ manager Tähtaeg/deadline: 15.11.2015 5. Closing remarks Support Center For People W ith Special Needs Tugilii su is a non- prof it organizat ion, which is act ive since 2003. Tugiliisu’s members are mentally disabled people, their f amilies, volunteer s, supporters a nd f riends. The goal of Tugiliisu is to involve mentally disabled people into societ y though var ious act ivities and pr ojects, to off er them maximum possible perf ormance and best independent coping with lif e. Since 2003 Tugiliisu is a member of Estonian Me ntally Disabled People Support Organizat ion. Tugiliisu off ers the f ollowing activities and ser vices to mentally disabled people and their f amilies: diff erent projects f or the improvement of the lif e qualit y of mentally disabled people, activit y center f or mentally disabled people, supported living services, daily lif e support, personal assistance ser vices, child care f or childr en with mental disabilities, counseling and support person ser vices f or adult people wit h mental disabilities. Tugiliisu began to im plement EQUASS almost t wo year s ago. As the opportunit y arose, Tugiliisu decided to take advantage of it, in order to become a more qualitative ser vice provider and receive the q ualit y certif icate meant f or social sector service providers. All personnel wa s involved in the 45 preparat ions f or EQUASS Assurance audit, leaded by the manager of the organizat ion. The whole documentation of the organizat ion was reviewed and updated f rom the point of view of EQUASS cr iter ia. The preparations have taken a lot of time and energ y f rom the organizat ion. The auditor exper ienced dur ing the audit, that the organization is dedicated to deliver ing services of high qualit y. The manager was dedicated to improving the lif e qualit y and ser vices meant f or mentally disabled people. The team showed strong synergy and care f or each other and f or the ir clients. The personnel was highly motivat ed to deliver good ser vice and empowering the per sons ser ved. All of them gave more than expected f rom their work positions. The co -operat ion part ners praised and supported t he activities of Tugiliisu and expressed sat isf action with the f ruitful cooper ation. The persons ser ved appreciated the service deliver y and cared much f or their act ivit y super visors. The y showed knowledge of their rights and du ties as well expressed satisf action with their individual plans. On the other hand, what proved def icient, was the leadership qualit y principle and the documentation of the organization. The annual planning cycle was not yet thoroughly implemented, includ ing the planning, implement ing and reviewing related documentation. The management of the organizat ion proved to be spontaneous, rather than regular and systematic. This also ref lect ed in the documentat ion. It was not systematically organized and turned out to be def icient f rom the point of view of EQUASS criter ia. The auditor f aced the manager of Tugiliisu , who was a person with charisma, f ull of energy and strength of will, and also highly respected among the employees and persons ser ved. But at the same time the auditor f ound also evidence of def icient knowledge about qualit y systems (especiall y continuous improvement cycle) and poor documentat ion of organization’s activities. Def iciencies were f ound in diff erent principles f or qualit y: leadership, compr ehensiveness, result orientat ion, cont inuous improvement . See chapter 3 ( De tailed f eedback on perf ormance) f or more detailed inf ormation. For the period of f ollowing two years, improvem ent act ions and additional developm ents have to be implemented. See cha pter 4 (Agreed additio nal developm ent / improvements) f or more detailed inf ormation. The whole Tugiliisu staff was ver y kind and cooperat ive in introducing the work of Tugiliisu, f inding necessar y evidential mater ials and shar ing inf ormation about f ulf illi ng EQUASS cr iter ia. 46 After verif ication of the indica t ors by reviewing documentation and conducting inter views, the auditor concluded that the crit eria f or qualit y assurance of the Eur opean Qualit y f or Social ser vices were partially f ulf illed. *** Erivajadustega Inimeste Toetusühing Tugiliisu on m ittetulundusühing, mis tegutseb aktiivselt aastast 2003. Tugiliisu liikmed on vaimupuudega inimesed, nende per eliikmed, vabatahtlikud, toetajad, sõbrad. Tugiliisu eesmärk on kaasata täiskasvanud vaimupuudega inime si ühiskonda läbi erinevate tegevuste ja projektide, pakkude neile maksimaalselt võimalikku tegutsemist ja parimat toimetulekut iseseisva eluga. Alat es 2003. aastast on Tugiliisu Tallinna Puuetega Inim este Koja liige. Tugiliisu pakub vaim upuudega inimestel e ning nende per ekondadele järgmisi tegevusi ja teenuseid: er inevad proj ektid vaimupuudega inimeste elu kvaliteedi parandamiseks, tegevuskeskus vaimupuudega inim estele, toetatud elam ise teenus, igapäevaelu toetamise teenus, isikliku abistaja teenus, lapsehoid vaimupuudega lastele, nõustamise t eenus ja t ugiisiku teenus täiskasvanud vaimupuudega inimestele. Tugiliisu alustas EQUASSi rakendam isega ligikaudu kaks aastat tagasi. Kui võimalus avanes, otsustas Tugiliisu seda kasutada, et saada kvaliteetsemaks teenuse osutajaks ning saada sot isaalsektori teenuse osutajatele suunatud kvaliteedi sertif ikaat. Kogu personal oli seotud ettevalm istustega EQUASSi auditiks, eesotsas asutuse juhatajaga. Kogu asutuse dokumentatsioon vaadat i üle ning seda uuendat i EQUASSi krit eer iumidest läht uvalt. Ettevalmistused on võtnud asutuselt palju aega ja energiat. Audiitor koges audit i läbiviimisel , et organisatsioon on pühendunud kvaliteetse teenuse osutamisele. Juhataja oli pühendunud vaimupuudega inimeste elukvaliteedi ning nendele mõeldud teenuste parendamisele. Meeskond näitas üles suurt sünergiat ja hoolivust nii üksteise kui ka teenusesaajat e vastu. Personal oli kõrgelt motiveer itud osutama head teenust ning teenuse saajate jõustamisele. Kõik nad andsid enam, kui nende ametikohtadelt oodatud. Koostööpartnerid kiitsid ja toetasid Tugiliisu tegevust ning välj endasid rahulolu vilj aka koostöö eest. Teenuse saaja d tunnustasid saadud teenuste osutamist ja väljendasid hoolivust oma tegevusjuhendajate suhtes. Nad näitasid üles teadmisi o m a õigustest ja kohustustest ning väljendasid rahulolu oma individuaalsete plaanidega. 47 Teisest küljest, mis osutus puudulikuks, oli juhtim ise kvalit eedi printsiip ja asutuse dokumentatsioon. Aastast planeerimise tsüklit ei olnud veel täielikult rakendatud, sh planeer imine, rakendamine ja seotud dokumentide ülevaatamine. Asutuse juht imine osutus pigem spontaanseks, kui regulaarseks ja süsteemseks. See väljendus ka a sutuse dokumentatsioonis. Seda ei olnud süsteemseks korrastatud ning see osut us puudulikuks EQAUSSi kriteeriumide vaatenurgast lähtuvalt. Audiitor oli silm itsi Tugiliisu juhiga, kes oli karismaat iline inimene, täis energiat ja tegutsemistahet, samut i kõrgelt austatud töötajaskonna ja teenuse saajate seas. Kuid samal ajal leidis audiitor ka tõendei d puudulike teadmiste kohta kvaliteedisüsteem idest (eriti kestva parendustsükli osas) ning puuduliku dokumentatsiooni asut use tegevuse kohta. Puudujääke leiti mitmes kvaliteedi põhimõtetes: juhtim ine, laiahaardelisus, tulemustele orienteer itus, kestev aren g. Vt täpsemat inf ormatsiooni ptk 3 (detailne tagasiside tegevuse kohta). Järgmiseks kaheks aastaks on vajalikud m itmed parendustegevused ja täiendavad arengud. Vt täpsemat inf ormatsiooni ptk 4 (kokkulepitud täiendavad arengud/ parendused). Kogu Tugiliisu perso nal oli väga lahke ja koostööald is, tut vustades Tugiliisu tööd, leides vajalikku tõendusmaterjali ja jagades inf ormatsiooni EQUASSi kriteeriumide täitmise kohta. Peale indikaatoritele vastamise tõendamist , tutvudes dokumentatsiooniga ja viies läbi inter vjuud, oli audiitor veendunud, et kriteer iumid Euroopa kvaliteedimärgi jaoks sotsiaalteenust es on osaliselt täidetud. Tallinn, 22. 11.2013 Mar iliis Männik -Sepp 48 Kristi Reimets Saatja: Keiu Talve Saatmisaeg: 17. detsember 2013. a. 11:58 Adressaat: Kristi Reimets Teema: FW: Audit report EIT Tugiliisu- EE2013- 11 Manused: Asutuse külastuse ettevalmistus_Tugiliisu.doc; EQ-ASS_AUD_Audit Report_Tugiliisu.doc; EQUASS_taotlusvorm_2013 audiit.xlsx; Additional Information Form (1).doc From: Keiu Talve Sent: Monday, December 02, 2013 4:17 PM To: Guus van Beek ([email protected]) Cc: Marie Dubost ([email protected]) Subject: Audit report EIT Tugiliisu- EE2013- 11 Dear Guus, Attached you’ll find an audit report of EIT Tugiliisu. Please review the report and let me know incase of comments needed! Keiu EQUASS Eesti Astangu KRK Tel: +372 5682 9104 www.equass.ee www.astangu.ee 1