How accreditation works
The accreditation programme takes
from six to nine months from the time a service registers
with the AIMS programme. Accreditation is completed in three
Phase 1: Self-Review
During this phase, the service
will undertakes a series of surveys, including staff,
carer and ward/unit manager questionnaires, a service user feedback
tool, a review of case notes and an audit of the
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. We will discuss with you the timetable for
completing the self-review, but this is a minimum of three months.
A summary of the results from the self-review forms the basis of
the discussion at the peer-review visit.
Phase 2: Peer-Review Visit by External
The peer-review visit takes places four
to eight weeks after you have completed your
self-review. A team, generally of four-five people
and comprising staff from other member services and a service
user and/or carer representative, will undertake a peer-review
visit. In addition to validating your self-review, 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 lead
reviewer and the service before being submitted to the
Accreditation Committee (AC). The Committee makes a
recommendation about the service’s accreditation to the
Special Committee on Professional Practice and Ethics
(SCPPE), as the awarding body.
There are four categories of
- accredited as excellent;
- accreditation deferred;
- not accredited.
Services that cannot achieve accreditation at
the point of review are but are expected to be able to do so in the
near future are deferred for a time-limited period in which they
must meet the necessary standards.
Accreditation is valid for up to three years,
subject to satisfactory completion of an annual self-review(s).
For a more detailed description of our
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