carf report template - the neighbourhood group...the neighbourhood group community services...

Accreditation Report Quality Improvement Plan & Benchmarking Data

Prepared for The Neighbourhood Group Community Services (formerly Central Neighbourhood House)

Accreditation Decision

Three-Year Accreditation Expiration: May 2018

Organization

The Neighbourhood Group Community Services (formerly Central Neighbourhood House) (TNG) 349 Ontario Street Toronto ON M5A 2V8 CANADA

Organizational Leadership

Veronica MacDonald, Director, In-Home Services Elizabeth Forestell, Executive Director

Survey Dates

June 22–24, 2015

Survey Team

James F. Bernardo, Administrative Surveyor Lori A. Greer, Program Surveyor

Programs/Services Surveyed

Home and Community Services

Governance Standards Applied

Previous Survey

May 14–16, 2012 Three-Year Accreditation

1 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report

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) Accreditation Report 2

Survey Summary

Areas of Strength

The Neighbourhood Group Community Services (formerly Central Neighbourhood House) (TNG) has strengths in many areas.

♦ TNG 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.

♦ TNG 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.

♦ TNG 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.


♦ 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

TNG 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.

Accreditation Decision

The Neighbourhood Group Community Services (formerly Central Neighbourhood House) has earned a Three-Year Accreditation. On balance, it is evident that TNG 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.


Exemplary Conformance

Section 1. ASPIRE to Excellence®

D. Input from Persons Served and Other Stakeholders ♦ TNG 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.


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.


Standards Conformance This section of the Accreditation 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 [email protected].

Reason for partial or non-conformance Is cited:

All components not addressed When a standard element requires more than one item, at least one item (but not all) is not in full conformance.

Credentials inadequate 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.

Data or information necessary to address conformance not collected and/or evaluated

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.

Documentation inadequate 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.

Effort not comprehensive When a standard element requires an activity to occur, the performance of the activity is insufficient to address the full scope of the activity.

Financial ratio calculation below the median

When the standard element rating is based on the calculation of a specific financial ratio, such ratio is below the 50th percentile.

Forms inadequate 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.

Frequency inadequate 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.

Information not communicated understandably

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.

Involvement by appropriate person(s) inadequate

When a standard element requires the involvement of certain persons, those persons are either not involved or not involved in a sufficient manner.

Non-compliance with law, regulation, or other rule

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.

Policy/plan/procedure/practice not consistently implemented

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.

Policy/plan/procedure/practice not developed

When a standard element requires a policy/plan/procedure/practice, it is not in existence.

Policy/plan/procedure/practice not implemented

When a standard element requires a policy/plan/procedure/practice, it exists but there is no actual performance.

Policy/plan/procedure/practice recently implemented

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.

Training inadequate 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.

Evidence of conformance inadequate When the requirement of a standard element is not satisfied, or is inconsistently satisfied and no other reasons apply.


Standard Number Standard Text

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1.B.5.b. Governance policies address executive leadership development and evaluation, including: An annually reviewed executive leadership succession plan.

X X

1.I.7.e. If students or volunteers are used by the organization, there is a system of management that includes: Assessment of performance.

X X

2.A.10.e.(7) Based on the scope of services, there is a written agreement: That contains information regarding: Refund policies.

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

Reasons for Partial or Non-conformance


Benchmarking This section of the Accreditation 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. ♦ Surveyed organizations with the same ownership type. ♦ Surveyed organizations in the same geographic region. ♦ Surveyed organizations with similar number of persons served annually. ♦ Surveyed 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): 100–499

Persons served annually: 1,000–4,999

To receive the information contained in this section in an alternate format, please contact [email protected].

* Excluding Governance.


All surveyed organizations

79.3%

88.7%

98.1%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation

CARF One-Year Accreditation

CARF Three-Year Accreditation

TNG

% of Conformance

Lead

ersh

ip

A: Assess the Environment

46.3%

81.7%

98.3%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



TNG

% of Conformance

Stra

tegi

c Pl

anni

ng

S: Set Strategy


All surveyed organizations – continued

60.0%

83.4%

99.8%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



TNG

% of Conformance

Inp

ut fr

om S

take

hold

ers

P: Persons Served and Other Stakeholders - Obtain Input

88.7%

94.7%

99.5%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



TNG

% of Conformance

Lega

l Req

uire

men

ts

I: Implement the Plan



69.2%

91.7%

99.2%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



TNG

% of ConformanceFina

ncia

l Pla

nnin

g an

d M

anag

emen

t


56.0%

79.7%

97.4%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



TNG

% of Conformance

Risk

Man

agem

ent




74.3%

84.0%

96.7%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



TNG

% of Conformance

Hea

lth

and

Saf

ety


72.9%

87.5%

97.6%

99.3%

0% 20% 40% 60% 80% 100%

Nonaccreditation



TNG

% of Conformance

Hum

an R

esou

rces




63.8%

85.2%

99.0%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



TNG

% of Conformance

Tech

nolo

gy


86.5%

93.4%

98.6%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



TNG

% of Conformance

Righ

ts o

f Per

sons

Ser

ved




50.5%

74.7%

96.3%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



TNG

% of Conformance

Acc

essi

bili

ty


41.9%

70.0%

97.3%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



TNG

% of Conformance

Perf

orm

ance

Mea

sure

men

t an

d

Man

agem

ent

R: Review Results



22.0%

41.7%

92.9%

100.0%

0% 20% 40% 60% 80% 100%

Nonaccreditation



TNG

% of Conformance

Perf

orm

ance

Im

pro

vem

ent

E: Effect Change


Other benchmarks

98.4%

98.3%

96.9%

97.4%

97.6%

100.0%

0% 20% 40% 60% 80% 100%

1,000 to 4,999 Persons Served

100 to 499 FTEs

Ontario

Private, Not for Profit

Aging Services

TNG

% of Conformance

Lead

ersh

ipA: Assess the Environment

99.2%

99.0%

98.2%

97.9%

97.5%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario


Aging Services

TNG

% of Conformance

Stra

tegi

c Pl

anni

ng

S: Set Strategy


Other benchmarks – continued

99.8%

100.0%

99.5%

99.6%

99.5%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario


Aging Services

TNG

% of Conformance

Inp

ut fr

om S

take

hold

ers

P: Persons Served and Other Stakeholders -Obtain Input

99.3%

99.6%

99.6%

99.2%

99.3%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario


Aging Services

TNG

% of Conformance

Lega

l Req

uire

men

ts




99.7%

99.5%

99.2%

99.3%

99.2%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario


Aging Services

TNG

% of Conformance

Fina

ncia

l Pla

nnin

g an

d M

anag

emen

t


97.5%

97.7%

97.6%

96.5%

97.8%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario


Aging Services

TNG

% of Conformance

Risk

Man

agem

ent




96.6%

96.9%

97.0%

95.9%

97.2%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario


Aging Services

TNG

% of Conformance

Hea

lth

& S

afet

y


97.5%

98.0%

97.5%

97.2%

97.8%

99.3%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario


Aging Services

TNG

% of Conformance

Hum

an R

esou

rces




99.0%

99.2%

99.3%

98.4%

99.1%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario


Aging Services

TNG

% of Conformance

Tech

nolo

gy


98.4%

98.6%

98.6%

98.2%

98.8%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario


Aging Services

TNG

% of Conformance

Righ

ts o

f Per

sons

Ser

ved




96.5%

97.0%

95.9%

95.3%

94.6%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario


Aging Services

TNG

% of Conformance

Acc

essi

bili

ty


98.2%

98.1%

98.3%

96.6%

99.2%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario


Aging Services

TNG

% of Conformance

Perf

orm

ance

Mea

sure

men

t an

d

Man

agem

ent

R: Review Results



94.9%

95.1%

94.5%

91.5%

97.4%

100.0%

0% 20% 40% 60% 80% 100%


100 to 499 FTEs

Ontario


Aging Services

TNG

% of Conformance

Perf

orm

ance

Im

pro

vem

ent

E: Effect Change


Previous survey

100.0%

100.0%

0% 20% 40% 60% 80% 100%

Previous Survey

Current Survey

% of Conformance

Lead

ersh

ip

A: Assess the Environment

87.0%

100.0%

0% 20% 40% 60% 80% 100%

Previous Survey

Current Survey

% of Conformance

Stra

tegi

c Pl

anni

ng

S: Set Strategy


Previous survey – continued

100.0%

100.0%

0% 20% 40% 60% 80% 100%

Previous Survey

Current Survey

% of Conformance

Inp

ut fr

om S

take

hold

ers

P: Persons Served and Other Stakeholders - Obtain Input

100.0%

100.0%

0% 20% 40% 60% 80% 100%

Previous Survey

Current Survey

% of Conformance

Lega

l Req

uire

men

ts




100.0%

100.0%

0% 20% 40% 60% 80% 100%

Previous Survey

Current Survey

% of Conformance

Fina

ncia

l Pla

nnin

g an

d M

anag

emen

t


93.8%

100.0%

0% 20% 40% 60% 80% 100%

Previous Survey

Current Survey

% of Conformance

Risk

Man

agem

ent




94.7%

100.0%

0% 20% 40% 60% 80% 100%

Previous Survey

Current Survey

% of Conformance

Hea

lth

and

Saf

ety


97.4%

99.3%

0% 20% 40% 60% 80% 100%

Previous Survey

Current Survey

% of Conformance

Hum

an R

esou

rces




90.0%

100.0%

0% 20% 40% 60% 80% 100%

Previous Survey

Current Survey

% of Conformance

Tech

nolo

gy


94.9%

100.0%

0% 20% 40% 60% 80% 100%

Previous Survey

Current Survey

% of Conformance

Righ

ts o

f Per

sons

Ser

ved




91.7%

100.0%

0% 20% 40% 60% 80% 100%

Previous Survey

Current Survey

% of Conformance

Acc

essi

bili

ty


34.3%

100.0%

0% 20% 40% 60% 80% 100%

Previous Survey

Current Survey

% of Conformance

Perf

orm

ance

Mea

sure

men

t an

d M

anag

emen

t

R: Review Results



100.0%

100.0%

0% 20% 40% 60% 80% 100%

Previous Survey

Current Survey

% of Conformance

Perf

orm

ance

Im

pro

vem

ent

E: Effect Change

95.3%

99.7%

0% 20% 40% 60% 80% 100%

Previous Survey

Current Survey

% of Conformance

A. P

rogr

am/S

ervi

ce S

truc

ture

Section 2. Care Process for the Persons Served



100.0%

99.7%

0% 20% 40% 60% 80% 100%

Previous Survey

Current Survey

% of Conformance

E. H

ome

and

Com

mun

ity

Serv

ices

Section 3. Program Specific Standards


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