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Accréditation Sans Frontières

International Accreditation of Healthcare Facilities

ASF Standards · Long-Term Care · Standard 7

Standard 7 — Governance & Staffing

5 criteria · 5 non-negotiable · 0 core · Version 3.0

Criteria in this standard

7.1

Staffing Levels Reflect Actual Resident Acuity, Not Just Headcount

Non-Negotiable

Nursing staffing levels are genuinely determined by the actual number, acuity, and diagnoses of current residents, based on a real facility assessment — not a fixed headcount applied regardless of how much the resident population's actual care needs have changed.

In plain terms: The number and skill of nursing staff on each shift are calculated from how many residents there are and how much care they actually need — not a fixed roster set years ago.

Facility category Crisis Transition Small Standard
Applicability Adapted Full Full Full

Why this matters

This is the care home equivalent of hospital 4.4. Understaffed care homes have more pressure injuries, more falls, more infections, more hospital admissions, and more deaths — the evidence is overwhelming. Staffing calculated from resident acuity (a validated dependency tool applied to every resident, summed to hours of care needed per shift) matches staff to need. A roster inherited from a time when the home had 40 independent residents does not match a home that now has 60 with advanced dementia. The calculation must be documented, reviewed when residents change, and used to set the roster.

What good looks like

  • Staffing levels genuinely reflect actual resident acuity and diagnoses.
  • The facility assessment is current and genuinely informs staffing.
  • Staffing responsively adjusts as resident acuity changes.

Common failure modes

  • A fixed headcount is maintained regardless of actual resident acuity.
  • The facility assessment is outdated or disconnected from actual staffing decisions.
  • Staffing remains static even as resident care needs genuinely increase.

Worked example

In practice
A 60-bed care home whose roster had not changed in five years while resident acuity rose sharply.
BeforeThree care assistants and one nurse per shift, set when the home was largely residential. Half the residents now had advanced dementia; a third needed two-person transfers. Staff were exhausted; pressure injuries had doubled; the last inspection cited staffing. No dependency assessment existed.
ActionA validated dependency tool was applied to every resident and summed to required care hours per shift. The gap between required and rostered was 35% on day shifts. The owner approved two additional care assistants on days and one on nights. The dependency assessment is repeated monthly and the roster adjusted quarterly. Staffing versus need is reported to the board.
AfterThe Monitor reviewed the dependency calculation, the revised roster, three quarterly reviews, and the pressure injury and falls trends (both down significantly). Verified.

If you are starting from zero — do this first

  1. Ask: when was the roster last calculated from resident need, and with what tool?
  2. Apply a validated dependency tool to every resident.
  3. Sum the hours needed per shift and compare to the roster.
  4. Take the gap to the owner or board with the evidence.
The most common mistake: Keeping the same roster because 'we've always had three on' — the residents have changed even if the number has not.

Self-assessment questions

1. Are staffing levels genuinely determined by actual resident acuity and diagnoses, not a fixed headcount alone? — Real, acuity-based staffing determination, not a static number applied regardless of resident needs.
Evidence: Facility assessment and staffing determination documentation
2. Is the facility assessment genuinely current, reflecting the actual present resident population? — A real, current assessment, not one that's grown stale relative to the facility's actual residents.
Evidence: Current facility assessment
3. When resident acuity increases, does staffing genuinely adjust, not remain fixed regardless of changing need? — Real, responsive adjustment, not a static staffing level maintained regardless of actual need.
Evidence: N/A — tested directly

Common reasons for a PARTIAL answer

  • The facility assessment exists and is periodically updated but staffing decisions don't consistently reflect its findings. — An assessment that doesn't genuinely inform staffing provides limited real protective value.
  • Staffing adjusts for major acuity changes but not for the cumulative effect of smaller changes across the resident population. — Gradual, cumulative acuity changes deserve the same genuine responsiveness as a single major change.
  • Staffing is adequate for day shifts but less clearly matched to acuity for evening and overnight coverage.

Implementation plan

When What
Week 1 Review current facility assessment for genuine currency and connection to staffing.
Week 2 Establish a systematic process connecting acuity changes to staffing adjustment.
Week 3 Review staffing adequacy specifically across evening and overnight shifts.
Ongoing Update the facility assessment and staffing determination as the resident population genuinely changes.

How the Monitor verifies this

Method What Detail
DOCUMENT Facility assessment review Reviews the facility assessment for genuine currency and connection to actual staffing determination.
DOCUMENT Staffing-acuity correlation review Reviews whether staffing levels genuinely correlate with documented resident acuity, not a fixed number.
ASK Staffing adjustment interview Asks administration how staffing genuinely adjusts when resident acuity increases.

Supervisor tips

  • Ask administration for a specific example of staffing adjusting in response to a genuine acuity increase. — A real, specific example reveals whether the connection between acuity and staffing is genuine, not just described in policy.
  • Check staffing levels specifically during evening and overnight shifts. — This is where staffing-to-acuity matching is most likely to show real gaps.

Evidence base

[31] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, require sufficient nursing staff determined by resident assessments, individual care plans, and the number, acuity, and diagnoses of the facility's actual resident population.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

7.2

Staffing Data Is Publicly Posted Daily and Genuinely Accurate

Non-Negotiable

Daily nurse staffing information is posted publicly in the facility, genuinely reflecting actual hours worked by each category of staff, retained for the required period — not posted data that doesn't match what actually happened, or missing entirely.

In plain terms: The actual nursing hours worked each day, by staff type, are posted where residents and families can see them — and the numbers are true.

Facility category Crisis Transition Small Standard
Applicability Adapted Full Full Full

Why this matters

Families cannot judge whether a home is adequately staffed unless they can see the numbers. Daily posting — how many nurses, how many care assistants, how many hours, for how many residents — is required by regulation in many jurisdictions and is good practice everywhere. It creates accountability: a home that posts three care assistants and has two on the floor is lying visibly. It must be accurate: actual hours worked, not rostered; updated daily; and reconciled against payroll. A posted number that does not match reality is worse than no posting.

What good looks like

  • Daily staffing information is genuinely, visibly posted publicly.
  • Posted data accurately reflects actual hours worked, verified against real records.
  • Staffing data is genuinely retained for at least 18 months.

Common failure modes

  • Staffing information isn't posted, or is posted somewhere not genuinely visible to the public.
  • Posted data doesn't match actual hours worked.
  • Retention has gaps or doesn't reach the required 18 months.

Worked example

In practice
A 70-bed care home that did not post staffing.
BeforeNo staffing information was available to families. When asked, managers gave the rostered numbers, which did not reflect sick leave, unfilled shifts, or agency gaps. A family who counted staff on a Sunday found two care assistants for 35 residents — the manager had said four.
ActionA daily staffing board was installed in the lobby: date, census, and for each shift the actual number of nurses and care assistants on duty and their hours, updated by the shift lead at the start of each shift from the actual sign-in. The board is photographed daily and reconciled monthly with payroll by the administrator. Discrepancies are reported to the board.
AfterThe Monitor checked the board against the sign-in sheet on two days (matched), and reviewed three monthly reconciliations against payroll. Verified.

If you are starting from zero — do this first

  1. Count staff on the floor right now. Compare to the roster.
  2. Install a daily staffing board in the lobby.
  3. Update it from actual sign-in at every shift start.
  4. Reconcile monthly with payroll.
The most common mistake: Posting the roster instead of the actual staff — the family who counts will find the difference.

Self-assessment questions

1. Is daily staffing information genuinely posted publicly, visible to residents, families, and visitors? — Real, visible public posting, not data technically available but not genuinely accessible.
Evidence: Daily staffing posting record
2. Does the posted data genuinely reflect actual hours worked, not planned or idealized staffing? — Accurate, real data matching what actually happened, not a schedule that doesn't reflect reality.
Evidence: Actual hours worked documentation
3. Is staffing data retained for at least 18 months, genuinely available on request? — Real, complete retention, not gaps or missing historical data.
Evidence: Staffing data retention record

Common reasons for a PARTIAL answer

  • Posting happens consistently but the location isn't genuinely visible or accessible to visitors. — A technically posted notice that's hard to find doesn't achieve genuine public transparency.
  • Data is generally accurate but occasional discrepancies exist between posted and actual hours. — Even occasional inaccuracy undermines the genuine reliability this transparency requirement is meant to provide.
  • Retention is maintained but not easily retrievable when specifically requested.

Implementation plan

When What
Week 1 Review current staffing posting location for genuine public visibility.
Week 2 Establish a verification process cross-checking posted data against actual timekeeping.
Week 3 Confirm staffing data retention meets the genuine 18-month requirement.
Ongoing Audit posted data accuracy against actual records periodically.

How the Monitor verifies this

Method What Detail
OBSERVE Public posting check Physically verifies daily staffing information is genuinely posted and visible in the facility.
DOCUMENT Accuracy verification review Cross-checks posted staffing data against actual timekeeping records for accuracy.
DOCUMENT Retention record review Reviews staffing data retention for genuine 18-month completeness.

Supervisor tips

  • Physically locate the posted staffing information as a visitor would. — This tests genuine visibility and accessibility, not just technical compliance.
  • Cross-check a specific day's posted data against actual timekeeping records. — A specific, real comparison reveals genuine accuracy, not assumed correctness.

Evidence base

[32] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, require regular, genuinely accurate public reporting of nurse staffing information, including actual hours worked by each category of licensed and unlicensed nursing staff.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

7.3

A Data-Driven Quality Improvement Program Genuinely Drives Improvement, Not Just Documentation

Non-Negotiable

The facility maintains an ongoing, data-driven quality assurance and performance improvement program that genuinely identifies and acts on real indicators of care and quality of life — including at least one annual improvement project targeting a genuine high-risk or problem-prone area — not a program that exists in documentation without producing genuine improvement.

In plain terms: The home has a real quality improvement programme — it collects data on falls, pressure injuries, infections, weight loss, and more, finds problems, fixes them, and can show the improvement.

Facility category Crisis Transition Small Standard
Applicability Adapted Full Full Full

Why this matters

Care homes have measurable outcomes: falls per 1,000 resident-days, pressure injury prevalence, infection rates, weight loss, hospital transfers, antipsychotic use, pain, restraint use. A quality programme collects these monthly, compares them to benchmarks and to the home's own history, identifies the ones that are worse than they should be, runs improvement projects, and remeasures. It is data-driven: the decision to focus on falls comes from the falls data, not from a hunch. And it produces evidence: this rate went from X to Y because we did Z. A programme that produces reports but no change is documentation.

What good looks like

  • The quality improvement program genuinely uses real, current data to identify indicators.
  • The annual improvement project genuinely targets a real high-risk area.
  • Real evidence shows measurable improvement, not just documented activity.

Common failure modes

  • The quality improvement program exists as documentation disconnected from actual facility data.
  • The annual project is symbolic or doesn't address a genuine high-risk area.
  • No real evidence connects quality improvement activity to measurable improvement.

Worked example

In practice
A 60-bed care home with a quality committee that met quarterly and reviewed incident reports.
BeforeThe quality committee discussed individual incidents. No rates were calculated; no benchmarks were used; no improvement projects had been run. The home did not know its falls rate, pressure injury prevalence, or antipsychotic use compared to any standard. Meetings produced minutes and no change.
ActionA QAPI programme was built: a monthly dashboard of ten indicators with rates, benchmarks, and trends; a quarterly committee review that selects the two worst indicators for improvement projects; each project follows a plan-do-study-act cycle with a measurable aim; results are reported to the board and posted for staff. First projects: falls (rate down 40%) and antipsychotic use (down 55%). A quality lead was appointed.
AfterThe Monitor reviewed nine monthly dashboards, two completed improvement projects with before/after data, and board reports. Verified.

If you are starting from zero — do this first

  1. Calculate your falls rate and pressure injury prevalence for the last three months.
  2. Compare each to a national benchmark.
  3. Pick the worst one and run one improvement project.
  4. Build a monthly dashboard of ten indicators.
The most common mistake: Reviewing incidents one at a time and never calculating a rate — you cannot improve what you have not measured.

Self-assessment questions

1. Does the quality improvement program genuinely use real, current data to identify quality and safety indicators? — Real data informing the program, not documentation disconnected from reality.
Evidence: quality improvement data documentation
2. Is there at least one annual improvement project genuinely targeting a real high-risk area? — A specific, genuine project, not a symbolic initiative.
Evidence: Annual improvement project documentation
3. Is there real evidence the program has driven measurable improvement, not just documented activity? — Actual, measurable improvement, not activity without demonstrated effect.
Evidence: Improvement outcome evidence

Common reasons for a PARTIAL answer

  • Data collection is thorough but analysis doesn't consistently translate into genuine corrective action. — Data without genuine action doesn't provide the real improvement this program is meant to drive.
  • The annual project addresses a real area but scope doesn't match the facility's actual size and complexity. — A project's scope should genuinely reflect the facility's own actual services and resources, not a generic template.
  • Improvement is documented but not clearly measured against a specific, quantifiable baseline.

Implementation plan

When What
Week 1 Review current quality improvement program for genuine, data-driven practice versus documentation alone.
Week 2 Select or confirm an annual improvement project genuinely targeting a real high-risk area.
Week 3 Establish specific, measurable baselines for tracking genuine improvement.
Ongoing Review quality improvement outcomes against measurable baselines to confirm genuine improvement.

How the Monitor verifies this

Method What Detail
DOCUMENT Data-driven practice review Reviews whether the quality improvement program genuinely uses real, current facility data.
DOCUMENT Annual project review Reviews the annual improvement project for genuine focus on a real high-risk area.
DOCUMENT Outcome evidence review Reviews evidence of genuine, measurable improvement resulting from quality improvement activity.

Supervisor tips

  • Ask for the specific, real data behind the current annual improvement project. — Real, specific data reveals whether the program is genuinely data-driven, not just documented as such.
  • Ask for measurable evidence that a past quality improvement project produced genuine improvement. — A real, measurable outcome distinguishes genuine improvement from activity recorded for compliance alone.

Evidence base

[33] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, require an effective, comprehensive, data-driven quality assurance and performance improvement program with documented evidence of systematic identification, investigation, and prevention of adverse events.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

7.4

Governance Sustains the Quality Improvement Program Through Leadership Transitions

Non-Negotiable

The facility's governing body holds genuine, documented accountability for the quality improvement program continuing through leadership and staffing transitions, with adequate resourcing — staff time, technical training — not a program that quietly weakens or lapses whenever key personnel change.

In plain terms: The owners or board are accountable for the quality programme continuing when the manager changes — it is in the governance documents, reviewed by the board, not dependent on one person.

Facility category Crisis Transition Small Standard
Applicability Adapted Full Full Full

Why this matters

Care home managers change frequently. The quality programme that the last manager built collapses when she leaves and the new manager has other priorities. Governance means the programme belongs to the organisation, not the individual: the board's terms of reference require it; the board receives the dashboard quarterly; the quality lead reports to the board, not only to the manager; the programme is in the new manager's induction; the board asks about it at every meeting. Leadership transitions are the moment quality programmes die; governance is what keeps them alive.

What good looks like

  • The governing body holds genuine, documented institutional accountability.
  • The quality improvement program has genuinely continued through real leadership transitions.
  • The program is adequately resourced with real staff time and training.

Common failure modes

  • Accountability rests informally on one individual, not the governing body itself.
  • The program has weakened or lapsed during a past leadership transition.
  • The program lacks genuine, adequate resourcing to function.

Worked example

In practice
A 50-bed care home that had lost its quality programme twice in five years to management changes.
BeforeThe quality programme was the manager's project. When she left, the new manager did not continue it; the dashboard stopped; the improvement projects stalled. The board had never seen the dashboard and did not know the programme had ended. The next manager started again from scratch.
ActionThe board amended its terms of reference to require a quality programme with defined indicators, quarterly board review, and a named quality lead reporting to the board. The programme was documented in a manual independent of any individual. The manager's job description includes maintaining it; the induction for any new manager includes a board briefing on it. The board's agenda has a standing quality item.
AfterThe Monitor reviewed the amended terms of reference, the programme manual, four quarterly board minutes with quality review, and — following a subsequent manager change — evidence that the programme continued without interruption. Verified.

If you are starting from zero — do this first

  1. Ask: if the manager left tomorrow, would the quality programme survive?
  2. Put the programme in the board's terms of reference.
  3. Have the quality lead report to the board quarterly.
  4. Document the programme in a manual, not in the manager's head.
The most common mistake: A quality programme that belongs to the manager — it leaves when she does.

Self-assessment questions

1. Does the governing body hold genuine, documented accountability for the quality improvement program? — Real, institutional accountability, not dependence on one person's commitment.
Evidence: Governing body accountability documentation
2. Has the program genuinely continued through a real leadership or staffing transition, without lapsing? — Real, demonstrated continuity, not an assumption it would hold up.
Evidence: quality improvement continuity record through transitions
3. Is the program adequately resourced, not left to function without real support? — Genuine, adequate resourcing, not a program expected to run on goodwill alone.
Evidence: quality improvement resourcing documentation

Common reasons for a PARTIAL answer

  • Governing body accountability is documented but genuine engagement in practice is inconsistent. — Documented accountability without genuine, active engagement provides limited real protection against program fragility.
  • The program has weathered smaller staffing changes but hasn't yet been tested by a major leadership transition. — Genuine resilience is best confirmed by how the program holds up under a real, significant transition, not assumed from smaller changes alone.
  • Resourcing is generally adequate but technical training for quality improvement-specific skills is limited.

Implementation plan

When What
Week 1 Review current quality improvement accountability structure for genuine governing body ownership.
Week 2 Establish documented processes ensuring program continuity through future transitions.
Week 3 Assess and strengthen resourcing, including quality improvement-specific technical training.
Ongoing Review program continuity and resourcing whenever a genuine leadership transition occurs.

How the Monitor verifies this

Method What Detail
DOCUMENT Governance accountability review Reviews documentation for genuine governing body accountability, not informal individual dependence.
DOCUMENT Transition continuity review Reviews evidence that the quality improvement program genuinely continued through a real past leadership transition.
DOCUMENT Resourcing review Reviews whether the program receives genuine, adequate resourcing.

Supervisor tips

  • Ask the governing body directly about their own role in quality improvement accountability, not just administration. — A specific, confident answer from governance itself reveals genuine institutional ownership.
  • Ask about a real, past leadership transition and how the quality improvement program held up. — A real example reveals genuine resilience, not just an assumption the structure would hold.

Evidence base

[34] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, establish that the governing body or executive leadership is responsible and accountable for ensuring a quality improvement program is sustained during transitions in leadership and staffing, and is adequately resourced.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

7.5

Staff Background Screening Prevents Hiring Anyone With a Documented Abuse Finding

Non-Negotiable

Every staff member is screened against relevant background checks and any national or regional care-worker registry before hire, with anyone found guilty of abuse, neglect, exploitation, or resident mistreatment genuinely excluded from employment — not a screening process that exists on paper but doesn't reliably catch a real, documented finding.

In plain terms: Every staff member is checked against criminal records and the care-worker abuse registry before they start — and anyone with an abuse finding is not hired, no exceptions.

Facility category Crisis Transition Small Standard
Applicability Adapted Full Full Full

Why this matters

Care home residents are among the most vulnerable people in society, and people who abuse them move from home to home. A registry of care workers with substantiated abuse findings exists in most jurisdictions precisely to stop this. Checking it — along with criminal records — before hire is the minimum. The check must be done before the person works a single shift, must cover every category of staff including kitchen, cleaning, and agency, and must be documented. A home that hires first and checks later has put an unknown person among its residents.

What good looks like

  • Every staff member receives genuine, complete pre-hire background screening.
  • Anyone with a documented abuse or mistreatment finding is reliably excluded.
  • Screening is genuinely repeated periodically, not only at initial hire.

Common failure modes

  • Background screening is inconsistent or incomplete for some hires.
  • The screening process has gaps that could miss a documented finding.
  • Screening happens only once, never rechecked after initial hire.

Worked example

In practice
A 60-bed care home with an HR process that checked references but not registries.
BeforeNew staff provided two references and started. Criminal record checks were requested but staff often started before results arrived. The care-worker registry was not checked. A care assistant was found to have a substantiated abuse finding from a previous employer, discovered only when a resident's family recognised her name.
ActionA pre-employment screening policy was written: criminal record check, care-worker registry check, professional registration check (for nurses), and two verified references — all completed and documented before the first shift, no exceptions, including agency and volunteer staff. HR maintains a screening file per person. A monthly audit checks that no one has started without complete screening. The policy was adopted by the board.
AfterThe Monitor reviewed 20 staff files: all with complete screening dated before the start date. Reviewed the monthly audit (100% compliance for six months). Verified.

If you are starting from zero — do this first

  1. Pull ten recent staff files. Was the registry checked before their first shift?
  2. Write the policy: no start without complete screening.
  3. Include agency, volunteer, kitchen, and cleaning staff.
  4. Audit monthly.
The most common mistake: Letting staff start 'pending' checks — the check exists to happen before, not after.

Self-assessment questions

1. Is every staff member genuinely screened against relevant background checks and any national or regional care-worker registry before hire? — Real, complete screening for every hire, not an inconsistent or partial process.
Evidence: Pre-hire background screening record
2. Is anyone with a documented abuse, neglect, or mistreatment finding genuinely excluded from employment? — A firm, reliable exclusion, not a screening process that misses real findings.
Evidence: N/A — tested directly
3. Is screening genuinely repeated or rechecked periodically, not only performed once at initial hire? — Ongoing, periodic verification, not a one-time check that could miss a finding entered later.
Evidence: Periodic rescreening record

Common reasons for a PARTIAL answer

  • Screening is thorough for direct care staff but less consistent for support or contracted staff. — Anyone with resident access deserves the same genuine screening, regardless of their specific role.
  • State registry checks are performed but not consistently documented as verified. — Undocumented verification is difficult to distinguish from a check that wasn't genuinely completed.
  • Initial screening is thorough but periodic rechecking isn't consistently performed.

Implementation plan

When What
Week 1 Review current background screening practice for completeness across all staff roles, including contracted staff.
Week 2 Establish consistent, documented registry verification for every hire.
Week 3 Establish a periodic rescreening schedule beyond initial hire.
Ongoing Audit screening completeness and documentation for new hires.

How the Monitor verifies this

Method What Detail
DOCUMENT Pre-hire screening review Reviews background screening records for a sample of recent hires for genuine completeness.
DOCUMENT Registry check verification Verifies actual registry checks were genuinely performed, not assumed.
DOCUMENT Periodic rescreening review Reviews whether screening is genuinely repeated periodically after initial hire.

Supervisor tips

  • Ask to see the actual background screening documentation for a specific, recent hire. — A specific, real record is the genuine evidence of a functioning process, not an assumed one.
  • Ask specifically about screening practice for contracted or agency staff, not only direct employees. — This is where screening consistency most commonly shows real gaps.

Evidence base

[35] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, prohibit employing individuals with a documented, substantiated finding of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property, verified through the relevant national or regional screening mechanism.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

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