Accreditation Report

Transcription

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2 Report Quality Improvement Plan & Benchmarking Data Prepared for The Neighbourhood Group Community Services (formerly Central Neighbourhood House)

3 Decision Three-Year Expiration: May 2018 Organization The Neighbourhood Group Community Services (formerly Central Neighbourhood House) () 349 Ontario Street Toronto ON M5A 2V8 CANADA Organizational Leadership Veronica MacDonald, Director, In-Home Services Elizabeth Forestell, Executive Director Dates June 22 24, 2015 Team James F. Bernardo, Administrative or Lori A. Greer, Program or Programs/Services ed Home and Community Services Governance Standards Applied Previous May 14 16, 2012 Three-Year 1 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report

4 Programs/Services by Location The Neighbourhood Group Community Services (formerly Central Neighbourhood House) 349 Ontario Street Toronto ON M5A 2V8 CANADA Administrative Location Only Governance Standards Applied In Home Services 365 Bloor Street East, Suite 1807 Toronto ON M4W 3L4 CANADA Home and Community Services The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report 2

5 Summary Areas of Strength The Neighbourhood Group Community Services (formerly Central Neighbourhood House) () has strengths in many areas. is a newly amalgamated organization, joining Central Neighbourhood House and Neighbourhood Link, two prominent services providers in Toronto. A comprehensive amalgamation and harmonization plan is being used to guide the joining of the organizations. The new organization has increased the geographic area of services and diversified the menu of services provided. The plan fully addresses governance, financial, operational, and organizational culture, and the new strategic and risk management plans are guided by the amalgamation plan. The organization is committed to providing quality service to the persons served. It is apparent that the organization is very committed to service excellence and that it is its culture to do whatever is necessary to meet the needs of the persons served and other stakeholders. Leadership provides the organization with the resources necessary to deliver high-quality services. has a strong commitment to living its mission, To engage the skills and talents of the people of our community to foster social justice and to build a vibrant neighbourhood where everyone lives with dignity and respect. The team, by the example of the management group, is highly dedicated and actively involved in all aspects of the operation. This level of professional commitment is found throughout the organization. This commitment begins with the board and is evident with leadership and care delivery staff. The organization is highly committed to fairly compensating its workforce and providing good benefits. It is also committed to operational and financial transparency, and its annual report has recently been recognized as a finalist for the Voluntary Sector Reporting Award given by Queen s University. There is a sense of pride among clients, support systems, personnel, and outside stakeholders for being involved with the organization. Frequent comments included feeling privileged to be connected with this organization. The mission and health and wellness philosophy are well known and confidently spoken and embodied across the organization. demonstrates a strong commitment to advocacy for the clients served to ensure that they receive services to meet their diverse needs. The Not Seen/Not Found investigative process reinforces the investment to ensure the safety and security of clients. The availability and responsiveness of personnel within the organization to meet the needs of the clients, support systems, personnel, and outside stakeholders are apparent. All provided examples of the organization being easily reached by telephone or to set up an in-person conference. The organization demonstrates teamwork in the sharing of information with clients, support systems, personnel, and outside stakeholders. The systems for documentation and information sharing are evidenced with client agreements, orientation for clients and support systems, and the care planning process. 3 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report

6 The organization demonstrates a commitment to its personnel. The organization and clients are appreciative of the services provided by the personal support workers. The organization provides ongoing orientation, training, and career advancement opportunities. The organization has several long-term staff members, and students are often hired on for permanent employment. Performance evaluations occur on a regular basis with interactive discussion between the employee and his or her supervisor. The staff members and their supervisors collaborate together to develop aspirations and goals. Areas for Improvement should seek improvement in the following areas. Although the board does have a process to address emergency succession, the organization should ensure that policies implemented to address executive leadership succession planning are reviewed annually. Although the organization has an informal method of addressing volunteer performance, there is no consistent formalized process implemented. The organization s system of management of volunteers should consistently address the assessment of performance. Although it is rare that refunds happen, the organization is urged to ensure that the written agreement contains information regarding refund policies. Although the organization has a policy that addresses that family members and support systems can be part of the team and the policy clearly addresses the organization s role and responsibilities regarding the inclusion of the family and support system as appropriate, the policy and procedures do not address the roles and responsibilities of the family or support system. The organization is urged to develop and implement policies and written procedures that address the clarification of the roles and responsibilities of the families/support systems. Decision The Neighbourhood Group Community Services (formerly Central Neighbourhood House) has earned a Three-Year. On balance, it is evident that provides quality services to its clients and is dedicated to ongoing quality improvement. Persons served and other stakeholders have all expressed high satisfaction with the services provided. The organization has a comprehensive plan in place for the amalgamation and harmonization of the two prominent service providers into one joint entity. Although a few opportunities for improvement have been identified, it is apparent that the organization has the resources and commitment to address these areas and to continue to use the CARF standards to further enhance the provision of its services. The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report 4

7 Exemplary Conformance Section 1. ASPIRE to Excellence D. Input from Persons Served and Other Stakeholders has a unique process to seek input from stakeholders and spur innovation. Each year the organization conducts a Bright Ideas Forum where all stakeholders are invited to a thought incubation symposium. One innovation is chosen from the symposium and then funded for one year through money that is raised for the innovation fund. This process is inclusive, is empowering, and ensures that funds are available for ongoing innovation. Consultation Section 1. ASPIRE to Excellence A. Leadership The continued evaluation of the impact that the amalgamation of the organization has on leadership structure and function is important. As service lines continue to broaden, the organization may want to explore ways to ensure that the necessary intellectual capital and expertise are present in its leadership structure. B. Governance It is suggested that the board of the organization continue to carefully evaluate the impact of the amalgamation on the process used to review and approve executive compensation. C. Strategic Planning The organization is encouraged to continually assess the resources it is able to devote to developing and operationalizing the broadening of its service lines. D. Input from Persons Served and Other Stakeholders Although the organization completes satisfaction surveys with clients, it is suggested that it consider developing additional formats to meet client needs and increase participation ratios. The organization analyzes the satisfaction surveys completed. It is suggested that all summaries and reports as a result of this process be dated. K. Rights of Persons Served It is suggested that the organization include the information from its policy in Schedule B of the client intake packet regarding the fact that making a complaint will not result in retaliation or barriers to service. L. Accessibility It is suggested that the identified and documented accessibility plans be merged for easier review and use by the organization. 5 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report

8 Section 2. Care Process for the Persons Served A. Program/Service Structure The organization documents its scope of services and reviews and updates the scope of services documents as necessary; however, it is suggested that these materials and any updates be dated. Section 3. Program Specific Standards E. Home and Community Services The organization is encouraged to include an implementation date on the community services policy and procedure for unsuccessful delivery of services and for the assignment of personnel. It is also encouraged to document the date of completion on the policy and procedure for referral/transition to other services. The organization has developed and implemented a risk assessment, and it is suggested that it include a place to sign and date this document. Consultation does not indicate non-conformance to standards, but is offered as a suggestion for further quality improvement. The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report 6

9 Standards Conformance This section of the Report displays the specific reasons for any partial or non-conformance to standards identified as a result of the survey. The standards listed in this section are addressed in the organization s Quality Improvement Plan, which can be accessed at customerconnect.carf.org. Below are the possible reasons for partial or non-conformance to standards, along with an explanation of why each reason is cited. To receive the information contained in this section in an alternate format, please contact editing@carf.org. Reason for partial or non-conformance All components not addressed Credentials inadequate Data or information necessary to address conformance not collected and/or evaluated Documentation inadequate Effort not comprehensive Financial ratio calculation below the median Forms inadequate Frequency inadequate Information not communicated understandably Involvement by appropriate person(s) inadequate Non-compliance with law, regulation, or other rule Policy/plan/procedure/practice not consistently implemented Policy/plan/procedure/practice not developed Policy/plan/procedure/practice not implemented Policy/plan/procedure/practice recently implemented Training inadequate Evidence of conformance inadequate Is cited: When a standard element requires more than one item, at least one item (but not all) is not in full conformance. When a standard element requires that an individual possess a specific credential or level of credential, the specific credential is not possessed, or the credential possessed is below the specified level. When the issue addressed by the standard element has not been considered and, consequently, the information necessary to address conformance has not been collected and/or evaluated in connection with the issue addressed. When a standard element requires documentation or that documentation contain specific information, the documentation either does not exist or does not contain the specific information. When a standard element requires an activity to occur, the performance of the activity is insufficient to address the full scope of the activity. When the standard element rating is based on the calculation of a specific financial ratio, such ratio is below the 50 th percentile. When a standard element requires use of a specific form or that the form contain specific information, the form is not used or does not contain the specific information. When a standard element requires that an activity occur with a specific frequency or some unspecified regularity, the performance of the activity does not occur, occurs less frequently than required, or occurs less frequently than appropriate if regularity unspecified. When a standard element requires that information be shared with certain persons, the information is either not shared or not shared in a manner that allows for comprehension by the recipient. When a standard element requires the involvement of certain persons, those persons are either not involved or not involved in a sufficient manner. When a standard element requires compliance with a legal requirement or a process for achieving legal compliance, sufficient evidence of compliance or the compliance process is not demonstrated. When a standard element requires a policy/plan/procedure/practice, it exists but the actual performance does not occur with sufficient regularity to be deemed standard operating procedure. When a standard element requires a policy/plan/procedure/practice, it is not in existence. When a standard element requires a policy/plan/procedure/practice, it exists but there is no actual performance. When a standard element requires a policy/plan/procedure/practice, it exists but the actual performance has not been in place for sufficient time to establish a track record. When a standard element requires that certain training occur, it either does not occur or does not occur with sufficient regularity to be deemed standard operating procedure. When the requirement of a standard element is not satisfied, or is inconsistently satisfied and no other reasons apply. 7 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report

10 Standard Number Standard Text Reasons for Partial or Non-conformance 1.B.5.b. Governance policies address executive leadership development and evaluation, including: An annually reviewed executive leadership succession plan. All components not addressed Credentials inadequate Data or information necessary to address conformance not collected and/or evaluated Documentation inadequate Effort not comprehensive Financial ratio calculation below median Frequency inadequate Information not communicated understandably Involvement by appropriate person(s) inadequate Non-compliance with law, regulation, or other rule Policy/plan/procedure/practice not consistently implemented X X Policy/plan not developed Procedure/practice not developed Policy/plan/procedure/practice not implemented Policy/plan/procedure/practice recently implemented Training inadequate Evidence of conformance inadequate 1.I.7.e. If students or volunteers are used by the organization, there is a system of management that includes: Assessment of performance. 2.A.10.e.(7) Based on the scope of services, there is a written agreement: That contains information regarding: Refund policies. X X X X 3.E.5.c.(1) Policies and written procedures are implemented that address, at a minimum, the following service delivery issues: Clarification of the roles and responsibilities of: Families/support systems. X The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report 8

11 Benchmarking This section of the Report benchmarks your organization s conformance to standards. By comparing strengths and areas for improvement with various comparator groups, benchmarking encourages your organization to improve effectiveness, efficiency, satisfaction, and access. This information should also stimulate discussions among stakeholders focused on better meeting the needs and preferences of the persons served. In addition, benchmarking: Encourages a culture of continuous evaluation and improvement. Accelerates understanding of and agreement on areas for improvement. Helps prioritize improvement opportunities. Shifts internal thinking towards a focus on outcomes. Provides a reference to increase performance expectations. Motivates your team to work collaboratively to surpass benchmarks. This report provides benchmarks (mean % of conformance) for each section of the ASPIRE to Excellence quality framework. * When available, benchmark comparison groups include: All surveyed organizations. All surveyed organizations in the same primary CARF customer service unit. ed organizations with the same ownership type. ed organizations in the same geographic region. ed organizations with similar number of persons served annually. ed organizations with similar staff size. In addition, standards conformance for each organization undergoing resurvey is benchmarked against its previous survey in all standards areas. Benchmark Comparison Groups Primary area of accreditation: Aging Services (AS) Ownership type: Private, Not for Profit Geographic region: Canada - ON Staff size (FTEs): Persons served annually: 1,000 4,999 To receive the information contained in this section in an alternate format, please contact editing@carf.org. * Excluding Governance. 9 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report

12 All surveyed organizations A: Assess the Environment Leadership CARF Three-Year CARF One-Year 88.7% 98.1% Nonaccreditation 79.3% S: Set Strategy Strategic Planning CARF Three-Year CARF One-Year Nonaccreditation 46.3% 81.7% 98.3% The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report 10

13 All surveyed organizations continued P: Persons Served and Other Stakeholders - Obtain Input Input from Stakeholders CARF Three-Year CARF One-Year Nonaccreditation 60.0% 83.4% 99.8% Legal Requirements CARF Three-Year CARF One-Year Nonaccreditation 99.5% 94.7% 88.7% 11 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report

14 All surveyed organizations continued Financial Planning and Management CARF Three-Year CARF One-Year Nonaccreditation 69.2% 91.7% 99.2% Risk Management CARF Three-Year CARF One-Year 79.7% 97.4% Nonaccreditation 56.0% The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report 12

15 All surveyed organizations continued Health and Safety CARF Three-Year CARF One-Year 84.0% 96.7% Nonaccreditation 74.3% Human Resources CARF Three-Year CARF One-Year 87.5% 99.3% 97.6% Nonaccreditation 72.9% 13 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report

16 All surveyed organizations continued Technology CARF Three-Year CARF One-Year 85.2% 99.0% Nonaccreditation 63.8% Rights of Persons Served CARF Three-Year CARF One-Year Nonaccreditation 98.6% 93.4% 86.5% The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report 14

17 All surveyed organizations continued Accessibility CARF Three-Year CARF One-Year 74.7% 96.3% Nonaccreditation 50.5% R: Review Results Performance Measurement and Management CARF Three-Year CARF One-Year Nonaccreditation 41.9% 70.0% 97.3% 15 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report

18 All surveyed organizations continued E: Effect Change Performance Improvement CARF Three-Year CARF One-Year Nonaccreditation 22.0% 41.7% 92.9% The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report 16

19 Other benchmarks A: Assess the Environment Leadership Aging Services Private, Not for Profit Ontario 97.6% 97.4% 96.9% 100 to 499 FTEs 98.3% 1,000 to 4,999 Persons Served 98.4% S: Set Strategy Strategic Planning Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 97.5% 97.9% 98.2% 99.0% 1,000 to 4,999 Persons Served 99.2% 17 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report

20 Other benchmarks continued P: Persons Served and Other Stakeholders - Obtain Input Input from Stakeholders Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 1,000 to 4,999 Persons Served 99.5% 99.6% 99.5% 99.8% Legal Requirements Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 1,000 to 4,999 Persons Served 99.3% 99.2% 99.6% 99.6% 99.3% The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report 18

21 Other benchmarks continued Financial Planning and Management Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 1,000 to 4,999 Persons Served 99.2% 99.3% 99.2% 99.5% 99.7% Risk Management Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 97.8% 96.5% 97.6% 97.7% 1,000 to 4,999 Persons Served 97.5% 19 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report

22 Other benchmarks continued Health & Safety Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 97.2% 95.9% 97.0% 96.9% 1,000 to 4,999 Persons Served 96.6% 99.3% Human Resources Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 97.8% 97.2% 97.5% 98.0% 1,000 to 4,999 Persons Served 97.5% The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report 20

23 Other benchmarks continued Technology Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 99.1% 98.4% 99.3% 99.2% 1,000 to 4,999 Persons Served 99.0% Rights of Persons Served Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 1,000 to 4,999 Persons Served 98.8% 98.2% 98.6% 98.6% 98.4% 21 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report

24 Other benchmarks continued Accessibility Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 94.6% 95.3% 95.9% 97.0% 1,000 to 4,999 Persons Served 96.5% R: Review Results Performance Measurement and Management Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 1,000 to 4,999 Persons Served 99.2% 96.6% 98.3% 98.1% 98.2% The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report 22

25 Other benchmarks continued E: Effect Change Performance Improvement Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 1,000 to 4,999 Persons Served 97.4% 91.5% 94.5% 95.1% 94.9% 23 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report

26 Previous survey A: Assess the Environment Leadership Current Previous S: Set Strategy Strategic Planning Current Previous 87.0% The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report 24

27 Previous survey continued P: Persons Served and Other Stakeholders - Obtain Input Input from Stakeholders Current Previous Legal Requirements Current Previous 25 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report

28 Previous survey continued Financial Planning and Management Current Previous Risk Management Current Previous 93.8% The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report 26

29 Previous survey continued Health and Safety Current Previous 94.7% Human Resources Current Previous 99.3% 97.4% 27 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report

30 Previous survey continued Technology Current Previous 90.0% Rights of Persons Served Current Previous 94.9% The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report 28

31 Previous survey continued Accessibility Current Previous 91.7% R: Review Results Performance Measurement and Management Current Previous 34.3% 29 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report

32 Previous survey continued E: Effect Change Performance Improvement Current Previous Section 2. Care Process for the Persons Served A. Program/Service Structure Current Previous 99.7% 95.3% The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report 30

33 Previous survey continued Section 3. Program Specific Standards E. Home and Community Services Current Previous 99.7% 31 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Report

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