How accreditation works

It takes around 6 to 9 months from the time a service registers with the MSNAP programme to point of accreditation.  Accreditation is completed in three phases:

Phase 1: Self review

During this phase, the service undertakes a series of activities, including distributing staff, referrer, carer and patient questionnaires, completing a review of case notes, an organisational checklist and an audit of the environment.  These enable the multi-disciplinary team to review their local procedures and practices against the standards and, if necessary, to make the changes required to achieve accreditation. The self review period is three months.  A summary report of the results from the self review forms the basis of the discussions at the peer review visit. 

Phase 2: Peer review visit by an external team

The peer review visit takes places 4 to 8 weeks after completion of the self review.  A team, generally of four people, comprising 2 professional or clinical reviewers from other MSNAP member services,  a service user and/or carer representative, and usually a member of the MSNAP Project Team undertakes a peer review visit.  In addition to validating the self review data, the peer review provides an opportunity for discussion, sharing of ideas and for the visiting team to offer advice and support.

Phase 3: Accreditation decision

Information from the self and peer review is compiled into a summary report which is verified by the peer review team and host team before being submitted to the Accreditation Committee (AC).  The AC includes nominated representatives from the Royal College of Psychiatrists, Royal College of Nursing, College of Occupational Therapists, British Psychological Society, Alzheimer’s Society and also service user and carer representatives.   The Committee makes a recommendation about the service’s accreditation to the Royal College of Psychiatrists’ Special Committee for Professional Ethics, as the awarding body.

There are 4 categories of accreditation status:

• Accredited as excellent
• Accredited
• Accreditation deferred
• Not accredited

Services that cannot achieve accreditation at the point of peer review are deferred for a time limited period in which they must meet the necessary standards.

Accreditation is valid for up to two years, subject to satisfactory completion of an annual self review. 

For a more detailed description of our accreditation process click here.