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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.
3 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report
♦ 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.
The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report 4
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.
5 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report
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) Accreditation Report 6
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.
7 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report
Standard Number Standard Text
All
com
po
ne
nts
no
t ad
dre
sse
d
Cre
de
ntia
ls in
ad
eq
ua
te
Da
ta o
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form
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n n
ece
ssa
ry to
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ss c
on
form
an
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ot
colle
cte
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/or
eva
lua
ted
Do
cum
en
tatio
n in
ad
eq
ua
te
Effo
rt n
ot c
om
pre
he
nsi
ve
Fin
an
cia
l ra
tio c
alc
ula
tion
be
low
me
dia
n
Fre
qu
en
cy in
ad
eq
ua
te
Info
rma
tion
no
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mm
un
ica
ted
un
de
rsta
nd
ab
ly
Invo
lve
me
nt b
y a
pp
rop
ria
te p
ers
on
(s)
ina
de
qu
ate
No
n-c
om
plia
nce
with
law
, re
gu
latio
n, o
r o
the
r ru
le
Po
licy/
pla
n/p
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du
re/p
ract
ice
no
t co
nsi
ste
ntly
imp
lem
en
ted
Po
licy/
pla
n n
ot d
eve
lop
ed
Pro
ced
ure
/pra
ctic
e n
ot d
eve
lop
ed
Po
licy/
pla
n/p
roce
du
re/p
ract
ice
no
t im
ple
me
nte
d
Po
licy/
pla
n/p
roce
du
re/p
ract
ice
re
cen
tly im
ple
me
nte
d
Tra
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g in
ad
eq
ua
te
Evi
de
nce
of c
on
form
an
ce in
ad
eq
ua
te
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
The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report 8
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.
9 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report
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
CARF One-Year Accreditation
CARF Three-Year Accreditation
TNG
% of Conformance
Stra
tegi
c Pl
anni
ng
S: Set Strategy
The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report 10
All surveyed organizations – continued
60.0%
83.4%
99.8%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
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
CARF One-Year Accreditation
CARF Three-Year Accreditation
TNG
% of Conformance
Lega
l Req
uire
men
ts
I: Implement the Plan
11 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report
All surveyed organizations – continued
69.2%
91.7%
99.2%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
TNG
% of ConformanceFina
ncia
l Pla
nnin
g an
d M
anag
emen
t
I: Implement the Plan
56.0%
79.7%
97.4%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
TNG
% of Conformance
Risk
Man
agem
ent
I: Implement the Plan
The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report 12
All surveyed organizations – continued
74.3%
84.0%
96.7%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
TNG
% of Conformance
Hea
lth
and
Saf
ety
I: Implement the Plan
72.9%
87.5%
97.6%
99.3%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
TNG
% of Conformance
Hum
an R
esou
rces
I: Implement the Plan
13 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report
All surveyed organizations – continued
63.8%
85.2%
99.0%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
TNG
% of Conformance
Tech
nolo
gy
I: Implement the Plan
86.5%
93.4%
98.6%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
TNG
% of Conformance
Righ
ts o
f Per
sons
Ser
ved
I: Implement the Plan
The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report 14
All surveyed organizations – continued
50.5%
74.7%
96.3%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
TNG
% of Conformance
Acc
essi
bili
ty
I: Implement the Plan
41.9%
70.0%
97.3%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
TNG
% of Conformance
Perf
orm
ance
Mea
sure
men
t an
d
Man
agem
ent
R: Review Results
15 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report
All surveyed organizations – continued
22.0%
41.7%
92.9%
100.0%
0% 20% 40% 60% 80% 100%
Nonaccreditation
CARF One-Year Accreditation
CARF Three-Year Accreditation
TNG
% of Conformance
Perf
orm
ance
Im
pro
vem
ent
E: Effect Change
The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report 16
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%
1,000 to 4,999 Persons Served
100 to 499 FTEs
Ontario
Private, Not for Profit
Aging Services
TNG
% of Conformance
Stra
tegi
c Pl
anni
ng
S: Set Strategy
17 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report
Other benchmarks – continued
99.8%
100.0%
99.5%
99.6%
99.5%
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
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%
1,000 to 4,999 Persons Served
100 to 499 FTEs
Ontario
Private, Not for Profit
Aging Services
TNG
% of Conformance
Lega
l Req
uire
men
ts
I: Implement the Plan
The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report 18
Other benchmarks – continued
99.7%
99.5%
99.2%
99.3%
99.2%
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
Fina
ncia
l Pla
nnin
g an
d M
anag
emen
t
I: Implement the Plan
97.5%
97.7%
97.6%
96.5%
97.8%
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
Risk
Man
agem
ent
I: Implement the Plan
19 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report
Other benchmarks – continued
96.6%
96.9%
97.0%
95.9%
97.2%
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
Hea
lth
& S
afet
y
I: Implement the Plan
97.5%
98.0%
97.5%
97.2%
97.8%
99.3%
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
Hum
an R
esou
rces
I: Implement the Plan
The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report 20
Other benchmarks – continued
99.0%
99.2%
99.3%
98.4%
99.1%
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
Tech
nolo
gy
I: Implement the Plan
98.4%
98.6%
98.6%
98.2%
98.8%
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
Righ
ts o
f Per
sons
Ser
ved
I: Implement the Plan
21 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report
Other benchmarks – continued
96.5%
97.0%
95.9%
95.3%
94.6%
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
Acc
essi
bili
ty
I: Implement the Plan
98.2%
98.1%
98.3%
96.6%
99.2%
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
Perf
orm
ance
Mea
sure
men
t an
d
Man
agem
ent
R: Review Results
The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report 22
Other benchmarks – continued
94.9%
95.1%
94.5%
91.5%
97.4%
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
Perf
orm
ance
Im
pro
vem
ent
E: Effect Change
23 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report
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
The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report 24
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
I: Implement the Plan
25 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report
Previous survey – continued
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
I: Implement the Plan
93.8%
100.0%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
Risk
Man
agem
ent
I: Implement the Plan
The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report 26
Previous survey – continued
94.7%
100.0%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
Hea
lth
and
Saf
ety
I: Implement the Plan
97.4%
99.3%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
Hum
an R
esou
rces
I: Implement the Plan
27 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report
Previous survey – continued
90.0%
100.0%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
Tech
nolo
gy
I: Implement the Plan
94.9%
100.0%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
Righ
ts o
f Per
sons
Ser
ved
I: Implement the Plan
The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report 28
Previous survey – continued
91.7%
100.0%
0% 20% 40% 60% 80% 100%
Previous Survey
Current Survey
% of Conformance
Acc
essi
bili
ty
I: Implement the Plan
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
29 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report
Previous survey – continued
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
The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report 30
Previous survey – continued
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
31 The Neighbourhood Group Community Services (formerly Central Neighbourhood House) Accreditation Report