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 phases:

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 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. 

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.

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.

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 accreditation status:

  • accredited as excellent;
  • accredited;
  • 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).

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