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Tartu Emajõe Kool auditi raport Brüsselisse

Astangu Kutserehabilitatsiooni Keskus · 2. märts 2016
Viit
6-13/129-1
Registreeritud
2. märts 2016
Dokumendi liik
Väljaminev kiri
Funktsioon
6 Arendustegevus
Sari
6-13 SOKK tegevus
Toimik
6-13/2016
Vastutaja
Kristi Viisimaa

Failid

  • 📎Additional Information Form 20.pdf225 KB
  • 📎Asutuse_kylastuse_vorm_Tartu_Emajoe_Kool 1.pdf471 KB
  • 📎EQ_Audit Report_Tartu_Emajõe_Kool 3.pdf444 KB
  • 📎EQUASS Assurance taotlusvormTEK.xlsx
  • 📎kiri välja_Tartu Emajõe Kool auditi raport Brüssel.pdf45 KB

Sisu (failidest)

EQUASS ASSURANCE APPLICATION ADDITIONAL INFORMATION 1. Short information about the organisation in the nati ve language T artu Em aj õe Ko o l o n r i i gik o o l p im ed at e l e j a v a eg n äg e v at e le õp i l as t e le . T ar t u Em aj õ e Ko o l is pak u t ak s e s o ts ia a ls e r eh a b il i ta ts io o n i t e en u s e i d pim e da te l e j a v ae g nä g e va t el e l as t e l e j a t äis k as v a nu te l e n i ng t öö a l as e r e ha b i l it at s i oo n i t e en us e id p im eda t el e j a v a eg n ä ge v a te l e tä is k as v an ut e le . As ut us e m is s i o o n ik s on p ak k uda reh a b i li t ats i oo n it e en us te k au d u p ar im ai d võ i m alus i p im ed at e l e j a v ae g nä g e va t el e l as t e le ja t ä is k as v an u te l e n en d e a ren g u t oe tam is ek s , ig ap ä e v ae l ug a hak k am as aam is ek s j a ü h is k on na e l lu k aas a m is ek s ni n g nõ us ta d a n äg em is p u ud e g a i nim es t e ga t ö öt a v ai d s pe ts ia l is te t e is t es E es ti r eh a bi l i ta ts io o n ias ut us t es . 2. Short information about the o rganisation in English (acti vities, clients, etc.) T artu Em aj õ e Sc h oo l is th e o n l y s pec i a l s t at e s c h oo l f or c hi l dr e n wi t h bl i n dn es s / v is ua l im pa ir m en t ( BV I) . Ac c or d i n g t o t h e m is s io n , T art u Em aj õe Sc ho o l work s f or th e im pr o vem en t of e duc a ti o na l op p ort u ni t i es of a l l v is ua l l y im pa ire d c h i l dre n in Es t o n ia ; pr o v i des r e h ab i l it a ti o n s er v ic es f or c h i l dre n an d a d u l ts wit h BV I a n d s up p orts th e ir inc l us i on wi t h in a ll as pec ts of s oc i e t y. T art u E m aj õe Sc h oo l is of f ic i a l l y rec o gn i ze d a s a n ed uc at i on a nd r eh a b il i ta t io n i ns t it u ti o n s p ec ia l i zi n g i n th e f i e ld of B VI. T he r eh a b il i ta t io n s er v ic es are pr o v id e d ac c or d i n g t o t h e Es t o ni a n S oc i a l W elf ar e Ac t b y t h e s p ec i a l t eac h e rs of v is ua l l y im pa ir ed , ps yc h o lo g is t , ph ys i ot h er ap is t, s oc ia l wor k er , ac t i vi t y t h er a p is t an d s pe ec h - t h er a p is t . I n a d d it i on , c ou ns e ll i n g s es s i ons ar e a v ai l a bl e f or t h e pe o p le wi t h b l in d nes s an d l o w v is o n, th e ir p are n ts , t eac h er s , ed uc at or s a n d ot h er s pec i a l is ts f rom a ll o v er Es to n i a . 3. Name of the organisation as you w ould w ant it to appear on the EQU ASS Assurance certificate Tartu Emajõe School - Estonian State School for Blind and Visuall y Impaired Children 1 4. Name of services / departments of the organi sation i n the scope of the application as you w ould w ant it to appear on the EQU ASS Assurance certifi cate: Rehabilitation department 5. Organisation’s logo Information to be published on EQUASS website: Name of the organi sation : Tart u Emajõe School – Estonian State School for Blind and Visuall y Impaired Children Web page: www.tek.tartu.ee Address: Vabaduse pst 14, 51004 Tartu , Estonia Director: Arvo Pattak Contact person: Ragne Kuusk Email: rehab@tek. tartu.ee 2 EQUASS ASSURANCE ASUTUSE KÜLASTUSE ETTEVALMISTAMISE VORM Asutuse külastus: 15.-16.02.2016 Tartu Emajõe Kool Mariliis Männik-Sepp © 2012 by European Quality for Social Services (EQUASS) Kõik õigused kaitstud. Antud dokumendi elemente ei tohi paljundada, kopeerida ega muul elektroonilisel moel salvestada ilma EQUASS kirjaliku loata. Asutuse külastuse ettevalmistamise küsimused EQ U AS S As s ur a nc e t ao t lus v or m i le j a a nt ud l is ai nf orm ats i oo n i l e p õh i n ed es pa l um e te i l e tt e va lm is t us ek s v as t at a j är g ne v at e l e s e l gi t us t n õ ud v at e l e k üs i m us tel e : Üldised teemad 1. Miks alustasite EQUASSi rakendamisega ja mida on kvaliteedi süsteemi rakendamisega saavutatud? 2. Mida olete teinud teenuste kvaliteedi tagamiseks ja tõstmiseks oma asutuses? 3. Kuidas o n kvaliteedisüsteemi rakendamine m õjutanud asutuse juhtimist ja perso nalijuhtimist? Millised muutused on toimunud? 4. Kirjeldage oma asutuse põhiprotsesse: planeerimise protsessi, kestva arengu protses si (PDCA tsükli) ja teenuste o s utamise protsessi rakendamist oma asutuses. 5. Millised on asutuse huvigrupid? 6. Kellega ja millist koostööd teete ning millist lisaväärtust seeläbi olete saavutanud? 7. Kuidas kaasate teenuse saajaid, personali ja muid huvigruppe teenuste arendamisse? 8. Milliste ko gukonnpõhiste tegevustega olete seotud olnud ja kuidas ühiskonnale lisaväärtust pakkunud? 9. Milliseid parendusprojekte/ innovatsiooniprojekte olete ellu viinud? Version 1.0 2 1. Kvaliteedi põhimõtetele ja EQ U ASS Assurance kriteeriumitele vastavuse küsimused/ teemad: Te en us e s a aj a d Huv i gr up i d P er s o n a l Dir ek tor Juht im in e 1. Missioon, visioon ja kvaliteedistandard 1.1. Millised on visioon, missioon ja väärtused ? Kus need on dokumenteeritud ja kuidas nendest töötajad teav itatakse? 1.2. Millised on kvaliteedi alased eesmärgid ? Kus need on dokumenteeritud? x x 1.3. Millised on pikaajalised eesmärgid ? Kus need on dokumenteeritud ja kuidas nendest töötajad teavitatakse? 1.4. Kuidas o n tagatud järjepidev areng (PDCA tsükli toimimine) ? 2. Kommuni katsi oon 2.1. Kuidas o n klientidel, nende pereko nnaliikmetel ja teenuse saajate organisatsioonidel võimalus anda tagasisidet teenuste ja programmide ko hta (nii isikliku, kui kollektiivse kogemuse alusel)? Kuidas huv igruppide (rahastajad, kliendid, perso nal) tagasiside dokumenteeritakse? 2.2. Kuidas asutus informeerib pakutavatest x x x x programmide ja teenustest kõiki huvigruppe? Sh 2.2.1. teenuste ja programmide arendamine 2.2.2. protsessid ja protseduurid 2.2.3. organisatsiooni tegevuse 2.2.4. eesolevad sündmused/ üritused 2.2.5. töötajate kaasamise ja arenguvõimalused 3. Aastaplaani koostami ne 3.1. Kirjeldage aastase planeerimise ja ülevaatamise/ x hindamise protsessi (sh rakendam ne ja ülevaatamine) ! Kus on see dokumenteeritud? Version 1.0 3 3.2. Kas aastaplaan sisaldab endas: 3.2.1. SMART eesmärke? 3.2.2. vajalikke tegevusi? 3.2.3. Mõõdetavaid tulemusi? 3.2.4. tegevuse ülevaatamist eesmärkide saavutamisel (sh hindamiseks ja läbivaatuseks ette nähtud ajakavad ja tegevused)? 4. Panus ühiskonda 4.1. Kuidas asutus rahuldab ühiskonna ootusi ja vajadusi? 4.1.1. Kuidas küsitakse tagasisidet ühiskonna erinevatelt huvigruppidelt? 4.1.2. Tooge näiteid tegevuste kohta , mis on suunatud ühiskonna vajaduste x rahuldamiseks? 4.2. Milliste tegevustega asutus näitab üles sotsiaalset vastutust; millega panustab ühiskonda? 4.2.1. Milliste ko gukonnapõ histe tegevustega asutus tegeleb? Millised tegevused on andnud lisaväärtust ühiskonnale? P er so na l 1. Personali juhtimi ne 1.1 Kirjeldage personali värbamis - ja ametis hoidmise korda ! Kus see on dokumenteeritud? 1.1.1 Kas see sisaldab kriteeriume personali värbamiseks? 1.1.2 Kas see põhineb töötajate teadmistel, oskustel ja kompetentsidel ? 1.2 Kirjeldage asutuse võrdsuse ja x x diskrimineerimis e vastasuse põhimõtteid! Kus need on dokumenteeritud? 1.3 Kuidas o n tagatud, et töö toimub õigusaktidega kooskõlas? 1.3.1 Kuidas o n tagatud töö ks sobivad tingimused ? Kuidas asutuses hinnatakse töötingimusi ? 1.3.2 Millised on töötajate tunnustamise põhimõtted? 2. Personali kvalifikatsioon j a arendamine x x Version 1.0 4 2.1 Kuidas toimub koolitus- ja arengukava koostamine ja elluviim ine? 2.1.1 Kas plaan on dokumenteeritud ja seda vaadatakse üle? 2.1.2 Kuidas toimub töötajate arenguvajaduse väljaselgitamine? 2.1.3 Milliseid andmeid säilitatakse toimunud koolituste kohta? 2.1.4 Kuidas asutus hindab koolituste efektiivsust ? 2.2 Kuidas o n määratletud ja kus on kirjeldatud perso nali rollidele ja funktsioonidele vastavad kompetentsusnõuded? 2.2.1 Kuidas neid hinnatakse? 2.2.2 Kuidas o n korraldatud otseselt teenust osutava personali jälgimine ? 3. Personali kaasami ne 3.1 Millised on töötajate kaasamise põhimõtted (asutuse tegevuste täiustamisse, teenuste arendamisse ja personali arendamisse)? 3.1.1 Kus need põhimõtted on kirjeldatud? x x 3.1.2 Kuidas dokumenteeritakse kaasamise läbi saadud tagasiside? 3.2 Millised on perso nali rahulolu tagamise ja motiveerimise põhimõtted ? Kas neid mõõdetakse, dokumenteeritakse, analüüsitakse? Õ igu se d 1. Õigused j a kohustused 1.1 Kirjeldage teenuse saajate õiguseid ja kohustusi ! Kus need on dokumenteeritud? 1.2 Kas need on vastavuses rahvusvaheliste hartadega? Millistega? 1.3 Kuidas teavitatakse personali klientide õigustest ja x x x kohustustest? 1.4 Kuidas teavitatakse kliente nende õigustest ja kohustustest? 2. Kirjeldage kaebustega tegelemise süsteemi ! Kuidas saab kaebusi esitada ja nende lahendamise kohta infot? 3. Enesemääramisõigus x x x Version 1.0 5 3.1 Kuidas näidatakse üles poolehoidu teenuse saaja enesemääratluse osas ? 3.1.1 Kuidas asutus hindab oma sellekohast tegevust? 4. Kuidas asutus toetab teenuse saajat eestkostja (eestkõneleja) ja/või tugiisiku leidmisel? 4.1.1 Kuidas asutus hindab oma sellekohast tegevust? E eti k a 1. Eetika eeskiri/ kord 1.1 Millised on asutuses kehtivad eetilised põhi mõtted, väärtus hinnangud j a tegevused, millest lähtutakse teenuse osutamisel? Kus need on dokumenteeritud? Kuidas neist o n töötajaid teavitatud? 1.1.1 Kas eetika koodeks käsitleb teenuse saajate väärikuse temaatikat, kaitseb neid lubamatu riski eest ja edendab sotsiaalset õiglust ? 1.1.2 Milliseid tegevusi tehakse teenuse saaja füüsilise, vaimse ja m ajandusliku ärakasutamise ennetamiseks ? 1.2 Mida on asutuses tehtud töökeskkonna tur valisuse x x kindlustamiseks ning teenuse saajatele turvalise keskkonna ja füüsilise turvalisuse tagamiseks? 1.2.1 Milline on asutuse töötervishoiu ja turvalisuse plaan? Kuidas on korraldatud riskianalüüs? Milliseid tegevusi tehakse töötervishoiu ja turvalisuse tagamiseks? 1.3 Kuidas o n tagatud andmete konfidentsiaalsus ? 1.3.1 Kus on andmekaitse protsess dokumenteeritud ja kuidas toimub selle ülevaatamine? 1.3.2 Kuidas teenuse saajad oma andmetele ligi pääsevad? 2. Rollid ja vastutus 2.1 Kuidas ja on määratletud teenuse juhtimise, disaini, osutamise, toetamise ja hindamisega tegeleva x x perso nali rollid ja vastutused , volitused ning omavahelised suhted ? 2.2 Kuidas neist rollidest teavitatakse? Koo stöö - suht ed 1. Partnerid teenus e osutamisel 1.1 Milliste organis atsioonidega teeb asutus ko ostööd? x x (sh sotsiaalpartnerid, rahastajad, teenuse saajate organisatsioonid, teenuse saajad) Tooge näiteid koostööst! Version 1.0 6 1.2 Kuidas ja millist koostööd teeb asutus teenuste arendamisel? 1.3 Kuidas selgitatakse välja väliste huvigruppide vajadused? 1.4 Kuidas asutus hindab koostööst tulenevat lisaväärtust ? O s al em in e x x x 1. Teenuse s aaj ate kaasamine 1.1 Kuidas kaasatakse teenuse saajaid vajaduste väljaselgitamisse, teenuse planeerimisse, hindamisse ja arendamisse ? (nii asutuse tasandil kui üksikisiku tasandil) 1.2 Kuidas koos kõlastatakse osalemine (protsessid, meetmed) teenuse saajatega? 1.3 Kuidas toimub teenuse saajate osalemisega seotud protsesside (tegevuse kirjelduste) ülevaatamine ja hindamine (nii individuaalsel, kui kollektiivs el tasandil)? x x 2. Teenuse s aaj ate j õustamine 2.1 Milliseid võttei d/ meetodeid kasutatakse teenuse saajate j õustamiseks ? Tooge näiteid, milliseid tulemusi on saav utatud erinevate jõustamise meetodite läbi? 2.2 Tooge näiteid, mida on asutus teinud, et luua jõustavat keskkonda ? 2.3 Milliseid koolitusi on töötajatele korraldatud, et aidata kaasa teenuse saajate jõ ustamisele? Is ik u - x x x x ke s ks us 1. Kliendi vajaduste välj aselgitami ne 1.1 Kuidas teete kindlaks teenuse saajate praeg used ja lähituleviku vajadused ? 1.2 Kuidas teete kindlaks huvigruppide (sh rahastajad, sotsiaalpartnerid) vajadused? 1.3 Kas asute teenuse saajale, tema pereliikmetele ja hooldajatele kõige sobivamas kohas ? 1.4 Kuidas teete kindlaks, et osutatud teenused (tulemused) vastavad seatud eesmärkidele ja teenuse saajate vajadustele ? x 2. Individuaal ne planeer imine 2.1 Kuidas selgitatakse välja teenuse saajate individuaalsed vaj adused ja ootused (sh teenuse osutamise osas)? Version 1.0 7 2.2 Kuidas individuaalsed vajadused dokumenteeritakse ? 2.3 Kas tegevusplaan põhineb teenuse saaja individuaalsetel vajadustel ja ootustel ? 2.4 Kas tegevusplaan hõlmab: 2.4.1 teenuse saaja oodatavat olukorda? 2.4.2 üldeesmäke? 2.4.3 kindlaid mõõdetavaid eesmärke? 2.4.4 kasutatavaid meetodeid i? 2.4.5 kaasatavat perso nali ja vastutusalasid? Lai ah a ar d x x el is us 1. Teenuse osutamise protsess 1.1 Kirjeldage teenuse osutamise protsessi. Kus on see dokumenteeritud? 1.2 Kas see on kooskõlas asutuse v isiooni, miss io oni ja kvaliteedipõhimõtetega? 1.3 Kas see on kooskõlas rahastajate märkustega? 1.4 Kuidas teenuse osutamise protsessi vaadatakse üle ? 1.5 Kas teenuse osutamise protsesse analüüsitakse siseauditite käigus? x x 2. Katkematu teenuse osutami ne 2.1 Kuidas o n tagatud teenuse osutamise järjepidevus (sh katkematus, sujuv üleminek, multidistsiplinaarne lähenemine, asutuste vahelin e koostöö )? 2.2 Kuidas hinnatakse ja arvestatakse teenuse saajate muutuvaid vajadusi ? 2.3 Kuidas reageeritakse takistustele teenuste osutamisel / nendele juurepääsul? 2.4 Kuidas takistustest raporteeritakse ? x x 3. Ter viklik lähenemi ne 3.1 Kuidas o n määratletud ja mõõdetakse teenuse saajate elukvaliteeti ? 3.2 Kuidas raporteeritakse elukvaliteedi hindamise tulemustest? 3.3 Millised on ja kus on dokumenteeritud töötajate kompetentsid, oskused ja perso nali toetamise meetodid teenuse saajate elukvaliteedi tõstmisega Version 1.0 8 seoses? T ulemu st e x x le 1. Tulemuste mõõtmine ori en te e rit 1.1 Kuidas mõõdetaks e asutuse tegevuseesmärkide us saavutamist ? 1.2 Kuidas dokumenteeritakse / raporteeritakse asutuste tegevuste tulemustest? 1.3 Kas tulemusi auditeerib sõltumatu väline üksus? 1.4 Kuidas hinnatakse individuaalsete tegevusplaanide täitmist / eesmärkide saavutamist (sh lisaväärtus)? 1.5 Kuidas hinnatakse kollektii vsel tasemel teenuste tulemusi / eesmärkide täitmist (sh lisaväärtus)? x 2. Tulemuste hi ndamine 2.1 Kuidas selgitatakse välja parim väärtus (seoses teenuste osutamisega) teenuse rahastajatele ? 2.2 Kuidas hinnatakse teenuse lisaväärtust teenuse saajate elukvaliteediga seoses? 2.3 Kuidas hinnatakse teenuse saajate rahulolu ? 2.4 Kuidas hinnatakse teiste huvigruppide rahulolu ? x x x 3. Tulemuste raporteeri mine 3.1 Kuidas avaldataks e asutuse tegevusar uanded huvigruppidele? 3.2 Kas aruanded on kättesaadavad ja lihtsasti arusaadavad ning sisaldavad personaalseid hinnanguid ja saavutusi ? 3.3 Kuidas jagatakse infot asutuse tegevuste ko hta perso nalile, teenuse saajate le ja teistele välistele huvigruppidele? Pi dev x ar en g 1. Kestva arengu ts ükkel 1.1 Kirjeldage kestva arengu protsessi ! Kus on see dokumenteeritud? 1.2 Kas protsess on tsüklilise iseloomuga : 1.2.1 planeeritud tegevused saavutavad seatud eesmärgi; 1.2.2 tegevused rakendatakse ellu; 1.2.3 tegevuste tulemusi hinnatakse; 1.2.4 parendustegevused rakendatakse ellu ( ja nende tulemused dokumenteeritakse? 1.3 Milliseid indikaatoreid kasutatakse, et mõõta Version 1.0 9 parendustegevuse tulemusi? 1.4 Tooge näiteid parendustegevustest , nende eesmärkidest ja tulemustest! x 2. Innovatsi oon 2.1 Tooge näiteid innovaatilistest töömeetoditest ! 2.2 Kuidas dokumenteeritakse innovatsiooniprojektid ja nende tulemused? 2. Nõutav dokumentat sioon EQ U AS S As s ur anc e ta ot l us es s e m ärg i tu d i nf o le j a lis a de l e p õh i n ed es pa l um e v aa t lus ek s e tt e v a lm is ta d a j är g n e v d ok um ent ats i oo n : 1. K v al i te e d ik äs ir a am at 2. A as t ap l a an 3. A as t aa r u a nn e 4. A lus d ok um end i d: t ö ök es k k onna oh ut us 5. A lus d ok um end i d: t a ga s is id e k üs i tl us l eh e d 6. A lus d ok um end i d: pr oj e k tid 7. A lus d ok um end i d: le p i n gu d S K A - g a 8. A lus d ok um end i d: k oo l i tus k a v a 9. A lus d ok um end i d: k oo l i tus e d 10 . A lus d ok um end i d: hi n n an g t ee n us e t u l em us l i k k us el e 11 . A lus d ok um end i d: ar e n gu v es tl us te k üs i t lus l e ht Version 1.0 10 3. Personali, teenuse saajate ja tei ste oluliste huvi gruppide intervjueerimine EQ U AS S As s ur anc e t ao t lus es an tu d v as t us te l e j a t õ en d it e l e p õh i ne d es p a lum e k orral d ad a i n ter vj u ud j är gm is te in im es t eg a (f unk ts io o n j a k es t v us ) : Juhtkond Kestvus 1. Dir ek tor 60 m in ut i t Personal Kestvus 1. Re h ab i l it ats i o on i m ees k onn a a 3 0 m in ut i t tö öt aj ad Teenuse saajad Kestvus 1. T een us e s a aj a d 30 m in ut i t Teised huvigrupid Kestvus 1. K oos tö ö p ar t ne r 30 m in ut i t 2. Ra h as t aj a 30 m in ut i t Version 1.0 11 Asutuse külastuse ajakava 15 . 02 .2 0 16 P äev 1 Ae g T egev us 10 . 30- 1 0. 4 5 A v ak oos o lek 10 . 45- 1 2. 4 5 T öö dok um en t id e ga 12 . 45- 1 3. 4 5 Lõ u na p aus 13 . 45- 1 4. 4 5 T öö dok um en t id e ga 14 . 45- 1 5. 4 5 Int erv j uu pe r son al ig a 15 . 45- 1 6. 0 0 Mä r k m ete t eg em in e 16 . 00- 1 6. 3 0 Int erv j uu r ah as ta ja ga 16 . 30- 1 7. 0 0 Int erv j uu ko ost ööp a r tne ri ga 17 . 00- 1 8. 3 0 T öö dok um en t id e ga 16 . 02 .2 0 16 P äev 2 Ae g T egev us 8. 0 0- 1 0. 0 0 T öö dok um en t id e ga 10 . 00- 1 0. 3 0 Int erv j uu t e enu s e s a aj at eg a ( es ind a jat eg a ) 10 . 30- 1 0. 4 5 Mä r k m ete t eg em in e 10 . 45- 1 1. 4 5 Int erv j uu di r ekt or ig a 11 . 45- 1 2. 4 5 Lõ u na p aus 12 . 45- 1 4. 3 0 T öö dok um en t id e ga 14 . 30- 1 5. 0 0 Lõ p uk oos o lek Version 1.0 12 Maarika Aro Saatja: Maarika Aro Saatmisaeg: 2. märts 2016. a. 12:44 Adressaat: 'Guus van Beek'; 'Marie Dubost' Koopia: Keiu Talve Teema: Tartu Emajõe Kool audit report Manused: Additional Information Form.doc; Asutuse_kylastuse_vorm_Tartu_Emajoe_Kool.docx; EQ_Audit Report_Tartu_Emajõe_Kool.doc; EQUASS Assurance taotlusvorm_TEK.xlsx Dear Marie, Dear Guus, Attached you’ll find an audit report and other documents of Tartu Emajõe kool EE2016-003. Please let Keiu to know in case there are some comments about the report. Best regards, Maarika 1 EQUASS ASSURANCE AUDIT REPORT Site visit: 15.-16.02.2016 Tartu Emajõe Kool (Estonian State School for Blind and Visually Impaired Children) Auditor: 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 Emajõe Kool, Estonian State School f or service provider Blind and Visually Impaired Children (hereinafter TEK) Address: Vabaduse pst 14, Tartu 51004 Post box: N/A Person responsible Ar vo Pattak , headmaster (CEO): Contact person: Ragne Kuusk , head of rehabilitation unit Phone: (+372) 740 5338 Fax: (+372) 7 422 298 E-mail: [email protected] Web site: http://www.tek.tartu.ee/ Name of Auditor: Mar iliis Männ ik-Sepp Dates of audit: 15.-16.02. 2016 Clients: Number of person served: 38 Staff: Number of staff : 10 Services: Rehabilitation ser vice 2 2. Audit program 15.02.2016 Day 1 Time Acti vit y 10.30-10.45 Opening meeting , documentation review 10.45-12.45 Documentation review 12.45-13.45 Lunch break 13.45-14.45 Documentation review 14.45-15.45 Interview with staff : Ragne Kuusk (head of rehabilitat ion unit), Monica Lõvi (social pedagogue), Anne Kõiv (special educat ion teacher 15.45-16.00 Up-dat ing f iles 16.00-16.30 Interview with f inancing body – Janeli Sinisalu (Social Insurance Board) 16.30-17.00 Interview with cooperation partners: Annely Timpmann (member of the board of the South -Estonian Associat ion of the Blind); Kr isto Ringas (Estonian Blind Sports Association) 17.00-18.30 Documentation review, up -dat ing f iles 16.02.2016 Day 2 Time Acti vit y 8.00-10.00 Documentation review, up -dat ing f iles 10.00-10.30 Interview with persons ser ved by the rehabilitation unit: Piret Everest ( mother of a chil d); Eva Kir illova (adult person ser ved); Anne Pirn (mother of a child) 10.30-10.45 Up-dat ing f iles 10.45-11.45 Interview with the headmaster Ar vo Pattak 12.30-12.45 Documentation review, up -dat ing f iles 11.45-12.45 Lunch break 12.45-14.30 Documentation review, up-dat ing f iles 14.30-15.00 Closing meeting 3 3. Detailed feedback on performance 1. The social servi ce provider defines documents and implements its visi on and mission values on servi ce provision. Remark from the auditor: The ser vices of the so cial 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 TEK are docum ented in the organizat ion’s quality manual and on its website http://tek.tartu.ee/ . The employees of TEK demonstrated 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. Employees were i nvolved in the development and concept ualization of the mission, vision and values . 2. The social servi ce provider defines, documents, and implements its qualit y policy by determining long term qualit y goals, and its commitment to continuous improvement. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The qualit y standard and commitment to continuous improvement of TEK is documented in the organizat ion’s qualit y manual. The organizat ion sees EQ UASS as an important tool helping in the qualit y assur ance process. It also 4 stresses the importance of the qualit y and development of its ser vices, involvem ent of stakeholders and cooperat ion wit h partners, constant training of employees, good work environment and eff ective use of resources. The long -term goals of TEK are descr ibed in the organizat ion’s development plan. It appeared f rom the inter views that the staff of TEK is knowledgeabl e of the qualit y standar d and long term goals of the organization. Also, the staff seemed to be devoted to deliver qualit y services and pursue f or continuous improvement . 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 Strengths Improvem ent & developm ents TEK has developed ways to 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 (summar y/analysis) so that this inf ormation could be used f or F.e questionnaires are used to improving the activit ies of the achieve this. Also roundtables and organizat ion and its ser vices and f or meetings have pr oved to be a making decisions on management valuable way to gain f eedback. level. Results of important meetings and Soovitatav on kindlustada, et 5 gatherings are recorded in written huvigruppidelt saadud tagasiside on minutes of the meetings . alat i korrektselt dokumenteerit ud (kokkuvõte/analüüs) , et saadud inf ormatsioon i saaks kasutada asutuse t egevuse ja teenust e täiustam iseks ning juhtimisotsust e tegemiseks. 4. The social service provider i nforms all stakeholders about the offered programmes and services avai lable. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments TEK inf orms its stakeholders about the services provided using a variet y of methods and approaches. This is done t hrough impor tant cooperation partners, issuing br ochures, through the homepage of TEK etc. The home page may be read by the blind and visually impaired using special Jaws screen reader program. The opportunit ies f or involvement are described in the qualit y manual of the organizat ion. As the number of staff is quite small, a lot of communication is inf ormal and oral. Important messages are sent in a written f orm. All em ployees have a chance to be involved in the act ivities concerning the development of ser vices and the organizat ion as a whole. 6 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 annual planning process exists process is integrated into the and is implemented, but a possibilit y management process of the f or development would be descr ibing organizat ion. the annual planning and revie w process in a mor e detailed manner t o The process is described in the depict all the inf ormation that is qualit y manual. The process is taken into account in the planning reviewed annually. process and all the r elated steps and personnel involved. There are annual action plans and twice a year report ing takes place Aastase planeer imise p rotsess on concerning the implementation of the kirjeldatud ning seda rakendatakse, plans. kuid arenguvõimaluseks on aastase planeer imise ja ülevaatuse protsessi kirjeldamine detailsemal moel, nii et see sisaldaks kogu plan eer imisel arvesse võetavat inf or matsiooni ning kõiki planeerim isega seotud etappe ja seotud personali. 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 ovid ers meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments 7 The annual planning process of TEK 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 the perf ormance activities, results and targets. indicators and target values and establish ones that work best f or the The annual plan is approved by the organizat ion and enable to better headmast er. measure the f ulf illment of goals. Also, the wording of goals could be improved. Kriteer ium on täidet ud, kuid tuleviku mõttes on soovitatav üle vaadata tulemusmõõdikud ja nende saavutustasemed ning kehtestada sellised, mis asut use jaoks häst i toimivad ning võimaldavad parem ini mõõta eesmärkide saavutamist. Samuti oleks soovitatav kohendada eesmärkide sõnastamist. 7. The social servi ce provider demonstrates organisation’s success in satisf ying the needs and expectations of the societ y. Remark from the audito r: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Feedback f rom diff erent stakeholders is collected and used to improve ser vices. Var ious projects and activit ies are organized with cooperation partners , which also ser ve the needs and expectat ions of society. The employees participate in workgroups dealing with the topics related to r aising the qualit y of lif e of blind and visually impair ed people 8 (deve loping policies at state level). They are involved in instructing researches as a result of which the exist ing work methodologies are amended. Last year TEK par ticipated in the planning of the construction of the Tartu Eastern Roundabout and also in the adaption of the crossroads to meet the needs of blind and visuall y impair ed. 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 soc ial ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments TEK has demonstrated social responsibilit y through diff erent activities contr ibut ing to the societ y. It has an active role in r aising the awareness of societ y about the existence and ser vices related to blind and visually impaired people . TEK organizes all kinds of events (f.e Valge Kepi päev) and is t he training base f or students . The personnel of TEK instruct students in writ i ng their master thesis. They also actively participate in discussions related to topics concerning blind and visuall y impair ed people and f ulf illing their 9 needs and expectat ions (state level social- polit ical discussions). 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 A ssurance certif ication program Strengths Improvem ent & developments Staff policy (including recruitment and select ion pr ocedures) is part of the qualit y manual. The qualit y manual includes the descr iption of required knowledge, skills and competences f or all employees. Also the rights and duties and the roles and dut ies of employees ar e descr ibed there. It appeared f rom the inter views wit h the personnel that they all are aware of their roles, rights and dut ies. It also came out that the employees are motivated, like t heir jobs and are devoted to deliver ing high qualit y ser vice. 10. The social service provider operates in compli ance w ith mandator y national legislation, providing appropriate w orking conditions, adequate and agreed staff level and staff ratio, and appropriate rew arding for staff and vol unteers. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program 10 Strengths Improvem ent & developments The documentat ion of TEK meets legal r equirements and is reviewed to do this. The staff level depends on the annual staff requirement analysis and the analysis of the structure of the organization. Also regulator y requirements are taken int o account. 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. Also external bodies audit and control the work environment. The principles f or showing recognit ion to employees are descr ibed in the qualit y manual . Joint events are organized to employees. Thank You notes and gifts are presented in case of excellent perf ormance. 11. The social service provider trains all staff based on a plan for leaning and developme nt 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 The principles f or training employees It would be advisable to gather are set in the qualit y manual. Annual inf ormation also on individual level – training plans are drawn up and who has participated in what 11 updated dur ing the year. trainings. Annual training plans are drawn up Soovitatav on koguda inf ormatsiooni based on the needs of the ka töötajate lõikes – kes on millistel employees and expectations of TEK. koolitustel osalenud. The necessit y f or trainings is evaluated during staff perf ormance inter views. Feedback on trainings is collect ed . Training materials are gathered and shared among employees. The eff ectiveness of the trainings is evaluated by employees. 12. The social servi ce provi der applies requirements for competence in the identified roles and functions of staff and evaluates them on annual basis. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The competence r equirements f or Besides perf ormance reviews and employees ar e descr ibed in the review of databases it would be qualit y manual and are reviewed advisable t o devel op other methods annually. to per iodically monitor t he perf ormance (delivery of service) of It was ver if ied by the inter views and staff . related documentation t hat perf ormance reviews of staff are Lisaks arenguvestlust ele ja carried out. andmest ike täitmise ülevaatusele on soovitatav välja töötada ka muud viisid töötajate tegevuste (teenuse osutamise) perioodiliseks jälgimis eks. 13. The social servi ce provi der recognizes the staff as a resource for feedback on organizational perf ormance, service development and staff development 12 Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of th e EQUASS Assurance certif ication program Strengths Improvem ent & developments The involvement of staff in the planning and evaluation of services is descr ibed in the qualit y manual. As the number of staff is small, ever ybody has a chance to be involved. TEK recognizes staff as a usef ul tool f or gaining inf ormation. It has regular staff meeting s. Minutes of meetings are prepared and are available f or all staff . During annual planning meetings and annual plan review meetings staff gives f eedback on orga nizat ional perf ormance, ser vice development and staff development . 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 perf ormance evaluat ions and staff questionnair es and are used to gain f eedback on satisf action and motivat ion. Mechanisms to provide satisf action and mot i vat ion ar e descr ibed in the qualit y manual. 13 Staff values highly joint events and trainings provided, which came out f rom the inter views. 15. The social servi ce provi der assures the rights of persons served outlined in a Chart er of Rights w hich is based on the EU Charter of Fundamental Rights , the European Convention for the Protection of Human Rights and Fundamental Freedoms of the Council of Europe and other int ernati onal human ri ghts conventions, especiall y those elaborat ed under the United Nations. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments TEK has developed the rights and duties of persons ser ved, which conf orm to int ernational human rights convent ions. They ar e introduced to persons ser ved by staff . The rights and duties of persons ser ved are made available f or publicit y on the web page of TEK. The staff and clients’ representat ives demonstrated their knowledge of th e rights and duties through the inter views. 16. The soci al service provider informs the person served about his/her rights and duties especiall y to equal treatment on grounds of age, disabilit y, gender, race, religion or belief and sexual orientation before recei ving the services. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program 14 Strengths Improvem ent & developments TEK has developed the rights and duties of person s served, which ar e introduced to t he persons ser ved b y staff in a way that is suitable f or the client. The staff and clients’ representat ives 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 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 Ass urance certif ication program Strengths Improvem ent & developments The principles f or handling complaints are described in t he qualit y manual. Complaints and pr oposals may be conveniently sent through the homepage. Also complaints and proposals f or warde d in telephone conversations, e -mails and mail are dealt with. 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. 15 18. The social service provider respe cts 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 auditor: The ser vices of the social ser vice pr oviders mee t this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments TEK values the persons’ ser ved right The criterion is f ulf illed, but in orde r to self -determinat ion , which comes to guarantee the annual evaluat ion out f rom the qualit y manual of the how the social service provider organizat ion. respects the f undamental right to self -determination of the person TEK processes and procedure have ser ved, it would be advisable to add been prepared, taking into account this act ivit y in the qualit y manual. the persons’ ser ved right to self - determination. Kriteer ium on täidet ud, kuid tagamaks iga-aastane It became evident through the enesemääratlusest lugupidamise inter views that the staff was aware of alane hindam istegevus, on this issue and the persons ser ved soovitatav see tegevus lisada were handled wit h respect. kvaliteedi käsiraamatusse. 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 The criterion is f ulf illed, but in order The need f or an advocates and/or to guarantee the annual evaluation in support ing persons is discussed with f acilitat ing f indin g advocates/ the persons ser ve d, if there seems to support ing persons , it would be be a necessit y f or that. advisable to add this activit y in the qualit y manual. The criterion was verif ied f ulf illed by 16 the evidence f ound in client work Kriteer ium on täidet ud, kuid documentat ion and interviews. tagamaks iga-aastane eestkostja/ tugiisiku leidmise alane hindamistegevus, on soovitatav see tegevus lisada kvaliteedi käsiraamatusse. 20. The social service provi der defines and documents its policy on ethics that respects and assures the dignit y of the persons served, protects them from undue risk and promotes soci al justice Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The code of ethics of TEK has been developed and is part of the qualit y manual. It is also available on the home page of the organi zat ion. Members of staff showed awareness about the related ethic pr inciples. 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 mechanis ms 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 Work processes of TEK are It would be advisable t o make an descr ibed in the light of the analysis of the possible threats and principles of ethical treatment of the measures and mechanisms, customers and preventing any f orm which prevent the physical, mental 17 of physical, mental and f inancial and f inancial abuse of persons abuse of persons ser ved. ser ved and use this inf ormation t o improve the existing work processes. They are assessed f rom time to time. Oleks soovitatav koostada analüüs, mis sisaldab võimalikke ohte , meetmed ja mehhanisme teenuse saajate f üüsilise, vaimse ja f inantsilise ärakasutamise ennetamiseks ning kasutada seda inf ormatsiooni asutuse protseduur ide täiustam iseks. 22. The social servi ce provi der provides services in a safe system of w orking w ithi n 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 TEK provides ser vices in a saf e system of working within a saf e environment. Risk assessments of the work place have been conduct ed 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 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 18 Strengths Improvem ent & developments The principles, values and procedures in ser vice deliver y are descr ibed in the qualit y policy and code of ethics. The aspects of respecting conf ident ialit y, accur acy, privacy and integrit y are seen as important values in the service deliver y processes. It was demonstrated through the inter views of staff that they ar e aware of the et hical principles related to their work. 24. The social service provider defines, documents, monitors and evaluat es procedures for assuring confidentialit y of data regardi ng the persons served and the service provided to them. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments There principles f or processing delicate personal data are addressed in the qualit y manual. Inf ormation about clients’ data is conf ident ial and accessible only t o author ized persons. The principles are over viewed annually with the staff and persons ser ved. 19 25. The social service provider defines the roles and responsibilities, authorities and th e 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 prog ram Strengths Improvem ent & developments The necessar y roles and responsibilities of the personnel who manage, design, deliver, support and evaluate the ser vice provision to person ser ved are descr ibed in the qualit y manual of the organizat ion. This inf ormation is also presented on the home page of TEK. 26. The social service provi der w orks in partnership w ith other organisations in the provision of servi ce s. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments TEK does a lot of cooper ation wit h its var ious partners, as it sees great synergy and value in partnerships. F.e TEK does tight cooper ation wit h its clients and their clos e ones, organizat ions of blind and visually impair ed (Lõuna - Eesti Pimedate Ühing, Eesti Pimedate Liit, Eest i Pimedate Spordiliit), Social Insurance Board, local governments, Estonian Unemployment Insurance 20 Fund, Tartu University Hospital etc. W ith cooperation partners var ious projects and activities are organized, which also ser ve the needs and expectat ions of society. TEK ser ves as the training base f or students. TEK discusses and evaluates the cooper ation relat ed to the services delivered with its 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 the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The persons ser ved, purchasers and other stakeholders are involved in the development of ser vices of TEK through meeting s and sur veys. TEK values highly the inf ormation and f eedback gained f rom its stakeholders and uses it in all possible ways in ser vice development. Good examples are coming f rom the cooper ation with the organizations of blind and visually i mpaired (Lõuna - Eesti Pimedate Ühing, Eest i Pimedate Liit, Eesti Pi medate Spordiliit). 21 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 dial ogue process in the management of the service, incl uding t he definition of the needs, the definition of the services, as w ell as of the evaluation of qualit y. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The service provision is client centered, taking into account the special needs and expectat ions of ever y individual person ser ved. Children and their parents or adults are in volved in every st ep of their ser vice deliver y pr ocess including ser vice planning, deliver y and appraisal proce ss. The criterion was ver if ied sat isf ied through exploring client work documentat ion and through inter views with staff and clients. 29. The social service provi der institutes an annual evaluation of partici pation of persons served bot h on indi vidual and/or group basis. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The measures, activities and polic y f or client participat ion ar e agreed with the persons served or representat ives of persons ser ved. 22 Persons ser ved or their representat ives provide a comprehensive assessme nt of ser vice qualit y at the end of the ser vice and give f eedback through questionnaires. All clients or their advocates have a chance to give f eedback about the organizat ion and t he developm ent of ser vices and to make suggestions. Related principles are described in the qualit y manual of TEK and are reviewed annually. 30. The social service provi der operates specific instruments f or users to improve their personal empow er ment and personal situation and that of their communit y. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Empowerment of persons ser ved is an int egral part of service deliver y. Together with partners trainings a nd social events are or ganized to blind and visually impaired people to widen their social net work and to empower them. TEK pays great attention to the customer's empowerment , raising motivat ion and awar eness of various leisure opportunit ies. F.e in cooper ation with the Estonian Blind Sports Association TEK f inds ways to engage people wit h visual 23 impairment in social lif e through organized sports act ivities. Many other examples of empower ing activities were evidenced in ser vices’ deliver y processes and also cam e out f rom the interviews with staff and persons ser ved. 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 TEK advises clients on the adaptat ion of the environment and helps to f ind t he most appropriate techniques and tools. Even after the terminat ion of the ser vice TEK encour ages customers to obtain inf ormation or to contact them in case of problems. The goal is to achieve greater individual independence, satisf action with their qualit y of lif e and greater involvement in communit y. 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 24 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 TEK has an over view of the needs of the persons served (queues, meetings with cooper ation partners ). The locat ion of TEK is pleasant and well accessible in Tartu both by car and also by public transportation. Directions how to reach TEK are presented on its hom e page. The rooms and f acilit ies have been adapted to meet the needs of the blind and visually impaired. All the ser vices are deliver ed at the same complex, which is ver y convenient f or the persons ser ved . In case of reasonable need, the ser vice is deliver ed at the home of the person ser ved. 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 TEK does cooper ation with the f unding bod y (Social Insurance Board) and has ascertained the needs and expectat ions of them. 25 The needs of other stakeholder s have also been discussed dur ing meetings and during dail y cooper ation (though e-mails, telephone) . The success and results of the exist ing ser vices have been determined. TEK evaluates the eff ectiveness of the services based on the achievement of the perf ormance indicators in the individual plans, customer f eedback and based on the ser vice provider ’s assessment. To assess the over all eff iciency of the ser vices TEK carr ies out customers’ sur veys and other stakeholders’ sur veys . 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 In the service planning and deliver y TEK uses customer -centered approa ch – the needs and expectat ions of cust omers are taken into account . TEK values the contribut ion of customers into the ser vice development. They carry out regular sur veys of the target group to assess 26 their needs. Ser vices off ered to clients ar e discusse d with t he persons ser ved, and they are based on individual action plans / rehabilitat ion plan s. This was ver if ied by examples of client documentation seen during the site visit. The process itself is described in the organizat ion’s qualit y manual. 35. The social service provider documents the planni ng of services based on the ident ification of indi vi dual needs and expectations of persons served in an Indi vidual Plan. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iteri on of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The clients’ individual needs and expectat ions are wr itten down in the individual plan s. The individual plans contain the desired situat ion of the person ser ved and are agreed by t he clients / representatives. 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 i n line w ith its vision, mission statement and quali t y policy. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program 27 Strengths Improvem ent & developments The service deli ver y processes are descr ibed in the qualit y policy. The rehabilitat ion ser vice process descr iption is also available on the home page of TEK. The key ser vice deliver y pr ocesses are in line with TEK’s vision, mission and qualit y pr inciples. All processes ar e regularly reviewed. 37. The social service provi der review s this delivery process and maintains control over the deli very of t he servi ce. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments TEK reviews the ser vice deliver y It would be advisable to lay down the process es. Perf ormance reports are principles f or carrying out internal composed. audits in the qualit y manual. The processes t hemselves are Soovitatav on kirjeldada siseauditit e reviewed per iodically. läbiviimise süsteem kv aliteedi käsiraamatus. The processes and the deliver y of ser vices are subject to analysis. Until now EQUASS test audits have covered the main procedures of the organizat ion. 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. 28 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 TEK ensures that the person s ser ved can access a cont inuum of services as the needs of persons ser ved ar e evaluated and descr ibed in individual plans. Necessar y ser vices are provided that are laid down in the individual plans . TEK guarantees the availabilit y of ser vices (smooth and cont inuous provision of the service), ensuring a suff icient number of specialists in the organization. In providing the ser vice, TEK f ollows a holistic approach, off ering ser vices ranging f rom early inter vention to support ing and evaluations. TEK supports their customers in making the necessary changes to improve their qualit y of lif e. 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 29 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. 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 im proving 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 TEK uses client -centered holistic approach, which is aimed to improve client ’s qualit y of lif e. The qualit y of lif e init iat ive’s eff ectiveness is measured and reported in individual plans . Physical wellbeing, economic wellbeing and social activit y are assessed. F.e dur ing Sof ie p roject an empowerment related questionnair e was developed f or adults, which is used now. The criterion was verif ied f ulf illed by also explor ing the client work documentat ion, where evidence was f ound about measur ing the qualit y of lif e. 30 41. The social se rvice 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 icatio n program Strengths Improvem ent & developments The necessar y competences and skills are descr ibed in the qualit y manual of TEK. The competences and skills are evaluated annually during employees’ perf ormance reviews. Trainings are provided to employee s, which was evidenced by training plans of TEK and came out from 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 Expect ed results are described in The var ious quality cr iteria and annual plans, which are reviewed perf ormance indicat ors are described twice a year. in the qualit y manual (structure, process, perf ormance criter ia). It Targeted results are measured and would be advisable to present them reported in annual reports, which ar e in a more detailed way and f ind a disclosed on the web page of TEK. way to make them more measurable so that the expe cted results can External reviews ar e conducted by more concretely be measured. the Social I nsurance Board . The 31 latest (2014) did not f ind any major Kvaliteedi käsiraamatus on esitatud violat ions or deviations f rom erinevad k valit eedikriteeriumid ja regulations and rules . tulemusindikaator id (struktuuri -, protsessi- ja tulemuskriteerium id). Soovitatav on esitada nendega seotud inf ormatsioon deta ilsemalt ning leida viis muutmaks need mõõdetavamaks, nii et oodatavaid tulemusi oleks millegi konkreetsema vastu võimalik mõõta. 43. The social servi ce provi der identifies and registers the outcomes and benefits for person served of the recei ve services on individual and collecti ve basi s. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments TEK gathers and documents inf ormation regarding results of providing ser vices (both on individual and collective basis). This inf ormation is available in individual reports and a summar y is disclosed also in the annual report of TEK. 44. The social service provider evaluates its business results in order to determine best value for purchasers and funders ( ‘best value’ can also be expressed in relation to the increased qualit y of life offered to the person bei ng served). Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments 32 TEK evaluat es the r esults and added value of its work during meetings. Plans and expect ed results are depicted in t he annual plan. Achieved results and outcome of perf ormance in described in the annual reports. The changes in the qualit y of lif e of persons ser ved are descr ibed in the evaluat ion section of the individual plans. 45. The social service provider evaluates the indi vidual and collecti ve satisfact ion of per sons 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 TEK organizes reg ular sur veys to It would be advisable t o review the receive f eedback f rom the persons questionnaires used to gain more ser ved / representatives . valuable f eedback. Most valuable f eedback is gained Soovitatav on üle vaadata f rom cooperation partners, with küsimustike sõnast us, et saada whom TEK works together on daily väärtuslikumat tagasisidet. basis. Also the satisf action of other stakeholders is evaluated by u sing diff erent means like meetings and questionnaires etc. The interviews with stakeholders proved that the satisf action level with the ser vices and with the work that the organizat ion does and with 33 the results it achieves is high. 46. The social service provider provides accessible and easil y understandable records on outcome, includ ing personal perception and achievements Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The records on outcome are communicat ed to stakeholders, staff and persons ser ved. The content and f ormat of deliver y depends on the target group. Related inf ormation is also available on the home page of TEK. There is inf ormation available in the reports about personal percept ion s and achie vements. 47. The soci al service provider acti vel y disseminates organization performance among its staff, service users and external stakeholders. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS As surance certif ication program Strengths Improvem ent & developments TEK reports its perf ormance to It would be advisable to update the f unding bodies, staff and ser vice inf ormation of the home page users using diff erent methods. regarding the various media releases concerning TEK. The content and f ormat depends on the target group. Kodulehel oleks soovitatav uuendada loetelu erinevat est me edia- Related inf ormation is also availabl e 34 on the home page of TEK. kajastustest, mis käsitlevad TEKi. 48. The so cial service provider has a standard procedure for continuous improvement on the basis of an improvement cycle. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The PDCA cycle is used and It would be advisable to describe the descr ibed in the qualit y manual of PDCA cycle in more detail in the TEK. qualit y manual, linking it to concret e activities. All the process and activit ies are reviewed regular ly. At least t wice a Oleks soovitatav kirjeldada kvaliteedi year TEK assess es its planned tsüklit täpsemalt kvalit eedi activities on schedule d meetings, käsiraamatus, seostades see analyzing their eff iciency and konkreetsemate tegevustega. eff ectiveness and makes necessar y changes. The results and perf ormance of TEK is measured and described in related reports. Qualit y improv ement projects are 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 TEK work s together with the visuall y impair ed people’s rehabilitation organizat ions and institutions both in Estonia and abroad, to develop and 35 implement the best practices and innovat ive ways of working to meet the needs of its customers. TEK is taking steps to become a competence center in its f ield of activit y. All improvement programs are document ed, include goals and respect ive perf ormance indicators. F.e lately work ing and acting abilit y assessment methodolog y was developed in cooperation in f rames of HMN project. This was verif ied th rough inspecting f ew examples during site visit. 50. The servi ce provider introduces and manages innovative w ays of w orking that have been identified based on the needs of stakeholders. Remark from the auditor: The ser vices of the social ser vice pr ovide rs meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments TEK f inds ways of being innovat ive, taking into account the needs and expectat ions of stakeholders. TEK participates in diff erent projects both in local and int ernational level. F.e TEK has been act ive in introducing innovative and entertaining apps and technolog y f or the blind and visually impaired (“Be my eyes” etc). 36 Also, f .e the Museum of Agriculture was adapted to the needs of blind and visual ly impaired wit h the help of TEK. All related inf ormation was verif ied to be docum ented. 37 4. Agreed additional development / improvements The applicant decided on the following improvement actions and/or additional development for the period of two year s: Short descript ion of the actions (including SMART objectives) 1. criterion 3 Make sure that the f eedback from stakeholders is always document ed in a proper way (summar y/analysis) so that this inf ormation could be used f or improving the activit ies of the organizat ion and its ser vices and f or making decisions on management level. Dokumenteer ida huvigruppidelt saadud tagasiside alati korrektselt (kokkuvõte/analüüs), et saadud inf ormatsiooni saaks kasutada asutuse tegevuse ja t eenust e täiustamiseks ning juhtim isotsuste tegemiseks. Person r esponsible / vast utaja: head of rehabilitat ion unit / rehabilitatsioonirühma juht Due date / tähtaeg: 01.03.2017 2. criterion 5 Descr ibe the annual planning and review process in a more detailed manner to depict all the inf ormation that is taken into account in the planning process and all the related steps and personnel involved. Kirjeldada aastase planeerim ise ja ülevaatuse protsessi detailsemal moel, nii et see sisaldaks kogu planeer imisel arvesse võetavat inf ormatsio oni ning kõiki planeer imisega seotud etappe ja seotud personali. Person r esponsible / vast utaja: head of rehabilitat ion unit / rehabilitatsioonirühma juht Due date / tähtaeg: 01.03.2017 3. criterion 6 Review the perf ormance indicators and target values an d establish ones that work best f or the organizat ion and enable to better measure t he f ulf illment of goals. Imporve the wor ding of goals. Üle vaadata tulemusmõõdikud ja nende saavutustasemed ning kehtestada sellised, mis asutuse jaoks hästi toimivad ning võimaldavad paremini mõõta eesmärkide saavutamist. 38 Kohendada eesmärkide sõnastamist. Person r esponsible / vast utaja: head of rehabilitat ion unit / rehabilitatsioonirühma juht Due date / tähtaeg: 01.03.2017 4. criterion 11 Gather inf ormation on individual l evel – who has participated in what trainings. Koguda inf ormatsiooni töötajate lõikes – kes on millistel koolitustel osalenud. Person r esponsible / vast utaja: head of rehabilitat ion unit / rehabilitatsioonirühma juht Due date / tähtaeg: 01.03.2017 5. criterion Develop other methods to periodically monitor the perf ormance 12 (deliver y of service) of staff . Välj a töötada ka muud viisid töötajate tegevuste (teenuse osutamise) perioodiliseks jälgimiseks. Person r esponsible / vast utaja: head of rehabilitat ion unit / rehabilitatsioonirühma juht Due date / tähtaeg: 01.03.2017 6. criterion To guarantee the annual evaluation , how the social ser vice 18 provider respects the f undamental r ight to self -determination of the person ser ved , add this activit y in the quali t y manual. Tagamaks iga-aastane enesemääratlusest lugupidamise alane hindamistegevus, lisada see tegevus kvalit eedi käsiraamatusse. Person r esponsible / vast utaja: head of rehabilitat ion unit / rehabilitatsioonirühma juht Due date / tähtaeg: 01.03.2017 7. criterion In order to guarantee the annual evaluation in f acilitating 19 f inding advocates/ support ing persons, add this act ivit y in the qualit y manual. Tagamaks iga-aastane eestkostja/ tugiisiku leidmise alane hindamistegevus, lisada see tegevus kvalit eedi käsiraamatusse. 39 Person r esponsible / vast utaja: head of rehabilitat ion unit / rehabilitatsioonirühma juht Due date / tähtaeg: 01.03.2017 8. criterion Make an analysis of the possible threats and the measures and 21 mechanisms, which prevent the physi cal, mental and f inancial abuse of persons served and use this inf ormation to improve the existing work processes. Koostada analüüs, mis sisaldab võimalikke ohte, meetmed ja mehhanisme teenuse saajate f üüsilise, vaimse ja f inantsilise ärakasutamise enneta miseks ning kasutada seda inf ormatsiooni asutuse protseduuride täiustam iseks. Person r esponsible / vast utaja: head of rehabilitat ion unit / rehabilitatsioonirühma juht Due date / tähtaeg: 01.03.2017 9. criterion Lay down the principles f or carrying out internal audits in the 37 qualit y manual. Kirjeldada siseaudit ite läbiviimise süsteem kvalit eedi käsiraamatus. Person r esponsible / vast utaja: head of rehabilitat ion unit / rehabilitatsioonirühma juht Due date / tähtaeg: 01.03.2017 10. criter ion Present qualit y cr iteria and perf ormance indicators in a more 42 detailed way in the qualit y manual and f ind a way to make them more measurable so that the expect ed results can m ore concretely be measured. Esitada k valit eedi käsiraamatus erinevad kvaliteedikriteeriu mid ja tulemusindikaator id detailsemalt ning leida viis muutmaks need mõõdetavam aks, nii et oodatavaid tulemusi oleks millegi konkreetsema vastu võimalik mõõta. Person r esponsible / vast utaja: head of rehabilitat ion unit / rehabilitatsioonirühma juht Due d ate / tähtaeg: 01.03.2017 11. criter ion Review the quest ionnaires used to gain more valuable 45 f eedback. 40 Üle vaadata küsim ustike sõnastus, et saada väärtuslikumat tagasisidet. Person responsible / vast utaja: head of rehabilitat ion unit / rehabilitatsioon irühma juht Due date / tähtaeg: 01.03.2017 12. criter ion Updat e the inf ormation of the home page regarding the various 47 media releases concerning TEK. Kodulehel uuendada loe t elu erinevatest meedia kajastustest, mis käsitlevad TEKi. Person responsible / vast utaja: head of rehabilitat ion unit / rehabilitatsioonirühma juht Due date / tähtaeg: 01.03.2017 13. criter ion Descr ibe t he PDCA cycle in more detail in the qualit y manual, 48 linking it to concret e activities. Kirjeldada kvaliteedi tsüklit täpsemalt kvaliteedi käsiraamatus, seostades see konkreetsemate tegevustega. Person responsible / vast utaja: head of rehabilitat ion unit / rehabilitatsioonirühma juht Due date / tähtaeg: 01.03.2017 41 5. Closing remarks Tartu Emajõe School is the only special state sc hool for children with blindness / visual impairment (BVI). According to its mission, the School works f or the improvement of educat ional opportunities of all visually impair ed children in Estonia; provides rehabilitation ser vices f or children and adults with BVI and supports their inclusion within all aspects of societ y. Tartu Emajõe School is off icially r ecognized as an education and rehabilitat ion institut ion specializing in t he f ield of BVI. The rehabilitation ser vices are provided accor ding to the Est onian Social W elf are Act by the special teachers of visually impaired, psychologist, physiot herapist, social worker, activit y therapist and speech - therapist. In addit ion, counselling sessions ar e available f or the people with blindness and low vison, their parents, teachers, educators and other specialists f rom all over Estonia. TEK started to implement EQUASS Assur ance qualit y system f ew years ago. The preparat ions f or EQUASS enabled to build up a qualit y management system f or that especially considers th e needs and expectations of social sector ser vice providers. The auditor exper ienced on sit e that the social ser vice provider TEK perf orms in compliance with t he EUQASS Assurance criter ia. The inter viewed representatives of partners, f inancing bodies, emp loyees of TEK and representatives of persons served conf irmed this, which was ref lected in their sat isf action. During the audit the organizat ion showed examples of good practice and proved that good cooperat ion with partners and person centered appr oach helps to achieve ver y good results. The whole staff was kind and cooperative in introducing the work of TEK, f inding necessar y evidential materials and sharing inf ormation about f ulf illing EQUASS crit eria. For the period of f ollowing two years, some impro vement 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 mentioned under the specif ic criter ia is given in detail in part 3. The improvement ar eas included in general improving the qualit y handbook of TEK (more detailed descr iptions of processes and principes) , maintaining more comprehensive documentat ion of f eedback received f rom stakeholders 42 and better wording of questions to be as ked to gain more valuable f eedback, reviewing the perf ormance indicators and target values used, developing additional methods t o per iodically monitor the perf ormance of staff, making an analysis of the possible measures, which prevent the abuse of persons ser ved, laying down the pr inciples f or carrying out int ernal audits and updat ing the home page of TEK. After verif ication of the indicators by r eviewing documentation, conduct ing inter views and performing site visit, the auditor was conf irmed that the criteria f or q ualit y assurance of the European Qualit y f or Social ser vices were f ulf illed. The auditor was convinced that TEK is devoted to qualit y assurance and improvem ent in its work and delivers ser vices of high qualit y. *** Tartu Emajõe Kool (TEK) on ainus riigikool pimedatele ja vaegnägevatele õpilastele. Koolis pakutakse sotsiaalse rehabilitatsiooni teenuseid pimedatele ja vaegnägevatele lastele ja täiskasvanutele ning tööalase rehabilitatsiooni teenuseid pimedatele ja vaegnägevatele täiskasvanutele. Asutuse miss iooniks on pakkuda rehabilitatsiooniteenuste kaudu par imaid võimalusi pimedatele ja vaegnägevatele lastele ja täiskasvanutele nende arengu toetamiseks, igapäevaeluga hakkamasaamiseks ja ühiskonnaellu kaasamiseks ning nõustada nägemispuudega inimestega tööt avaid spetsialiste teistes Eesti rehabilitatsiooniasutustes. TEK alustas EQUASS Assurance kvaliteedisüsteem i rakendamisega mõned aastad tagasi. EQUASSi rakendamiseks ettevalmistamine võimaldas ehitada üles asut use k valiteedijuhtimise süsteemi , lähtudes sp etsiaalselt sotsiaalvaldkonna teenuseid osutavat e asutuste vajadustest j a ootustest . Kohapeal koges audiitor, et sotsiaalteenuse osutaja tegutseb vastavuses EQUASS Assurance kriteeriumitega. Intervjueer itud huvigruppide ja rahastajate esindaja d, TEK töötajad ja teenuse saaja d samuti kinnitasid seda, mis väljendus nende rahulolus. Auditi käigus oli asutusel ette näidata m itmeid häid näiteid heast praktikast ning tõestas, et koostöö oma partneritega ja isikukeskne lähenem ine aitab saavutada väga häid tulemu si. Kogu asutuse töötajaskond oli lahke ja koostööaldis TEK töö tutvustam isel, vajaliku tõendusmaterjali leidmisel ning inf ormatsiooni jagamisel EQUASS -i kriteeriumite täitmise kohta. 43 Järgnevaks kaheks aastaks lepit i kokku mõned parendustegevused ja täien davad arendused, mis on välja toodud aruande 4 -ndas osas. Detailsem ülevaade parendussoovitustest konkreetsete kriteeriumite lõikes on esitatud aruande 3-ndas osas. Parendusvaldkonnad hõlmasid üldises plaanis TEK kvaliteedikäsiraamatu täiustam ist (täpsemalt protsesside ja põhimõtete kirjeldamine) , huvigruppidelt saadava tagasiside k õikehõlmavamat dokumenteerimist, küsimustike paremat sõnastamist saamaks väärtuslikumat tagasisidet, tulemusmõõdikute ja siht väärtuste ülevaatamist, täiendavate viiside väljatöötamist töötajate jälgim iseks, ärakasutamise ennetam iseks võimalike meetmete analüüsim ist , siseaudit ite läbiviimise põhimõtete kirjeldamist ning TEK kodulehe täiendamist. Peale indikaator itele vastamise tõendamist, tut vudes dokumentatsiooniga ning viies läb i inter vjuud, oli audiitor veendunud, et kriteeriumid Eur oopa kvaliteedimärgi jaoks sotsiaalteenustes on täidetud. Audiitor sai veendumuse, et TEK on pühendunud kvaliteedi tagamisele ja täiustamisele oma töös ning osutab kõrge kvaliteediga teenuseid. Tallinn, 29. 02.2016 Mar iliis Männik -Sepp EQUASS- i auditor / EQUASS auditor 44
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