EQUASS ASSURANCE AUDIT REPORT

Transkript

1 EQUASS ASSURANCE AUDIT REPORT Site visit: 6 th and 7 th of March 2013 Jobbintro AS auditor Steinar Næs 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.

2 1. Information of the social service provider Name of the social service provider Jobbintro AS Address: Johan Solliesgate 13, 3196 Horten Person responsible (CEO): Contact person: Gro Merethe Rørvig Linda Lier Phone: Fax: Web site: Name of Auditor: Steinar Næs Dates of audit: 6.March - 7.March 2013 Clients: Number of person served: 200 As of (date): 6 th of March 2013 Staff: Number of Full time staff: 36 Number of Part time staff: 0 Number of Contracted staff: 0 Number of volunteers (if applicable) 0 Services: Avklaring, Arbeidspraksis i skjermet virksomhet (APS), Arbeid med bistand (AB), Varig tilrettelagt arbeid (VTA), Jobbsøkerkurs (AMO) og Arbeidsrettet rehabilitering (ARR) 2

3 2. Audit program (Format for sched ule of t he site visit) 6 th of March. Dag 1 (D ay 1) Klokkeslett (Tim e) Aktivitet (k ort beskri vels e av den planlagte aktivitet en) Activity (bri ef descri ption of plan ned activit y) Møte med ledelsen. Kort orientering om virksomheten Introduksjon av dokumentasjon. 08:30 Dokumentgjennomgang for revisor Lunsj Gruppesamtale med veiledere Dokumentgjennomgang for revisor 13:00 Samtale med representanter fra NAV 13:30 Dokumentgjennomgang for revisor Oppsummering av dagen med kvalitetsleder, evt. Just.prog Slutt dag 1 7 th of March. Dag 2 (D ay 2) Klokkeslett (Tim e) Aktivitet (k ort beskri vels e av den planlagte aktivitet en) Activity (bri ef descri ption of plan ned activit y) Dokumentgjennomgang for revisor Møte med 5 arbeidsledere Møte med representant for Horten kommune Samtale med rep. for Styret Dokumentgjennomgang for revisor 11:15 Lunsj Intervju med 5 deltagere Dokumentgjennomgang for revisor 15:30 Sluttmøte med leder og kvailtetssjef om veien videre Revisjonen avsluttes 3

4 3. Detailed feedback on performance 1. The social service provider defines documents and implements its vision and mission values on service provision. Jobbintro AS has implemented their vision; JobbIntro utfordrer fremtiden. The mission is documented in the; Strategidokumenter and it is published on the homepage. The values are also documented on the website. During the interviews it was documented that both the mission, vision and the values are implemented in the whole organisation. 2. The social service provider defines, documents, and implements its quality policy by determining long term quality goals, and its commitment to continuous improvement. 4

5 Jobbintro defines their quality polic y in the Virksomhetshåndbok, and it is verified implemented through interview with staff and in the different documentation presented during the audit. The polic y includes principles concerning determining of long term goals and continuous improvement. In the virksomhetshåndbok and the documented projects it was documented that the polic y is carried out in practise. 3. Persons served, family members and service user organisations are able to give feedback on their individual and collective experience of programmes and services. At Jobbintro it is possibilities for all the stakeholders to give feedback on their individual and collective experience of programmes and services. The channels for feedback are evaluation meetings, a complaint management s ystem that has detailed procedures for handling complaints. The organisation has also implemented surveys for collecting feedback. 5

6 4. The social service provider informs all stakeholders about the offered programmes and services available. The stakeholders are informed about the offered programmes and services thru brochures, - the web site and in other marketing activities. Persons served are informed both individually and in user meetings. 5. The social service provider management establishes and documents an annual planning and review process. The management has established an annual review and planning process. This is documented in Virksomhetsplan, reports and minutes. 6. The plan includes: 6

7 annual outcomes / targets the activities 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 review and revision. There is an annual virksomhetsplan plan with annual targets and needed activities to achieving the annual outcomes/targets. There are included a plan for monitoring the performance and measuring the results of the action. Both the SMART and PDCA principles are included. The plan is approved by the board of directors. 7. The social service provider demonstrates organisation s suc cess in satisf ying the needs and expectations of the society. There is an annual virksomhets - plan with annual targets and needed 7

8 activities to achieving the annual outcomes/targets. There are included a plan for monitoring the performance and measuring the results of the action. Both the SMART and PDCA principles are included. The plan is approved by the board of directors. 8. The social service provider demonstrates organisation s social responsibility through activities contributing to the society. Assurance certificat ion program Jobbintro demonstrates their social responsibility in several ways. It is documented in all interviews and the annual report. Their different products and social services are clearly appreciated by the interviewed stakeholders. Thru their work they give persons served a meaningful position in the society, and the society get access to useful products and servic es produced by Jobbintro. They have an annual open day where they sell different products, and show their facilities and workplaces to the society. Jobbintro has demonstrated to be among the leading providers, when it comes to quality and continuous 8

9 improvement. 9. The social service provider has a staff recruitment and retention polic y that promotes the selection of qualified personnel based on required knowledge, skills and competences. Jobbintro has a clearly documented staff recruitment and retention polic y. This polic y promotes the selection of qualified personnel based on knowledge, skills and competences. This was documented in the Retningslinjer og prosedyrer for rekruttering. During the interview off stakeholders it was documented that the organisation has succeeded in recruiting the required competences. 10. The social service provider operates in compliance with mandatory national legislation, providing appropriate working conditions, adequate and agreed staff level and staff ratio, and appropriate rewarding for staff and volunteers. 9

10 At Jobbintro the mandatory national legislations are followed. By following these governing documents the appropriate working conditions are secured. Central documents are the different national laws, specifications from NAV and the code of ethics. And during interviews it was documented that the intentions of these documents was carried out in practise. 11. The social service trains all staff based on a plan for leaning and development and evaluates the effectiveness of the training. There is a plan for staff training and development at Jobbintro. This plan is evaluated on a continuous basis. The systematic evaluation focus on the result and effectiveness of the training and it is very eas y to get an impression of all training and develo pment activities. The results of staff training are included in the Kompetanseplan 2013 inkl. evaluering av

11 12. The social service provider applies requirements for competence in the identified roles and functions of staff and evaluates them on annual basis. The requirements for competence are evaluated on an annual basis during individual performance appraisal and meetings with NAV. This was documented during interviews with NAV and staff, in reports from the individual appraisal and in the annual virksomhetsplan. The performances of the staff are evaluated in surveys, meetings and performance appraisals. 13. The social service provider recognises the staff as a resource for feedback on organisational performance, service development and staff development At Jobbintro the most important resource for feedback on organisational performance and development of 11

12 services and staff, is the staff and stakeholders themself. There is evidence of this in annual report and annual virksomhetsplan plan. The management involves the staff and stakeholders in a s ystematically way, for example by the use of strategy seminars for employees and management. This was documented during the interviews and in minutes from different seminars and meetings. 14. The social service provider has mechanisms in place to enhance satisfaction and motivation of staff The motivation and satisfaction are identified during on an individual basis during the annual performance appraisals. There are also meeting that opens up for feedback from the staff in a more collective basis, as well as in the day to day interaction between manager and employee. During interviews of the staff the social environment as well as the good commitment to the ideas of Jobbintro, purpose of the company and degree of identification to the vision and mission was reported as major motivational 12

13 factors. 15. The social service provider assures the rights of persons served outlined in a Charter of Rights which 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 international human rights conventions, especially those elaborated under the United Nations. The organisation assures that the rights that are outlined in all the govern ing documents mentioned in the criterion 15. These rights are documented in the etiske retningslinjer / the code of ethics. During the interviews it was documented that these guidelines was implemented and followed throughout the departments and sites. 16. The social service provider informs the person served about his/her rights and duties especially t o equal treatment on grounds of age, disability, gender, race, religion or belief and sexual orientation before receiving the services. 13

14 The persons served are informed about their rights and duties. Their rights and duties especially focus at equal treatment on grounds of age, disability, gender, race, religion or belief and sexual orientation. This information is given the day the person served start to receive the services. This was documented during the interview of persons served. 17. The social service provider has accessible complaint management system, which registers feedback on performance from persons served, purchasers and other relevant stakeholders. During the interviews the persons served confirmed that they had knowledge about the complaint prucedure. It was also stated that it was eas y to place a complaint if they wanted to. There where 2 formal complaint regarding their service delivery in 2011, 14

15 and that is reported in the annual report to NAV. The complaints are evaluated in accordance with the complaint management s ystem. 18. The social service provider respects the fundamental right to self - determination of the person served. They freely determine their political status and freely pursue their economic, social and cultural development. At Jobbintro the fundamental rights to self-determination of person served are documented in the procedure for brukermedvirkning. During the interviews of persons served it was documented that the intentions in the documents above are carried out in practise. 19. The social service provider facilitates the person served in choosing and having access to advocates and/or supporting persons. 15

16 Jobbintro facilitates access to supporting persons and/or organisations on an individual basis. The needs of support are detected in individual meetings with the person served, and the general needs are assessed continuously, normally every 3 weeks. This was documented during interviews of staff and persons served. 20. The social service provider defines and documents its policy on ethics that respects and assures the dignity of the persons served, protects them from undue risk and promotes social justice The polic y on ethics is documented in the ethical guidelines that also can be found in a particular employee leaflet. By following this guidelines Jobbintro ensure that persons served are met with respect and assures dignity. This also protects the persons served from undue risk and promotes social justic e. 21. The social service provider operates mechanisms, which prevent the physical, mental and financial abuse of users. 16

17 There are several mechanisms that are developed to prevent the persons served from being physical, mental or financial abused. The polic y to prevent physical, mental and financial abuse of person served can be found in the Etiske retningslinjer There are governing regulations given by NAV that regulates the economical aspect. 22. The social service provider provides services in a safe system of working within a safe environment to ensure the physical security of persons served, their families and caretakers. The HMS-Prosedyre, Etiske retningslinjer and Handlingsplaner for kvalitet og internkontroll ensures that the persons served, staff and other stakeholders works in a safe environment. Physical and social security has a high priority at 17

18 Jobbintro. During the interview of persons served it was confirmed that there are clear guidelines for security, and that these are well implemented. 23. The social service provider defines, documents, monitors and evaluates a set of principles, va lues and procedures that govern behaviour in service delivery containing aspects of confidentiality, accurac y, privac y and integrity. The organisation defines a set of principles and values that govern behaviour in service delivery containing aspects of confidentiality, accurac y, privac y and integrity. These values and principles are documented several places like Etiske retningslinjer and Ansattes perm. These guidelines and procedures are subject to an evaluation on an annual basis. During the interview it was documented that this values and princip les are well known by the staff and management. 24. The social service provider defines, documents, monitors and evaluates 18

19 procedures for assuring confidentiality of data regarding the persons served and the service provided to them. The procedures for assuring confidentiality regarding the persons served and the service provided to them are defined and documented in the polic y of confidentiality, which can be found in the Prosedyre for konfidensialitet og informasjonsdeling document. This policy/procedure also ensures that the procedures are monitored and evaluated. Persons served also get information about this polic y before they start receiving services from Jobbintro. 25. The social service provider defines the roles and responsibilities, authorities and the interrelation of all personnel who manage, design, deliver, support and evaluate the service provision to person served. The services of the social service providers meet this criterion of th e EQUASS There are documents where roles and 19

20 responsibilities according to the requirements in this criterion are described in Stillingsbeskrivelser, Organisasjonskart and in the Styreinstruks During the interviews it was documented that both management and staff were aware of their roles and responsibilities on an individual basis. 26. The social service provider works in partnership with other organisations in the provision of services. Jobbintro works in partnership with other organisations in provision of services. Among these are Ansvarsgruppe, NAV, Fønix Kompetanse as well as Horten kommune. This was documented in interviews of stakeholders and reports that were presented during the audit. The focus at working in partnership with other organisations was stated as strength b y stakeholders during the interviews. 27. The social service provider works in partnership with persons served, 20

21 purchasers and other stakeholders in the development of services. W orking in partnership with other organisations are according to NAV, other stakeholders and Jobbintro itself, a basic prerequisite to develop the services. The focus at including persons served and other stakeholders in development of services was clearly stated during the interviews. 28. The social service provider includes persons served as active participants in planning and have set up appraisal made up of on-going of an on-going structured dialogue process in the management of the service, including the definition of the needs, the definition of the services, as well as of the evaluation of quality. There are adequate tools and methods that open up for including the persons served as active participants in all aspects of the service provision. 21

22 During the interview of persons served there was documented that this tools and methods was used according to its intention, and the persons served had an impression of being in charge, and that the individual needs where fulfilled. During the interview of persons served it was documented that the procedures for the individual plan was followed. 29. The social service provider institutes an annual evaluation of participation of persons served both on individual and/or group basis. There is carried out evaluations annually, both an individual and a group basis. Surveys and individual meetings are used to evaluate the participation of the persons served and the result of this surveys documented that the requirements in this criterion is met. In addition it was confirmed during interviews of persons served that the y was involved in this evaluati on. 30. The social service provider operates specific instruments for users to improve their personal empowerment and personal situation and. that of their community 22

23 In Brukerundersøkelser and Prosedyre for evaluering og for kontinuerlig forbedring and the Individual Plan it is defined procedures that meet the principles for empowerment. W hen these principles are carried out in practice by involving the persons served, they become instruments for the users to improve their personal empowerment. 31. The social service provider operates specific mechanisms for establishing an empowering environment. Jobbintro gives a clear impression that it is developed a corporate culture that promotes empowerment of the persons served. This is done by including the principles of empowerment in staff training programs and by removing 23

24 barriers between the professionals and the service users. This is documented both in how the services are provided, and during interviews. 32. The social service provider selects programmes which are based on a needs assessment at the location which is most convenient for the person served, family and care takers The selected programmes at Jobbintro are based on several needs assessments. The assessments were a combination of local (i.e. beskrivelse jobbsøkerkurs) and national requirements. There were documents from NAV, Ansvarsgruppemøte and internal needs assessments /SW OT - analysis developed by the organisation. 33. The social service provider offers programmes consistent with the identified needs of its customers and objectives for the programme. 24

25 The delivered programmes are consistent with the identified needs of its customers and objectives for the programme. To ensure that the programmes are consist ent with the needs, Jobbintro has a close dialog with NAV and other external stakeholders, that is docum ented in the ref. samarbeidsmøter that is produced on a monthly basis. They also check and evaluate to what extent the needs of stakeholders and the persons served is met. The success rates are documented in different reports; among these is the annual report to NAV and the Brukerundersøkelser. 34. The social service provider operates individual processes that are driven by the needs of the person served. There are individual processes that are driven by the needs of the person served. The main tool to operate this individual processes are the Individual Plan in combination with a dialog with the person responsible for the person 25

26 served in NAV. During the interviews the persons served clearly stated that their individual needs are met in the process. 35. The social service provider documents the planning of services based on the identification of individual needs and expectations of persons served in an Individual Plan. The planning of the services based on the identification of individual needs and expectations of persons served are documented in an Individual Plan. The plan included all the requirements and was signed by the person served that owned the plan. During the interviews it was confirmed by the persons served that they all had an Individual plan. The plan is based on their individual needs and expectations. 36. The social service provider identifies, documents, and maintains the key service delivery processes to the persons served in line with its vision, mission statement and quality polic y. 26

27 The key service delivery processes to the persons served are in line with the vision, mission and quality polic y at Jobbintro. The key services are identified in cooperation with NAV and are described in the Attføringsprosessen and at the web-site. During the interviews the staff confirmed that they have a common understanding of the key processes at Jobbintro. There are 2 meetings monthly with NAV that in combination with internal meetings maintain the key service delivery processes. By reviewing the different versions of the documentation of the key processes it is well documented that the processes are maintained on a regular basis. 37. The social service provider reviews this delivery process and maintains control over the delivery of the service. 27

28 The delivery process is reviewed and controls over the delivery of the services are maintained, typically in the Rapport til NAV. This is documented in the agreements with NAV as well as in t he document Rapport fra fagmøte and in statusrapporter During the interviews it was also documented that there are a continuous cooperation with persons served and stakeholders to keep control of the delivery of services. 38. The social service provider ensures that the person served can access a continuum of services that span from early intervention to support and respond to changing requirements over time. It is ensured that the person served can access a continuum of services. This continuum of services span from early intervention to support and respond to changing requirements over time. This is ensured by working according to the Kravspesifikasjon, close dialog with NAV and by follow the routines described in the documented key 28

29 processes and the Individual Plan. The continuum of services are evaluated annually according to Statusrapporter and minutes from the meetings with NAV. 39. The social service provider develops a seamless continuum of services and reduces barriers in a multi-disciplinary or multi-agenc y setting. There is developed a seamless continuum of services and the due to a multi-disciplinary and/or multi-agenc y setting the barriers are reduced. This is documented in the formalised cooperation with other organisations and in the different procedures that are documented. Jobbintro works in a clear and innovative way when it comes to including a multi-disciplinary and multiagenc y approach. 40. The social service provider operates services from a holistic approach based on the needs and expectations of the person served with the aim of improving the quality of life for the person served. 29

30 Based on the needs and expectations of the person served the organisation includes a holistic approach to meet the aim of improving the quality of life for the person served. This is documented in the Individual Plan that shows that en multidisciplinary approach is included. And during all the interviews there was a joint and very clear perception that Jobbintro has a strong focus and competence on improving the quality of life for the persons served. 41. The social service provider identifies the needed competences, skills and support for staff to enhance the quality of life for person served. The needed competences, skills and support for staff to enhance the qualit y of life for person served are identified in the annual medarbeidersamtale as well as in the analyse av kompetansebehov og tiltak This is identified in dialog with NAV and 30

31 documented during the recruitment process as well as annually for employees, as it is also a topic d uring the performance appraisal that is carried out for each of the staff members. 42. The social service provider identifies its business results and provides formal periodic and independent review and procedures to achieve the targeted results. The business results are identified and the organisation provides a periodic and independent review. This is documented in different annual reports. The reports are distributed to adequate recipients like NAV and the owner that also approve the results. 43. The social service provider identifies and registers the outcomes and benefits for person served of the receive services on individual and collective basis. 31

32 The organisation identifies and registers the aims and objectives of the Individual Plan and measures in to what extent these objectives have been met. This is documented on an individual basis in the Individual Plan, minutes of various meetings and in interviews. In reports from surveys and in the annual report it is documented that this is identified and registered on a collective basis. 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 quality of life offered to the person being served). The business results are evaluated on a regular basis in to determine best value for purchasers and funders. This evaluation is carried out by the organisation it self and by an external auditor. The economic results are approved by the owner Horten Kommune and documented in the annual report, and the outcome in increased quality of life and empowerment of the persons 32

33 served are approved by NAV. The results of the evaluati on are documented in the report Årsrapport til Nav, Styrets årsberetning and distributed to adequate organisations and persons. 45. The social service provider evaluates the individual and collective satisfaction of persons served and other stakeholders by internal and/or external evaluation. The individual and collective satisfaction of persons served and other stakeholders is evaluated by internal evaluation and during the equass audit. This is verified using internal surveys and the auditors interviews. During the interviews it was confirmed that this surveys had been carried ou t, and the results is documented. 46. The social service provider provides accessible and easil y understandable records on outcome, including personal perception and achievements 33

34 Jobbintro provides accessible and eas y understandable records on outcome perception. This was documented in the annual report where the results from surveys and other evaluations were commented by the organisation. During the interview it was documented that reports of different kind were posted to adequate receivers and that they had a clear understanding of the content. This also includes individual report concerning persons served. 47. The social service provider actively disseminates organisation performance among its staff, service users and external stakeholders. The social service provider actively disseminates organisation performance among its staff, service users and external stakeholders. During the interview it was documented that reports of different kind was posted to adequate receivers such as NAV and the owners. This also includes 34

35 individual report on persons served. The management produces a monthl y report where they inform the staff about the results of the organisations performance. 48. The social service provider has a standard procedure for continuous improvement on the basis of an improvement c ycle. Jobbintro has developed a standard procedure for continuous improvements based on the PDCA-c ycle. During the interview it was documented that the staff have knowle dge to the principles in the PDC A-cycle. 49 The social service provider identifies performance indicators for measuring the results of the improvement actions. Jobbintro identifies performance indicators for measuring results of 35

36 improvements. This was documented in Prosedyre for evauleringer og forbedringer as well as in handlingsplaner. Evidence is also found in the evaluations of different improvement projects. 50. The service provider introduces and manages innovative ways of working that have been identified based on the needs of stakeholders. The organisation has a clear focus at innovative ways of working and this work is based of the needs of stakeholders. During all interviews of stakeholders this innovative approach was stated as strength at Jobbintro. The result of the projects is evaluated and documented. During a guided tour in the different arenas for job training it was documented that Jobbintro are transferring their innovative ideas into practice. 4. Agreed additional development / improvements 36

37 The applicant decided on the following improvement actions and/or additional development for the period of two years: Short description of the actions (including SM ART objectives) 1 Topic: Market orientation Goal: Evaluate, assess and suggest developments on how Jobbintro could improve how we add value for our present and future customers. How can we improve how we can reqruite businesses that can be placement arenas in the future. W hat partnerships will we need to develop/establish? Period: The project work will start 7/03/2013 and be completed and evaluated 12/13/2013. Responsibility: Gro Merethe Rørvig and Anne Marthe Jarrett, - and a project group of 3 coaches w ill be involved for the practical project management and implementation. 2 Topic: BAT (Benchmarking in Attføringsbedriftene ) Goal: Assess and suggest developments on how we can improve our business results on the measures that NAV wants us to be benchmarked on. How can we increase throughput towards ordinary employment. Period: The project work will start 3/03/2013 and be completed and evaluated 31/12/2014. Responsibility: Gro Merethe Rørvig and Anne Marthe Jarrett. - The quality coordinator and fagkoordinator will be involved for the practical project management and implementation. 37

38 3 Topic: Oktav, (Opplæringskontor for tilrettelagt arbeid I Vestfold. Kompetansebevis for VTA kandidater/lærekandidater) Goal: Evaluate and suggest action points for how Jobbintro should receive participants, - and find/customize training arenas within Jobbintro. In addition we shall evaluate how we can develop/customize god external training arenas for these candidates. Period: The project work will start 7/3/2013 and be completed and evaluated 31/12/2014. Responsibility: Gro Merethe Rørvig and Anne Marthe Jarret t, - and a project group of 5 Arbeidsledere will be involved. The VTA-coordinator shall act as project leader, and write the documentation and conduct practical project implementation.. 5. Closing remarks Jobbintro AS was for the first time certified by the equass assurance s ystem in June 2009 (the eight entity in Norway to receive the certificate). During this audit it was documented that they have been focusing on continuous improvement over the past four years, and has com e a long way. In the report there are 3 agreed areas for development and/or improvements. Jobbintro has shown a very good effort to work with continuous improvements, - that has changed them significant ly over the last 4 years. 38

39 Jobbintro has given evidence of the implementation of all equass criteria s. Nonetheless, during the audit it was challenging to find many of the reference documents instantly, - as the reference often was found in a document that was present either on the intrane t of Jobbintro, - or on the file structure on the shared server area within Jobbintro. The reference was not quite as precise as I as auditor would wish. The development of a list with hyperlinks to the references might be beneficial for Jobbintro s emplo yees as well as for the quality auditor on the next equass audit. I would like to wish Jobbintro all the best in their continuous improvement s in the years to come. Skien 7 th of March 2013 Steinar Næs 39