Standards › Standard 1 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · STF-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 1.8
At a glance
- Before the first shift, verify the licence, registration and qualifications of every person who works here.
- Record the verification on STF-FRM-001 with the date and who checked it.
- Check the scope of practice matches the post.
- Diary the next recheck. Remind the person 30 days before any expiry.
- Stop the person from working the day their registration lapses.
- Stop and get help straight away if: a licence cannot be verified, has lapsed, or does not cover the work being done.
1. Purpose
To make sure every person who provides care is qualified, licensed and current for their role before they start, and remains so while they work here [E-006, EC].
2. Scope
| Applies to | All clinical staff, non-clinical staff who may come into contact with patients, locums, students, volunteers and contractors |
| Locations | All sites and services at the facility |
| When | Before the first shift; at each renewal date; before any change of role or scope |
| Does not apply to | Staff who only work in offices with no patient contact, unless their role requires a licence |
3. Definitions
| Term | Meaning |
|---|---|
| Verification | Confirming, with the issuing body or an original or certified copy, that a licence, registration or qualification is valid |
| Scope of practice | The procedures and duties a person is allowed to perform under their licence |
| Recheck date | The date by which the person’s credential must be checked again |
| Issuing body | The authority that grants the licence or registration |
4. Background
Patient safety depends on staff who are qualified for their role. A lapsed licence or a role outside the scope of practice is a serious risk. Verification is a one-time check at start and a recurring check through the employment.
This SOP is the method for criterion 1.8: every staff member’s verification is in one register, with the next recheck date. The register is the audit evidence. No personal documents are kept beyond what the register needs (see the privacy policy).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| HR lead | Holds the register; runs the recheck calendar; stops access when credentials lapse | HR and compliance training |
| Clinical director | Confirms the scope of practice for each clinician | Clinical leadership |
| Department or ward head | Checks the person is verified before they are rostered; reports gaps | Management training |
| Staff member | Provides valid documents on time; tells the HR lead of any change or lapse | Own responsibility |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Original or certified copy of each licence or registration | Valid, issued by the authority, shows name and expiry date | Name matches identity; not expired |
| Online register of the issuing body (where available) | Official site only; no third-party sites | Date and result recorded |
| Staff verification register (STF-FRM-001) | Current version | Available to the HR lead and quality lead |
7. Safety
- Do not allow any person to work on a patient until verification is complete.
- Keep personal documents secure. Access is limited to the HR lead and the quality lead.
- Do not accept a photocopy of a licence without checking it against an original or the issuing body.
8. Before you start
- Ask the candidate for their licence, registration and qualification documents in advance of the start date.
- Check the post or rota they are applying for, to know the scope required.
9. Procedure
Step 1. Collect the documents before the first shift.
- Ask for the original, or a certified copy, of each licence, registration, certificate and required insurance.
- Note the name on each document and confirm it matches the identity document.
- Keep the copies in the secure HR file.
Key point: A name that does not match is a flag, not a formality.
Step 2. Verify with the issuing body.
- Check the licence on the issuing body’s official register, where one exists.
- If there is no online register, contact the issuing body directly, and record the reference and person spoken to.
- Record the result, the date, and your name.
Key point: The original document can be fake. The issuing body is the check that matters.
Step 3. Check the scope of practice.
- Compare the licence scope with the duties in the post.
- If the scope does not cover a duty, the person is not rostered for that duty until the scope is confirmed by the clinical director.
Key point: Qualified in one area does not mean qualified in another.
Step 4. Record the verification on STF-FRM-001.
- Enter the name, role, issuing body, licence or certificate number, verification date, who verified, scope confirmed (yes or no), and the next recheck date.
- Do not record the personal document itself in the register.
Key point: The register must show the verification date and the next recheck. Both are audited.
Step 5. Confirm the person is allowed to start work.
- Tell the rota or department head that the person is verified.
- Do not allocate duties before the register is updated.
Key point: The register and the rota must agree.
Step 6. Set the recheck and reminders.
- Diary the expiry date of each credential.
- Send a reminder to the person and their manager 30 days before the expiry date.
- On the expiry date, if the renewal is not shown, stop the person from working in the scope that requires the licence, and tell the clinical director the same day.
Key point: Most lapses happen because nobody is looking at the dates.
Step 7. Review the register.
- Review all dates each quarter with the quality lead.
- Audit a sample of 10% of staff each quarter against the source documents.
- Report gaps to the clinical director and the governing body.
Key point: An audit against source documents is the only way to know the register is right.
10. Decision points
- If the verification succeeds and the scope matches, the person may start work.
- If the verification fails or the scope does not match, the person does not start, and the HR lead informs the manager and the clinical director.
11. Special situations
| Situation | Action |
|---|---|
| Locums and agency staff | The agency provides the verification evidence before the shift. The hospital still verifies with the issuing body (EC). |
| Students | Verified by the training institution and recorded in the register, with the supervising clinician named. |
| Overseas-qualified staff | Verified with the issuing body in the country of qualification and with the national authority. Allow more time (EC). |
| Renewal in progress | The person does not work in the licensed scope until renewal is confirmed. Under a supervised plan only, if the rules allow (EC). |
12. Escalation
- If a licence has lapsed, stop the person from working in scope at once and inform the clinical director the same day.
- If a credential appears to be false, do not employ or continue; report to the issuing body and to the governing body.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Staff verified before first shift | 100% | Each new starter; monthly summary | HR lead | Escalated to the chief executive |
| Licences expired while in use | Zero | Monthly | HR lead | Immediate suspension from scope; incident report |
| Register matches source documents (quarterly sample of 10%) | 100% accurate | Quarterly | Quality lead | Full review of the register; retraining of HR staff |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| STF-FRM-001 Staff Verification Register | HR secure file (access limited) | Duration of employment plus the period set by the facility’s records policy years, or as the law requires |
| Copies of licences and certificates | HR secure file | Duration of employment plus the law’s requirement |
15. Training
- HR staff are trained in this SOP at induction and each year (EC).
- Department heads are briefed on the rota check at induction.
16. Related documents
| ID | Title | Use |
|---|---|---|
| STF-FRM-001 | Staff Verification Register | Used in steps 1 to 4 |
| SOP-072 | Staff Background Check Procedure (generic) | Background checks are a separate step |
| PHM-SOP-001 | Medicine Storage and Temperature Monitoring | Only verified staff handle medicines |
| REC-POL-001 | Records Management and Retention | Governs storage and retention of personal documents |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. |
| E-009 | ASF Expert Committee consensus. Overseas verification and renewal rules set by the ASF Expert Committee against national law. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | Full procedure written; added verification steps, scope check, recheck, special cases and monitoring | Approved by the ASF Expert Committee |
E-learning for this document
- Credentialing, Competence and the Training Matrix (T-14)
- Safety Training Programme & Competency Assessment (TRAIN-01)
- Staff Health Screening & Wellness Standards (STAFF-01)
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)