Astangu Kutserehabilitatsiooni Keskus · 11. jaanuar 2016
Sisu (failidest)
EQUASS ASSURANCE
ASUTUSE KÜLASTUSE
ETTEVALMISTAMISE VORM
Asutuse külastus: 15-16. detsember 2015
SA Koeru Hooldekeskus
Audiitor: Epp Sillaste
© 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 n c e t ao t lus v or m i le j a a nt ud l is ai nf orm ats i oo n i l e p õh i n ed es pa l um e
te i l e tt e va lm is t us ek s v as t at a j är g ne v at e l e s e l gi t us t n õ ud v at e l e k üs i m us tel e :
Üldised teemad (max. 10 küsimust)
1. M i d a o le t e v i im as e 2 a as t a j o ok s ul e tt e v õt n ud , e t s uu re nd a da k l ie nt i d e,
k lie n ti d e l äh e d as t e r a hu l o lu t ee n us t e k v a l it ee d i ga ?
2. Mi d a o l et e vi im as e 2 a as ta j ook s u l e tt e v õ tn u d, e t t õ hus ta d a k oos t ö öd om a
k oos t öö p ar t n er i t eg a j a s u ur en d ad a n e nd e ra hu l o lu ?
3. K as k li e nt i de I nd i v i du a als e tes te g e vus p la a ni d es o n f ik s e er i tu d m õõ de ta v a d
s pe ts i if i l is e d e es m är g i d j a k as ut at a v ad m eet od i d/s ek k um is ed?
4. K u id as t o im ub k lie n ti d e in d i v id u aa ls et e t e ge v us pl a a ni d e ees m ärk id e ja
tu l em us te m õõtm i ne ?
5. Ku i das on t e en us e os u t am is e k ä i gus k ai ts tu d k l i en d i õ i gus e d?
6. K u i das o l e te l ä h en e nu d e e lm is e a ud it i 6- l e p are n dus e tt e pa n ek ul e - p a lu n
nä i d ak e.
7. K as ol e te v i im as e 2 aas t a j o ok s ul t u vas t a nu d tak is tus i , m is e i v õ im al da s uj u v a l t
te e nus t os ut ad a j a k as o n n ä it e id , k us o l et e s e ll ek s m id ag i e tt e v õ t nu d ?
8. P a lu n k ir j e ld a ge lü h i da l t om a or g an is ats i o on i i g a - aas tas t te g e vu s te p l an e er im is e
j a aru a n dl us e pr ots es s i.
9. Pa l un t o o ge n ä i de /p aar nä i d et i n no v a ts i o o n is t t e ie or g a nis a ts i o o n is .
10 . Mi l l is e id p ar e nd us i om a t ee n us t es o l et e v i im as e k a h e aas t a j ook s u l e ll u vi i n ud ?
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1. Kvaliteedi põhimõtetele ja EQ U ASS Assurance kriteeriumitele
vastavuse küsimused / teemad:
Te en us e s a aj a d
Kv al i te e d i ju ht
J uh t/ dir ek tor
Huv i gr up i d
P ers o n a l
Juht im in e 1. K u id as l o od i or g a nis ats i oo n i m is s i oo n
j a v is io o n n in g m i l vi is i l ta g at i s e l l e
x
k om m unik a ts i o on k õ ig i l e o lu l is t e l e
os a p oo l te l e ?
2. P a lu n t ut v us t a ge j a nä i d ak e, k u id as
to im ub t e ie org a ni s a ts i oo n is te g e vus t e
p la n eer im in e , t öö s s e rak en d am ine , x
tu l em us te h i n dam i ne j a p are n dus t e
te g em in e ehk PD C A ts ük k el.
3. K u id as k o g ut e er i ne v at e lt
hu v i gr up p i de l t ta g as is i de t j a k as o l et e
x x x
s e ll es t tu l en e v a lt om a te g e vus tes m id a gi
m uutn u d?
P er so na l 1 K u id as h i nn a tak s e t e ie
or g a n is a ts io o n is pe rs o na l i l e s ea t ud x x
tö öt i n gim us i?
2 K u id as h i nd a te p ers on a l i k om pe te nts e ? x x
3 K u id as t ag a te t ur v al i s e tö ök es k k onna
n in g k u i das t o im ub t öö k es k k onna x
h in d am in e?
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4 K as j a k u i das t o im ub t e ie
or g a n is a ts io o n is pe rs o na l i x x
tu n nus tam i ne ?
5 K as j a k u i das h i n da t e p ers o n a li
x x
k ool i tus te ef ek ti i vs us t ?
Õ igu se d 1. Ku i das t o im ub k li e n ti d e
i nf or m eer im in e tem a õ i gus tes t j a x x
k ohus tus tes t ?
2. Ku i das on t a ga t ud p ers o n a l i te a dl ik k us
x
k lie n d i õ ig us t es t j a k o hus t us t es t ?
3. K u id as o l et e a v a ld a nu d k li e nt i de l e
to et us t ne n de is e x x
ots us t am is e / en es em äära t lus e os as ?
4. Ku i das t o im ib t e ie k ae b us t e
m enet l em is e pr o ts es s , k as t e i l on
pr es e nt e er id a m õ ni k o nk ree tn e x x
j uh tum /n ä i de /n ä it e i d k ae b us t e
m enet l em is e j a l a h en d am is e k o ht a ?
4. Kas h i n da t e i ga- a as tas e lt k oos
te e nus e s a aj a te g a om a k ä it um is t
x x x
te e nus e s a aj a te e n es em äär am is õ ig us es t
l ug u pi d am is e os as ?
E et i k a 1. Ku i das (m i l v i is il) o n tö ö taj ad
i nf or m eer it u d or ga n is a ts i o on i e e tik a
po l i it ik as t ni n g k ä it um i s e x
põ h i pr in ts ii p i des t j a v ä ärt us t es t te e nus e
os u t am is e l?
2. K as te i l o n t uu a m õn i n ä id e
ed us am m udes t tu r va l i s us e j a
x
ter v is ek ai ts e t a g am is e l t ee n us e
os u t am is e as uk oh as ?
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3. K u id as t ag a tak s e t e en us e s a aj a te
k onf id e nts i aa ls us j a is ik ua n dm ete x x
k aits e?
4. K u id as h i nd a te om a
k äit um is e/ t eg e v us t e ef ek ti i vs us t t ee n us e
x
s aaj at e f üüs i l is e, va im s e v õ i f in a nts i l is e
är ak as ut am is e e n n et a m is el ?
5.
Koo st öö suh t ed 1. K u id as t o im ub k oos t öö
s ots i aa l p art n eri t e n in g ra h as t aj a t eg a
x x x
te e nus e s a aj a te l e t ee n us t e os ut am is e
ees m är gi l ?
2. K u id as t o im ub k oos t öö t e en us te x x x x
ar e n d am is e l?
3. M i l l is t e k ri t eer i um it e a lus e l h i nd at e x x
k oos t öös u he tes t t ul e n e va t
l is a n d vä är tus t ?
O s al em in e 1. K as o n k ok k u l ep i tu d j a k õi g il e x x
os a p oo l te l e t ea d a, k ui das t e en us e
s aaj a d os a l e v ad t e en u s te
v ä lj a tö öt am is e l j a k va l it e ed i /t u lem us t e
h in d am is e l?
2. K u id as o n t ee n us e s aaj a id j õ us ta tu d ? x x
4. K u id as a n al ü üs it e te en us e s a aj a te võ i x x x
ne n de es i n daj a te / lä h e das t e
os a l em is e g a /k aas am is eg a s e ot u d
te g e vus i j a pr o ts e d uur e ( n en d e
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ef ek ti i vs us t) ?
Is ik uk e sk su s 1. K u id as o l et e k i n dl ak s t e in u d x
po t en ts ia a ls e t e te e nus e s a aj a te
v aj a d us e d ?
2. P a lu n k irj e ld a g e j a n ä id ak e, k ui das x x
o le te t o im in u d, k ui t ee nus e s a aj a
o luk or d j a v aj a d us e d o n m uu tu n u d n in g
es ia l gs e l t k o os t at u d p l aa n e i o l e e nam
v aj a d us t e le vas t a v.
3. M i l v i is i l t e et e k in d la k s ol u lis t e x x
hu v i gr up p i de vaj a dus e d?
4. Kas o l et e t e in u d m u ud a tus i om a x x x
te e nus tes ( v õ i l oo n ud uus i t e en us ei d)
l äh tu v a lt t e en us e s a aj at e v aj ad us t es t,
ne i l t s aa d ud t a gas is i d es t ? P a lu n t o og e
nä i d e/ nä i te i d.
Lai ah a ar de li su s 1. K u id as m õ õd at e k li e nd i e l uk v al i te e t i x
par e n da v at e t eg e v us t e ef ek t i i vs us t?
2. K u id as t ag a te , et t e en us e x
os u t am is e ga s e o tu d p eam is ed
pr o ts es s i d o n vas ta v u s es te e nus e
os tj at e j a r a h as t aj a te po o lt t e ht u d
et te p an ek ut e/m ärk us t e ga ?
3. M i ll is e i d m ee tm ei d o m a x
or g a n is a ts io o n is r ak en da t e, e t ta g ad a
k lie n ti d e le n e n de vaj a dus t el e vas ta v
k atk em atu t e e nus ?
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4. K u id as a i ta te pers o n a li l ar e n da d a X x
om a os k us i j a k om pe t en ts e te e nus e
s aaj at e e l uk va l i te e d i t õs tm is ek s ?
T ulemu st el e 1. Ku i das o le te k om m un ik eer i nu d om a x x x
ori en t e e rit u s te g e vus te t ul em us t e a rua n d ed o l u l is t e le
hu v i gr up p i de l e?
2. K u id as m õ õd at e t ee nus e s a aj a t e x x x x
r ah u l o lu j a m il l is ed o n t u lem us e d ?
3. K as o le t e r a hu l p os it s i oo n ig a ra h u lo l u x
s k aal a l?
4.
5.
Pi dev a r eng 1. P a lu n pr es en te er i ge üh e võ i k ah e x
nä i te ab i l P DC A ts ük l i to im i vus t te i e
or g a n is a ts io o n is
2. P a lu n t oo g e n äi d e i n no v a at i l is es t x
tö öm eet o d is t .
3. P a lu n t oo g e ük s ar e nd us pr oj ek ti x
nä i d e.
4.
5.
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3. 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. T ege v us p la a n j a i gak u i ne h i n dam i ne
2. K l ie nt i d e k o os o l ek ut e pr o t ok ol l i d
3. P ers o n a li p o l ii t ik a
4. Ris k i a na l üüs
5. Ar en g u ves t lus t e k ok k uv õt e
6. Am et ij u h en d
7. T een i n dus s ta n da r d i d
8. K oo l it us p la a n
9. Str uk tu ur i ük s us t e j uh t i de k oos o lek u pr o tok o l l i d
10 . Is ik u an dm et e tö ö tl em i s e k or d
11 . R eh a b il i ta ts io o n ip l a a n
12 . T ag as is i d e le h t k oo l i tu s te k oh ta
13 . K ae b us t e l a he n dam is e k or d
14 . Nõ uk og u k o os o l ek u pr ot ok ol l
15 . V an em ho o ld aj at e k o os o lek u pr ot ok o ll
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4. Personali, teenuse saajate ja teiste 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. O rg an is ats i o on i j u ht 30m i n
2.
3.
4.
5.
6.
Personal Kestvus
1. P ers on a l igr u pp nr 1 - k un i 5 t ö öt aj a t 45m i n
2. P ers on a l igr u pp nr 2 - k un i 5 t ö öt aj a t 45m i n
4.
5
6.
Teenuse saajad Kestvus
1. K l i en d i gr u p p 1, 2 - m õlem as k u ni 5 45m i n +4 5m in
k lie n ti ( er in e v at e te e n us e k l ie n di d) .
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2.
3.
4.
5.
6.
Teised huvigrupid Kestvus
1. Ra h as t aj a es i n d aj a 30m i n
2. P eam is e k oos tö ö p ar t n er i es i n daj a d 45m i n (s o o vi t a va l t k or rag a)
( v äh em al t 2)
3. K l ie nt i d e l äh e das e d ( v äh em al t 3 ) 45 m in (s o o v it a v a lt k orra ga)
4.
5.
6.
5. Asutuse kül astuse ajakava formaat
9.15-10.00 Auditi protsessi tutvustus , põgus tutvum ine Koer u HK -ga
10.00-13.00 Tutvumine dokumentatsiooniga
13.00-13.30 Lõunapaus
13.45-14.15 Inter vjuu peamiste koostööpartneritega***
14.15-15.30 Auditi dokumentatsiooni koostamine
15.30-16.15 Inter vjuu personaligrupiga nr 1 *
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16.15-17.00 Kohtumine kliendigrupiga nr 1**
17.00-.17. 30 Audit i dokumentatsiooni koostamine
2 P ÄEV
9.00-9.45 Inter vjuu personaligrupiga nr 2*
10.00-10.45 Kohtumine kliendig rupiga nr 2**
12.00-12.30 Inter vjuu rahastajaga
12.30-13.00 Lõuna
13.15-14.00 Inter vjuu klient ide lähedastega ****
14.00-14.30 Inter vjuu juhatajaga
14.30-16.30 Auditi dokumentatsiooni koostamine
16.30- Auditi lõpetamine ja tagasiside andm ine
*Personaligruppidesse 1, 2 võiks kuuluda erinevaid vahetult
klientidega kokku puutuvaid spetsi aliste (v.a juhid), ühes grupis 3
kuni 5 töötajat.
** Kliendigruppidesse 1, 2 palun kutsuda samuti 3 kuni 5 klienti ühes
grupis.
*** Peamise koost ööpartneri intervjuul oleks soov kohtuda vähemalt
2 teie organisatsiooni koostööpart neriga, kellega on teil kõige enam
kokkupuudet.
**** Klientide lähedaste gruppi võiks kuuluda kuni 3 inimest.
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EQU ASS ASSU R ANCE
AU DIT REPORT
Site visi t: 15-16.12.2015
Koeru Hoo ldek eskus SA
Epp Si llaste
© 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 t he socia l se rvice provider
Name of the s ocial
service p rovider Koeru Ho oldek eskus SA
Add re ss :
Ida 2, Koeru, 73001 Jä rvamaa
Post bo x:
Person res ponsi ble rynno.lass @ko eruhk.ee
(CE O):
Contact pe rs on: Monika N ee msalu, pe rsonnel and
commu nic ation specialist
Phone : +372 38 39210
Fax : +372 38 3 920 5
E-mail: rynno.lass @ko eruhk.ee
Web site : w ww.koeruhk.e e
Name of Auditor: Epp Sillast e
Dates of a udit : 15-16.12.2015
Cli ents: Num ber of person served: 215
As of (date): per ye ar (16.12.20 15)
Staff: Num ber of Full t ime staff : 107
Num ber of Part tim e staff : 7
Num ber of C ontracte d staff :
Num ber of volunteer s (if applicable )
2
Servic es : 24 hour c areta king w ith reinforc ed
supe rvision
3
2. Aud it program
DAY 1
9.15-10.00 Aud iti protses s i tut vust us, põg us tutvum in e Koeru HK-ga
10.00-13.00 Tutv um ine dok um ent atsi ooniga
13.00-13.30 Lõuna paus
13.45-14.15 Intervjuu peam iste k oostööpartneritega* **
14.15-15.30 Audit i doku m ent atsiooni koos tam ine
15.30-16.15 Intervjuu person al igr up iga nr 1*
16.15-17.00 Kohtum ine kliendigrupi ga nr 1**
17.00-.17.30 Audit i doku m ent atsiooni koos tam ine
DAY 2
9.00-9.45 Int ervjuu perso nal igrupiga nr 2 *
10.00-10.45 Kohtum ine kliendigrupig a nr 2**
12.00-12.30 Intervjuu rahastaja ga
12.30-13.00 Lõuna
13.15-14.00 Intervjuu klient ide lä hedaste ga****
14.00-14.30 Intervjuu juhatajag a
14.30-16.30 Audit i doku m ent atsiooni koos tam ine
16.30- Audit i lõ peta m ine ja tagasisi de andm in e
4
3. Detai led feedback on pe rfo rmance
1. The social ser vice provid er def ines d ocum ents and im plem ents its
vis ion and m ission v alues on s er vic e pro vis ion.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
Koeru Hooldek es kus def in es,
docum ents, and im plem ents its
vis ion an d m ission on servic e
provision c lea rl y and precis el y.
During the interv iew s was va li date d
that em ployees and externa l
custom ers are aware of the vision,
m ission a nd corporat e values.
2. The social servic e provider def in es , docum ents, and im plement s its
qua lit y po lic y b y determ inin g long term qualit y goa ls, and its
comm i tment to conti nuous im provem ent.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
5
Koeru H oo ldek eskus def ines its
qua lit y policy and princ iples in
Deve lopm ent Plan ( Strategy, longer
period) an d Qua lit y Prom otion and
Leadership Ac tion Plan ( yearl y) , and
has im plem e nted its qua lit y po lic y by
determ inin g long term qualit y goals,
qua lit y obj ectiv es a nd its
com mi tm ent to conti nuo us
im provem ent.
Staff m emb ers consi der all the
qua lit y p olicies and procedures an d
other docum ents that r egulat e the
servic e del iver y a s gu idelines on
their work .
3. Person s served, f am ily m em bers and service us er orga nis ati ons ar e
abl e t o give f ee db ac k on their ind iv idual and collect ive exper ience of
programm e s and ser vice s.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
6
There are se veral possibil it ies f or
giv in g and c ol lec tin g f eedback-
organ izat ions hom epage
(satisf action wit h servic es,
com plaints), satisf action su rve ys,
m eetings for clients and s pecialists.
Colle cting f eedback f rom f under and
m ain co-partners is organized m ostly
through m eetings or e-m ail.
During the interv iew s was va li dated
that the stak ehol ders have
opportunit y to give f eedba ck .
4. The social ser vice provider inf orm s all stak ehol ders a bout the
off ered programm es and serv ices ava ilable.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
Koeru Hoo ldek eskus inf orm s its
stakeholders about programm es and
servic es ava ilable m ostl y t hrough
hom epage and on the lobby wal l.
Bes ides wr itten distrib ut ion of
inf orm ation , there was a lso oral
inf orm ation that is distributed to
diff erent part ies t hrough different
m eetings .
Also m eeting prot ocol s were
presente d as proof that all relev ant
inf orm ation was pr esented to al l
interest ed part ies.
7
5. The social ser vice pro vi der m anagem ent establish es and docum ents
an annual planning and rev ie w proces s.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
The annu al plann ing and the rev ie w
process is doc um ented in the Qua lit y
Prom otion a nd Le adership Act io n
Plan. Ther e is c lea rl y define d ho w
the process is co nd ucted. Ther e is
als o proof of annu al pla nn ing and
reviewing m eetings protocols.
6. The plan i ncludes:
• annual outcom es / targets
• the activit ies t o be u ndertaken in achievi ng the annua l t ar ge ts
• m onitoring of the per f orm ance of the organisatio n i n m eeting its
annual targets
• tim e-scales and proc edures for re view an d revis io n.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
8
The a nnu al plann ing is he ld in th e
docum ent “Qualit y Prom otion and
Leadership Action Plan” . Th e
docum ent inclu de d object ives ,
activ ities, m easurable results, d ates,
perf orm ers.
Docum ent is appr oved b y m a nager
of the organiz ation.
7. The soc ial service provider dem onstr ates organisat ion’s success in
satisf ying th e needs and ex pectat ions of the soc iet y.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
Koeru Hoold ek esk us co llects
f eedback from clients , staff , f under
and m ain co-partner s. The f eedback
is g iven both in verbal an d written.
There is proof of organisations
success in sat isf ying the need s and
expectat ions of the society. Fr om
satisf action surve y we co uld f ind
several im provem ent propos als an d
during the au dit w e f ound proof on
satisf ying th ese n ee ds and m eeting
clients expecta tions.
Koeru Hoo ldek eskus has a lso
pub lished arti cl es.
9
8. The social ser vice provid er dem onstr ates organis at io n’s social
responsibilit y through a ctiv ities contributing to the societ y.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
There was proof of organisation`s
success in contribut ion to the
soci et y.
Koeru Hoold ek esk us has organized
com munity ba sed events and
activ ities (craf t f airs, concerts etc).
They off er sauna serv ic e and
caf eteria ser vices to lo ca l
popula tion.
9. The socia l ser vic e pro vi der h as a staff recruitm ent and r etention
polic y that prom otes the selecti on o f qualif ied p ersonnel b as ed on
required k no wledge, sk ill s and com petenc es.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
10
Koeru Hooldek esk us has Pers onnel
Polic y which consist procedures f or
recruitm ent, training a nd retention.
Staff is chosen based on their
com petences, sk il ls and prev io us
work exper ien ce th at are list ed in jo b
descr ipt io ns. Re cruitm ent is base d
on eq ual opportunitie s and non-
discrim ination.
10. The social ser vice pro vi der operat es in com pliance with m andator y
natio na l legislat ion, providi ng appropriat e work ing condition s,
adequate and agreed staff level and st aff ratio, and ap propriat e
rewarding f or staff and v ol unte er s.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
11
Koeru Hoold ek esk us has reviewed its
docum entation and work proced ures
and assures that it work s in
com pliance with nat ional legislati on.
There have been audits an d c hecks
carrie d o ut int ernall y and b y ext ern al
bod ies to ver if y nece ssary
com pliance .
The social serv ice pro vider has
pol ic y f or showin g recognition to
staff.
Staff members are recogn is ed in
m any ways- t hroug h off ered tr ain ing
poss ibili ties, s taff engagem ent days
and events. Ever y year th e
organ izat ion recog nize s on e of their
staff m em ber b y choosi ng “W orker of
the year”.
Work place risk asse ssm ent s ystem is
in place a nd rev iewed p eriodicall y.
Staff m embers sign t he risk
assessm ent docum ent s to sho w th eir
understa nd ing of it .
11. The so cial s er vice t rains all st aff based on a pl an f or l eaning and
developm ent and ev aluates the eff ectiveness of the train ing.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
12
There is a Tra ining Plan that inclu des There is a sp ecial f orm deve loped to
all the nece ssar y t rainings duri ng eva luate th e eff ectiveness of each
one yea r period. There are also train ing but there wa s no overa ll
intern al train ings f or the staff anal ys is m ade. Auditors suggestion
m em bers to be able to prom ote the is t o m a ke t he analysis an d
princ ip les set to the service conclus io ns wh ic h m ak es it eas ier to
provision. plan eff ective tra inings i n the f uture.
Tra in ing act ivit ies are ev aluated, Töötaj ad täid avad küll s pets iaa ls e
Staff gives f eedbac k af ter trainings k oolitu se tagasis id e vorm i, k uid
with spec ia l f orm s. k ok kuvõte või anal üü s tagas isi dest
puud ub. Audiit ori so ovit us on teha
analüüsist jä reldusi
(personal itöötaja l), mis oleks
alusek s edaspi dis te k oolituste
planeerim i se l.
12. The soc ia l servi ce pro vider applies requirem ents f or com petenc e
in the ident if ied roles and f unction s of staff and evaluates them on
annual basis.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
13
Al l the spec ial is ts in Koeru Person ne l Policy d ec lares that
Hoo ld ek esk us have a job desc ription developm ent di scuss ions with s taff
that cons ist of requirem ents f or are cond ucted ever y ye ar. Fr om
work ing in that p articul ar po sition. interv iews with stuff auditor foun d
out that m any dev el opm ent
Com pete nces of staff are discus sed discuss ions tak e pla ce once aft er 2
and ev al uat ed in staff supervision years. Au ditors suggestion is to
m eetings and al so monthly thr ough f ollow the po lic y or change it
perf om anc e based rem uneration accor dance with re al life.
s ystem .
Person al i poliitikas on sätes tatud, et
During th e interv ie ws was vali dated töötaj ate arenguvestlus ed viiak se
that staff is f amiliar with the läbi k ord aastas. Int ervjuude käigus
requirem ents fo r competences and sel gus, et osade tööt ajatega o n
als o with t he evaluat ion process. vestlu sed k ord kahe aasta jooksul.
Aud iitori ettepan ek on viia
personalip oli itik a k ooskõlla tegeliku
eluga. Pers onali
k om petentsusnõudeid tuleb hinnata
iga- aastase lt. Te ie v alik on, ka s te
teete seda läbi aren guvestluste v õi
m uul viisil (nä itek s l äbi
tulem ustasustam ise süsteem i).
13. The soc ia l serv ic e pro vi der recognise s the s taff as a resource f or
f eedback on organisatio na l perf orm ance, service development and
staff developm ent
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
14
Involv em ent of staff member s in
organ isat ions pl anning and
m onitoring p roces s is reg ulated b y
the Personne l Pol icy.
Staff m embers give t heir input to
annual p la nn ing, m onitor ing an d
review process through spec ia l
m eetings but also t hro ugh staff
superv ision m eeting s an d
satisf action (f eedback ) surve y.
14. The social s ervic e pro vi de r has m echanism s in plac e to enhanc e
satisfaction and m otivation of staff
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
Staff Satis faction Survey is carr ie d
out to get f eedback f rom staff about
their sat isf action and m otivation.
Staff m emb ers are recogn is ed a lso
through offer ed tra in ing poss ib ilit ies,
staff engagem ent days a nd ev ent s.
Also m onetary re co gnit ion f or specia l
and intensive work results .
Em ployees who ha ve done d uring the
ye ar m ore than is required in job
descr ipt io n are rewa rded each year.
15
15. The soc ial ser vice provider assures the right s of persons served
outline d in a Charter of Rights which is based on t he EU Charter of
Fundam ental R ights, the Eur op ean Convention f or the Pr ote ct ion of
Hum an Rights a nd Fundam ental Freedom s of t he Co uncil of Europ e
and othe r i nternat io nal hum an rights co nvent ions, es peci all y thos e
ela borated und er the United Nat ions.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & develo pm ents
Koeru Hooldek esk us has a Charter of
Rights and Res pons ibi lities a s part of
their Rules of Proc edure and i n the
lob by wall and in their hom epag e (f or
ever ybo dy to see).
Charter of Righ ts an d
Resp ons ibilit ies and Equal
Opp ortunities Poli cy ref ers to
relev ant inter national and Europea n
regulations.
During the interv iews it was a ls o
valid ated that staff is aware of the
charter of right s.
16. The soc ia l s ervic e provider inf orm s t he person serv ed a bout his/ he r
rights and dut ies es pec ially to eq ual tre atm ent on groun ds of age,
dis ab ility, gender, race, rel igion or beli ef and sexual or ie ntat ion before
receiving the servic e s.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
16
Strengths Im provem ent & developm ents
Koeru HK inf orm s service users
about their rights and duties durin g
the f irst evaluat ion and pla nnin g
m eeting. Rig hts and duties are also
part of Rules and Procedures f or
Clients, wh ic h is ava ilable f or all the
clients.
During the interv iews it was valid at ed
that ser vice users are we ll aware of
their rights an d dut ie s.
17. The social ser vic e pro vider has a cc essib le c omplaint m anagem ent
s ystem which r egiste rs f eedback o n perf orm an ce f rom persons served,
purchasers and othe r relevant stak eho ld er s.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
Com plaints and inadequac y`s ar e
recorded in s pec ial form s.
Stakehol ders ar e aware of the right
to subm it a c la im in case of a need
but servic e users m ostly pref er
solv ing problem s through discussion
as the y f ind the c om m unication with
servic e prov ider eas ier.
17
18. The social service provid er respects t he fu ndam ental right to self -
determ inatio n of the person serve d. The y f reel y determi ne t heir
pol it ical status and freel y purs ue their econ om ic, social and cultural
developm ent.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
Right to self- determ ination is
regulated with Ch arter of Rights and
Resp ons ibilit ies, Com plai nt
m anagem ent s ystem .
Right to self -deter m ination is al so
disc ussed when client is enter ing the
servic e- dur in g the evaluation
process.
Eva luat ion on se lf - determ ination is
carrie d out throu gh Se rv ice User
Satisf actio n Surv ey, m eeti ngs with
clients and supp ort persons and
m onitoring of com plaints.
19. The socia l ser vice provid er f acilit ates the person s erved in
choos in g and hav ing access to advocat es and/o r supporting persons.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
18
Right to self -determ inati on is
disc ussed when cl ient is enter in g the
servic e- during the eva luat ion
process but also in r egular m eetings
with cl ients.
Eva luat ion of the perf orm ance in
f acilit atin g persons served in hav ing
access to support ing persons is
organ ized by speci al m eetings.
Protocols of these m eeting s were
presente d.
20. The social ser vice pro vider defines and d oc um ents its poli cy o n
ethics that respects and as sures the dignit y of the persons serv ed,
protects them from undue risk and prom otes soci al j ust ice
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
Polic y on Ethics is part of Ser vic e
Prov isi on Stand ar d (f or staff ) and is
gui deline on et hics in th e
organ isat ion s ervice prov is i on.
Protocols of me etin gs where this
pol ic y is pres ented to staff and
disc ussed wer e shown.
21. The soc ia l service pro vi der op erates m echanism s which preve nt
the phys ical, m ental an d f inancial a buse of users.
19
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
Koeru HK has doc um ented pol ic ies
and proc edu re s t o prevent ph ysical,
m enta l and financia l abus e of
persons s erved in their Serv ice
Prov isi on Sta ndar d and in their
intern al work procedur es (a lso
clients m oney m anagem ent
proced ure).
Internal work procedure s are
m andator y to all staff m em bers. All
staff mem bers sign co nt racts, wh ich
conf irm s that they respect am ong
other things these pr ocedur es.
Koeru HK e va luates th e
eff ective ness of its policy to preve nt
physic al, m ental and financ ia l abuse
of persons serv ed through spec ia l
m eetings (once a year).
22. Th e socia l s er vic e provid er provides services in a saf e system of
work ing within a safe env ironm ent to ensure the phys ical sec urit y of
persons s erved, their f am ilies and caretak ers.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
20
There exists Workplace Risk
Assessm ent s yst em .
Staff tr ai ning plan c onsist s of
trainings f or securi ng He alth and
Saf et y at work as prescri bed b y
nationa l law (ever y year the y
organ ize f ire dr ill).
The risk assessm ent also includes a
m easures concer ning health an d
saf ety iss ues a nd for ensuring saf e
env ironm ent and ph ysica l s ecur it y of
staff and persons served.
23. The soc ia l ser vice provi der def ines , docum ents, m onit ors an d
eva luates a set of principle s, values and proc edures that govern
behav io ur in s ervic e del iv er y conta in ing asp ects of conf identia lit y,
accurac y, priv acy an d in tegrit y.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
Koeru Hool dek eskus has defined,
docum ented and is cont inuous ly
evaluat ing t he principle s an d
proced ures to ensure the servic e
del iv er y, wh ich is based on
conf ident ialit y, acc ura cy, integrit y
and pr ivac y.
Protocols of meetings where all th e
relev ant topic s were introduced and
disc ussed wer e pres ented.
21
24. The soc ia l ser vice provi der def ines , docum ents , m onit ors an d
eva luates proced ures f or assuring co nf identia lit y of data regardin g the
persons s erved and t he service provided t o them .
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
Koeru HK has doc um ented its Data
Protection and Proc essing Polic y.
During the interv iew s was va li date d
that service users are we ll awar e of
their righ t f or con fidentia lit y of dat a.
Serv ice u sers k no w ab out their
person al f olders and how to access
them .
Polic ie s are reviewed with staff
m em bers and clients regularl y.
25. The soc ial servic e pro vider def ines th e role s a nd responsi bilit ies,
author itie s and the i nterrelatio n of all p ersonnel who m anage , design,
deliv er, suppor t and eva luate the s erv ice provis ion to per son serv ed.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
22
Koeru Hooldek eskus has def ined the
roles and resp onsibiliti es of
m anagem ent and a lso the role s an d
responsibilitie s and author itie s f or al l
staff who are f ocusi ng on clie nt
servic e prov iding process.
Roles and r espons ibiliti es of
spec ialists who c om municate direct ly
with c lie nts are doc um ented in job
descr ipt io ns and intr od uce d to
clients in th eir f irst m eeting with the
spec ialist.
26. The social service provid er work s in par tners hip with ot her
organ isat ions in the provision of services .
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
23
Koeru H K is working in partners hi p
with
1. soci al partners, m ostl y loca l
Cultural C entre an d paris h, but a ls o
schools, f am ily m embers, guardi ans.
2. Fundin g Age nc y- The Soc ial
Insurance Boa rd . Th e c oo-operation
is m ostly wit h loca l departm ent.
Adde d val ue of its partnersh ip is
evaluate d a nnual ly an d
developm ents are disc ussed a lso
while reviewing the Dev elopm ent
Strategy a nd Qua lit y Prom otion and
Leadership Actio n P lan ( yearl y) .
27. The socia l service pro vi der work s in partners h ip with pers ons
served, purch as ers and other stak eho ld ers in the de ve lop m en t of
servic es.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
24
Partnership with pe rsons served in
the developm ent on serv ices is
organ ized throu gh s pec ial f eedback
quest ion naires but also dis c ussed i n
clients m eetings.
Partnership with f under s in that topic
is m ain ly done t hrough special
f eedback f orm s.
Involv em ent to need s asse ssm ent of
persons served i s organised b y clie nt
assessm ent m eeting s.
28. The soc ia l service provider inc lud es persons serv ed as act ive
partic ip ants in pl anning and ha ve set up appraisal m ad e up of on-
goi ng of an on-going structured dialogue process in the m anagem ent
of the service, inc lu ding the def initi on of the needs, the def init ion of
the services, as well as of the eva luat ion of qualit y.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
25
Persons served partic ipat e in
assessm ent of indiv id ua l needs
through c lie nt-spec ial ists m eetings.
During that m eeting they dis cuss and
agree f urther plans and actions an d
com pile needs-assessm ent
docum ent (Action Pl an).
Eva luat ion of rece ived servi ce s is
organ ised the sam e way as pl annin g
(through m eetings) and Actio n P la n
is im pr oved duri ng t hat process.
Persons served c an also g ive
f eedback of received servic es by
Satisf actio n Surv ey.
29. The soc ia l ser vice provider institutes an an nual evaluat ion of
partic ip atio n of per sons se rved bot h o n individua l an d/or g ro up basis.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & develo pm ents
26
In int ernal house rules f or persons
served th ere is a p rocess f or
inv olvem ent of service users. That
process is m onitored and evalu ated
regularl y on in divi dua l and group
lev el.
Serv ice U ser Sat isf actio n Surv ey is
carrie d out to evaluate the lev el of
satisf action with participat ion and
inv olvem ent and fam ilies/s upp ort
persons ar e involved in that i n case
of need.
Satisf actio n with inv olvem ent is also
disc ussed in cl ients m eetings
(individual and co lle ctive level ).
30. The social servic e provider o perates s pec if ic ins trum ents f or users
to im prove their per sonal em powerm ent and personal situati on and.
that of their comm unity
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
27
Serv ice Pro vi sio n Proce dures and
staff tra inings gi ve fram ework f or
em powerm ent of service u sers.
Exam ples of tangible re sults on
em powerm ent were presente d
through success stories, clie nt
interv ie ws (f or exam ple f orm ation of
clients si ng ing gro up , m ore and
m ore clients tak e par t of events,
clients are helping in everyday work
etc).
Deve lopm ents of clie nts are st ated in
clients ind ividual plans.
31. The soc ia l service pro vi der oper ates spec if ic m echanism s f or
estab lishing a n em power ing e nv ironm ent.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
28
Prin ci ples of em powe rm ent are
regulated in internal work
docum ents.
As em powerm ent in m ost cases is
som ething very indiv i dua l then
spec if ic m easures are put in place to
m eet all the specif ic needs of service
users. Usua lly through indiv idual
pla nning and ev aluat ion pr ocess.
The m ost im portant way of
em powering clie nts is to find f or each
client appropria te ever yd ay
work /activ it y, so the y ca n f ee l
needf ul and e xp erie nce suc cess.
Staff m embers are t rained to
support the em po we rm ent of service
users.
32. The social service provider se lects pr ogramm es which are based on
a needs assessm ent at the location wh ich is m ost conveni ent f or the
person served, f amily and care take rs
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
29
Needs of cur rent service users ar e
stated i n Individua l Plans .
Needs of potential persons serve d
are id ent if ied through cooperat ion
with partners, Open Da y` s Events
and based on an al ys is of each
ind iv i dual p lan (con tinu it y needs of
servic es).
33. The soc ia l ser vic e provi der offers programm es c ons is tent with the
identif ied n eeds of its c ustom ers and o bj ectives f or the program m e.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
Funder`s needs are dis cussed and
agreed while m akin g service
agreem ents. Everyda y c oo peration is
organ ised m ostly wit h Funders lo ca l
departm ent . Cooperati on with
Funders he ad off ice is m ostl y with e-
m ails.
Reac hing the obje cti ves and m eeting
the needs of the persons served is
conducted wit h c li ents indiv idual
action pla ns.
They eva luate t he qua lit y of
partne rship with clients
(repre sentatives, f am il y), partners
and staff periodically.
30
34. The s oc ia l ser vic e pro vi der operates ind ividual pr oces ses that ar e
drive n b y the n eeds of the person s erved .
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
Needs of persons served are
disc ussed a nd agreed from the
m om ent clients ar e enter ing th e
servic e.
Serv ice users have Individ ual Pl ans
(action p lan s). Th ese p lans co ntain
client´s s pecif ic goals (de sired
situ ations , overall goal s, spec if ic
m easurable objecti ves, m et hods).
Actio n Pl ans are overv iewed and
disc ussed with cli ent s perio dica ll y.
Clients sign the ir Indiv idual Pl ans.
35. The soci al ser vice pro vider docum ents the pl anning of servic es
based on the id ent ificat ion of ind iv idual needs an d ex pectations of
persons s erved i n a n Indiv idual Pla n.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
31
Al l ser vic e us er s ha ve an In dividua l
Plan. Ind iv idual plans contain t he
des ired s ituat ion of t he persons
served, goals, m easurabl e
obj ectives, int ervent i ons.
Each In dividua l Plan is agreed by t he
person served or h is /her guardia n.
36. The soc ia l service provid er iden tif ie s, docum ents, and m aintains
the ke y serv ic e de liv ery proc es ses to the persons serv ed in li ne with
its vision, m issio n statem ent and qua lit y polic y.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
The k ey serv ic e de livery processes
are i dent if ied and describe d in
Serv ice Pro visio n Pr ocedur es.
Process es are revie wed (in terna l
aud its) on regular b asis. Ext er na l
aud its are organi sed by Soc ial
Insurance Board (t he f under).
Integration of m ission and qua lit y
pol ic y int o t he service del iv er y is
evident and staff mem bers are wel l
a ware of the qual it y prin ci ple s.
37. The s ocial ser vice provider revie ws this d elivery proc ess an d
m aintains c ontro l over the delivery of the servic e.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
32
Strengths Im provem ent & developm ents
Koeru HK m onitors t he perf orm ance
of the key serv ice deliver y pr ocess es
through i nternal audits (reg ularl y).
They hav e conne cte d it with their
perf om anc e based rem uneration
s ystem, which m eans that they
exam ine their s er vice prov ision
m onth ly.
Reports were m ade availab le f or
aud itor.
38. The social service provid er ensures that the pe rs on serv ed can
access a c ontinuum of ser vices that span f rom early interv ention to
support a nd respond to changin g requi re ments over tim e.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
Eva luat ion of continu ing serv ice
del iv er y is carr ie d out through
perf om anc e based rem uneration
s ystem (m onthly) and b y revis io n of
ind iv i dual plans. The n a ls o
continuity of servic es is d is cussed.
Resu lts are als o doc um ented .
Koeru HK off ers 10 diff erent service s
f or their clients to get the he lp and
support the y need.
33
39. The socia l ser vice pro vi der develops a s eam less continu um of
servic es and r ed uc es barr iers in a m ulti-disc ip li nar y or m ult i-agenc y
setting.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & develo pm ents
Koeru H K off ers servic es by differ ent
Spec ia lis ts ensuring t hat
m ultidis cipl inary appro ach cou ld be
app lied.
Risk s are eva luated, rep or ted and
ana lysed. Barriers are reported in
annual reports
40. The soci al service provider operat es service s from a h olist ic
approach base d on the ne eds and exp ec tatio ns of the perso n s erve d
with th e a im of im proving the qu al it y of life for the person serv ed.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
Qua lit y of Lif e and m easures of
enhanci ng Qua lit y of Lif e of service
users are inte grat ed into person
centred planning. Indiv idual plans
activ ities are m easured on regular
bas is thr ou gh develo pm ent
disc uss ion s and als o docum ented.
Individua l pla ns are m onitored,
result s assess ed a nd reported
34
41. The social ser vi ce pro vi der ident if ies t he needed com petence s,
sk ill s and support f or staff to enhance the qual it y of l if e f or person
served.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
Sk il ls a nd com petencies of staff to
enhance qu alit y of lif e of persons
served are docum ented in Personne l
Polic y and j ob descript ions.
Com pete nces of staff are discussed
in staff supervi sion m eetings.
Tra in ing syst em giv es an oppo rt unit y
to be m ore skilled and h ave hi gher
com petences in ord er to be able to
support and em p ower service users.
Koeru HK a lso support s the ir
spec ialists t o appl y for prof essiona l
certificate i n the ir f iel d of work .
42. The soc ial ser vice provid er identifies its business res ul ts and
provides f orm al peri odic and indep endent revie w and proce dures to
achieve t he targeted results.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
35
Koeru HK h as annu al plan where
they s et the ye ars objectives and
activ ities and strateg y docum ent f or
lon ger per iod.
They m ea sure their perf orm ances
aga inst busi ness ob jectives once a
ye ar and com pile speci al report. This
report is m ade available for all
stakeholders.
External audits are carried out to
m easure the p er f ormance and results
(by Fun ders , Env ironm ental
Inspectorat e, Veteri nar y an d Food
Board). T he y also ha ve to repor t t heir
result s to their Board.
43. The social ser vi ce provider iden tif ie s and registers the outcom es
and be nef its f or perso n serv ed of the rec eive serv ices on indi vi dual
and collective basis.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
W ithin ind iv id ual pl anning proce ss
each in di vi dual’s outc om es and
benef its are measured.
The achieved resul ts and ben ef its of
the received serv ic es o n collectiv e
bas is are als o m easured
(satisf action su rve ys) and
docum ented.
36
44. The social servic e provider eva luat es its bu s iness results in or der
to determ i ne b es t value f or purc hasers and f unde rs (‘best value ’ can
als o be expressed in relat ion to t he incre ased qualit y of lif e off ered to
the person being se rved).
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
Annu al Re ports and Satisf action
Surve ys Repo rts ref lect added valu e
of the servic es. These r epo rts are
presente d to all re le vant
stakeholders.
Clients Indiv id ua l plans wi th
obj ectives an d be nef its are regular ly
evaluate d which ens ures that adde d
value of t he serv ices f or qualit y of lif e
is m onitored.
45. The socia l ser vic e provi der eva luat es the individual and collect ive
satisfaction of persons served a nd oth er stak eholders by intern al
and/or externa l eval uation .
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
37
To co lle ct f eedback and m eas ur e the
satisf action of persons served,
f unding bod ies and co-partn er s is
one part of organi sations Qua lit y
Polic y.
Satisf actio n Surv ey of persons
served and partn er s is carried out
af ter 2 years. There are spec ia l
f eedback f orm s and i ntervie ws
organ ised f or that matter.
Clients can give f eedback relatio n to
satisf action al so t h rough regu lar
m eetings .
Funders f eedback related to
satisf action is asked once a year an d
als o docum ented.
46. The social service provider prov ides acc ess ible and easil y
understa ndable rec ords on outcom e, inc luding p ersona l perce ption
and ac hi evem ents
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
38
Al l the relevant report s- annua l
pla ns, annu al repo rts, sa tisf action
surve y re port are ava ilable in
organ isat ions webpage and on s ite.
The conte nt of the se docum ents are
disc ussed in regu lar client and s taff
m eetings .
The docum ents co ntain also person al
percept ions and achi evem ents.
47. The social ser vice provider activel y dis sem inates o rgan isation
perf orm ance am ong its staff , servi ce users and extern al stakeho lders.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
39
Inf orm ation about organ isat ions
perf om anc e, results and even ts are
avail able on organ is ation s webp age,
Inf o stands. The y provi de inf orm ation
als o b y e-m ails.
Annu al re ports wit h annual results,
achievem ents and p ersonal
percept ions are provided to diff erent
stakeholders onc e a ye ar.
Resu lts are dis cuss ed in m eetings
with Board m embers, staff and
ind iv i dual achi ev em ents and
percept ions of service us ers are
disc ussed on individual b ases.
Al l r elevant protoc o ls of m entioned
m eetings were pre sented and
interv ie ws confirm ed th eir
occurren ce.
48. Th e soc ia l s er vic e provider has a standard procedure f or conti nuous
im provem ent on the ba si s of an im provem e nt cycle.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
40
Organi satio n compiles Qu alit y
Prom otion and Le adership Act ion
Plan for one year and Deve lopm ent
Plan f or longer per iod.
Perf orm ance in dicators are
m easured at the e nd of the year
(Qualit y Prom ot ion an d L eadership
Actio n Plan, Annu al Report). Ther e
exists a PDC A cyc le in annua l
pla nning an d it`s re vie wing process.
Qua lit y im provem ent proj ects were
docum ented.
49 The s oc ia l s er vice provider iden tif ie s perform ance indic ato rs f or
m easuring the results of the im provem e nt ac tions.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
Strengths Im provem ent & developm ents
Koeru HK has perf orm ance ind icators
f or m easuring t he results of all th eir
im provem ent proj ects in their annua l
pla n. Im provement projects
obj ectives are def ined and res ults
m easured.
50. The ser vice provid er intr oduc es an d m anages innovati ve wa ys of
work ing t hat have be en ident if ied bas ed on the nee ds of stak eholders.
Rem ark from the audit or: The servi ces of the soc ial se rv ic e providers m eet
this criterion of the EQUASS Ass uran ce cer tif ication program
41
Strengths Im provem ent & developm ents
Koeru HK m anages innovat ive wa ys
of work ing th at have been id entif ied
based on the needs of stak eholders.
For exam pl e ne w action and p lay
ground f or their clients, ne w
activ ities and a lso openi ng ne w
corpus in t heir build ing to off er
servic es in better c ondit ions f or their
clients.
They ar e dev el op ing their s ervices
and f inding ways to us e i nno vatio n i n
their work with client s.
Innovat ion projects are docum ented
in the ir Annua l P la n and R epor ts.
42
4. Agreed a ddi tional deve lopment / imp rove ments
Target Activities Date
Continuous improvement of • Building new corpus for clients with 12.2017
physical environment in mixed disability
order to increase the quality • Repair works at dining hall, terrace, C
of service provision corpus, B corpus.
Elaboration of marketing • Developing cooperation with new 12.2017
strategy in order to partners in international and internal
promote services to level
different stakeholders • Experimentation and introduction of
(clients, partners) new and different media and marketing
channels
Deve lopm ent of Job • Monitoring of current system and 12.2017
perf om anc e identifying „bottlenecks“
m anagem ent and • Collecting feedback from staff
perf om anc e based • Making improvements to current
rem unerat io n s yst em system
Eesmärk Tegevus Tähtaeg
Füüsilise keskkonna • Uue korpuse ehitamine liitpuudega 12.2017
parandamine klientidele peahoonest eemal
suurendamaks teenuse • C osakonna soojustamine ja
osutamise kvaliteeti renoveerimine
• Toitlustuskorpuse terrassi remont ja
haljastuse uuendamine
• Söögisaali remont
• B osakonna siseuste vahetamine
Hooldekeskuse • Koostöö arendamine nii siseriiklike kui 12.2017
turundustegevuse välja välispartneritega
töötamine uutele • Erinevate meediakanalite kaasamine
sihtgruppidele ning keskuse turundustegevusse
olemasolevate tegevuste
edasiarendamine
Töösoorituse juhtimise ja • Olemasoleva süsteemi monitooring 12.2017
tulemustasustamise • Personali tagasiside olemasolevale
süsteemi edasiarendamine süsteemile
• Süsteemi parendamine
43
5. Closi ng remarks
Koeru Hooldek esk us ce lebrated in 2015 their 65. birthday a nd is the o ldest
and biggest we lf are inst itutio ns in Jär vam aa. Toda y Koeru H ool deke skus
off ers 10 different types of services. They ha ve expanded their services duri ng
the la st ye ars bas ed on soc iet y n eeds.
Koeru Hoold ek esk us applies EQU ASS qual if icat ion f or 1 service- 24 hour
caretak ing with reinf orced superv is io n. The y are off er ing servi ces for 215
clients, from whic h 97 are in 24 hour caretak ing with reinf or ced superv ision
servic e. Th eir o ldest cl ient is 93 ye ars old and youngest 19.
At the m om ent there are 109 em plo yees working in the organ izat ion. Staff
turnover over the last 3 years has de creased f rom 18,7% in 201 3 to 11% in
2015 and i nterv ie ws with staff showed satisf action wit h work and wor king
conditions.
Every year they org anis e diff erent events to involve t heir client s, partners and
staff to various act i vities. The y h av e s om e traditional eve nts, f or ex am ple
every ye ar they visit different plac es (excurs ions ), harvest par ty in autum n and
at christm as tim e they celebr ate and ha ve eve nt s with all t heir c lients and
staff. The y acknowledge good wo rk and d evel opme nt of their s taff , every yea r
they prom ote one of their staff m ember by c hoos ing the best em plo yee of the
yea r.
Audit lasted 2 days. Al l the intervi ews took place in tim e. Intervie ws with staff
gave confirm ation of comm itm ent and m otivation towar ds their work.
Interviews with partners gave overview of organisat ions c ontribution and
com m itment towards cooperation. Meeti ng with c lients s ho wed s atisf action
with s ervices, people and environm ent.
44
The criteri a f or developm ent a nd im provement fr om the auditors point of vie w,
based on 2-days au dit are the f ollowing:
Criter ia 11: There is a s pecial form deve loped to eva lua te t he eff ectiv enes s
of each traini ng but there was no ov erall anal ys is m ade. Audit ors suggest ion
is t o ma ke t he anal ysis and conclusions wh ich m akes it ea sier t o plan
eff ective trai nings in the f uture.
Criter ia 12: Personnel Pol ic y d ec lares th at developm ent discussi ons wi th
staff are conducted ever y year. From interv iews wi th stuff audit or f ound out
that m an y deve lopm ent dis cuss ions tak e place onc e af ter 2 years. Auditors
sugge stion is to fol low the po lic y or chan ge it accorda nce wit h real lif e.
Koeru Hooldek esk us in th e sc ope of th is audit f ully m eet the criter ia of
EQUASS Assuranc e. Evi denc e gi ven and intervie ws carrie d out were suff ici ent
to prove the com plia nce to EQUASS principles.
Kokkuvõte
Koeru Hooldek esk us tähista s 20 15. aastal om a 65. sünnipäeva olles Järvam aa
van im aid ja suurim aid hoolek andeas ut usi . Keskus on v iim astel aastatel om a
teenuste v al ik ut jõud salt la iendanu d pak kudes täna kümm et erinevat teen ust.
Koeru Ho oldek esk us taotleb Equass sertif ik aati vaid ühele teenu sele -
ööpäevarings ele eri hoold usteenusele.
Täna pak utak se teenust 215- le k lie nd ile aastas, k ell est 97 klienti on
ööpäevaringsel erihoolduteenus el. Kesk use vanim k lient on 93 aastane ning
noorim 19.
Koeru Hoold ek esk uses töötab 109 töötaj at. Person al i vo olavus on v iim ase 3
aastaga k ahanenud 18,7%- t 2013. aasta l 11%-le 201 5. aastal. Audit i aja l läb i
viidud inter vj uud k innitasid personali rah ulo lu töö j a töötingim ustega.
Keskus org anise erib igal aastal erinev ai d üritu si om a k lienti dele, partnerite le
ning t öötaj atele. Tradits ioo niks on saa nu d lõik us pidu süg is el, ek s kursioon id
erinevatess e paik adesse ning tradits ioon ilis ed ürit used ja k ontsert id jõuluajal.
Igal a astal valib keskus om a parim a töötaja, k es saab väärilise tunnustuse .
Audit k estis 2 päeva. Kõik int ervjuud leids id as et k okk ulepitud aegad el.
Intervj uud personaliga andsid k inn it ust töötaj ate püh endum usest ja
45
m otivatsioo ni st om a töö vastu. Intervjuud k oostööpartneritega k innitasid, et
Koeru Hoold ek esk us panustab k oostöösse ning hindab seda. Intervjuud
k lient ide ga ands id ülevaate, et ollak se rahul nii teen use k ui ka spetsialist ide
ning k eskk onnaga.
Are ndusettepanekud, mis põhinev ad 2- päevasel auditil on järg mis ed:
Kriteer ium 11: Töötajad täid avad k üll spets ia al se k oolituse t agas is ide vorm i,
k uid kokk uvõte või ana lüüs tag asisidest puudub. Audiitor i soov itus on t eha
ana lüü sist järeldusi (personalitöötaja l), m is olek s alusek s edaspidist e
k oolitu ste pl aneerim isel.
Kriteer ium 12: Persona lip oli itik as o n sät e statud, et tööt ajate a renguv estlu sed
viiak se läbi kord aastas. Intervj uu de k äigus se lgus, et osade töötajatega on
vestlu sed kord k ahe aast a j ooksul. Au diitori et tepanek on vi ia
personalip ol iitik a k ooskõlla te ge lik u e luga. Per sona li k om petentsus nõude id
tuleb hinnat a ig a-aastaselt. Te ie v alik on, k as te t eete seda läbi
arenguvestl uste või m uul vii si l (näitek s l äbi tulem ustasu stam ise sü steem i).
Auditi v aatluse a ll ol nud teenus te osas v ast ab Koeru H oo lde keskus täiel ik ult
Equass As surance k riteerium itele, vaad eldud dok umendid j a i ntervjuud ands id
k innitu st vastavusest Equas s Assuranc e p õhim õte tele.
Epp Sillaste
Tallinn, dets em ber 201 5
46
47
EQUASS ASSURANCE APPLICATION
ADDITIONAL INFORMATION
1. Short information about the organisation in the nati ve language
215 kohalise multifunktsionaalse asutusena pakub hooldekeskus erinevatele
kliendigruppidele järgmisi teenuseid:
täisealiste ööpäevaringne hooldusteenus – 86 kliendile;
Alzheimeri ja dementsuse diagnoosiga klientidele eraldi teenus – 30
kliendile
ööpäevaringne erihooldusteenus – 83 kliendile;
ööpäevaringne erihooldusteenus sügav a liitpuudega isikutele – 15
kliendile;
hooldusravi teenus – 12 voodit (170 ravijuhtu);
koduõendus-hooldusteenus (16 juhtu);
rehabilitatsiooniteenused;
ning ajutise hooldamise teenuseid.
Suurus ja klientide arv annab võimaluse ja eelise erinevate teenuste
pakkumiseks.
Meie eesmärgiks elanike eest hoolitsemisel on
edendada isiku lugupidamist, väärikust ja autonoomsust;
arendada tema võimeid, elukvaliteeti ja sotsiaalset integreerumist;
saata inimest ühiskonna elust osavõtmisel.
Meie missiooniks on t oetada oma keskuses inimeste sotsiaalset ja tervislikku
toimetulekut.
2. Short information about the organisation in English (acti vities,
clients, etc.)
The Health and Social Care Centre as a multifunctio nal organisation housing
215 people provides the following services for different clientele groups:
around the clock adult care services: 86 clients;
special services for clients diagnosed with Alzheimer and dementia: 30
clients
around the clock special care services: 83 clients;
around the clock services for clients with severe multiple disabilities:
15 clients;
care treatment services: 12 beds (170 treatment cases);
home nursing care services: 16 cases;
rehabilitation services;
and temporary care servic es.
1
It is our mission to support people’s ability for social and healthy coping in
our centre.
3. Name of the organisation as you w ould w ant it to appear on the
EQU ASS Assurance certificate
Sihtasutus Koeru Hooldekeskus
4. Name of services / department s of the organisation i n the scope of
the application as you w ould w ant it to appear on the EQU ASS
Assurance certificate:
Ööpäevaringne erihooldusteenus
5. Organisation’s logo
Information to be published on EQUASS website:
Name of the organi sation : The Foundation of Koeru Health and Social Care
Centre
Post address: Ida 2, Koeru vald, 73001, Järva maakond, Estonia
Director: Mr Rünno Lass
Contact person: Mr Rünno Lass
Email: rynno.lass@ koeruhk.ee
Web: http://w ww.koeruhk.ee
2
Maarika Aro
Saatja: Maarika Aro
Saatmisaeg: 4. jaanuar 2016. a. 12:54
Adressaat: 'Guus van Beek'; Marie Dubost
Koopia: Keiu Talve
Teema: Koeru Hooldekeskus audit report
Manused: EQ-ASS_AUD_Audit Report-Koeru HK.pdf; EQUASS taotluvorm_SA Koeru
Hooldekeskus-1.xlsx; Additional Information Form _SA Koeru Hooldekeskus.docx;
Asutuse külastuse ettevalmistuse vorm- Koeru HK.docx
Dear Marie, Dear Guus,
Attached you’ll find an audit report and other documents of Koeru Hooldekeskus EE2015-028.
Please let Keiu to know in case there are some comments about the report.
Best,
Maarika
1