The accreditation pathway

Accreditation is a supportive process involving self-assessment and external peer assessment against accreditation standards, to establish and promote a culture of continual  quality improvement. In order to gain accreditation, services follow the below pathway​.


Stage 1: Self assessment  - level one

The service undertakes an online self-assessment at Level one. This level is about focusing on areas for improvement. The service undergoes a self-led programme of quality improvement. The evidence is reviewed and a service gains access to Level two. 

Stage 2: Self assessment - level two

The service works through the additional standards for Level two, collates evidence and prepares for assessment. 

Stage 3a: Remote assessment

The assessment team review the evidence remotely and provide feedback to the service. The service responds to the assessors remotely and provides additional evidence if required. 

Stage 3b: Site assessment

The assessors visit the service, tour the facilities meet the staff and review the evidence with the service. 

Services are either deferred or accredited. Deferred services are given up to three months to provide additional evidence against identified areas. 

Stage 4: Annual renewal 

The service is accredited for five years subject to an annual renewal of accreditation. The annual renewal is designed to assess the service's continued compliance with the standards. 

Stage 5: Re-accreditation 

After the fourth annual renewal assessment, the service will begin building its evidence for assessment, as per stage one. Services remain accredited throughout this stage. 

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