STF-SOP-001: Staff Credential Verification and Recheck

This is a controlled copy when approved. Printed copies are uncontrolled; check the version against the document register before use.

Contents

Abbreviations

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 at the facility. Patients are harmed when care is given by someone who is not qualified or not licensed for the work, and the harm is often not recognised until a complaint or an incident. This SOP sets out how credentials are checked, how the check is recorded, and how renewals are managed. The evidence reference E-006 cited in this document is to be confirmed (see References).

Scope

Definitions

Background

A licence is a legal permission to practise, and it can be suspended or lapse without the individual or the facility noticing. A check made once, at recruitment, does not show whether the licence is still valid or covers the work now being done. The verification is therefore repeated at each renewal, and it is recorded so that it can be inspected at any time.

Responsibilities

Materials and equipment

Safety and exceptions

• Not verified. A person whose credentials have not been verified does not work with patients unsupervised, and does not work alone with patients.
• Lapse. Where a registration or licence lapses, the person is stopped from work on the day it lapses, and the line manager is informed the same day. The person does not return until verification is complete.
• Scope. Where the scope held does not cover a task, the person does not carry out that task, and the line manager arranges the cover.

Procedure

Before you start

• Check that STF-FRM-001 and the recheck diary are current.
• Confirm the post, and the scope of practice that the post requires.

Step 1. Verify before the first shift

1. Obtain the licence or registration number and the qualification details from the person.
2. Verify each with the issuing body, using its public register where one exists, or from the original certificate that the verifier has seen. Do not accept a copy alone.
3. Check that the scope of practice covers the post, and record any restriction.
4. Record the verification on STF-FRM-001: the date, the source, the expiry date, the scope, and the name of the person who checked it.

Step 2. Diary the next check

1. Diary the reminder for 30 days before expiry, and the recheck for the renewal date.
2. Send the person a reminder 30 days before expiry, and record that it was sent.

Step 3. Recheck and act on a lapse

1. Recheck at each renewal date, and before any change of role or scope.
2. If the registration has lapsed, stop the person from working on the day it lapses. Inform the line manager the same day.
3. Once the registration is restored, verify it again and record the verification before the person returns to work.

Worked examples

Decision points

Escalation

Monitoring and compliance

Records

Training and competence

• Induction: the verification steps, the public registers, the form, and the lapse rule, for HR staff and line managers.
• Annual update: an audit of the verification file against this SOP.

Related documents

References

1. ASF Expert Committee decision on staff credential verification. Evidence reference E-006 is cited in the current document; the reference has not been verified against an external source and must be confirmed before publication.

Change history

Annex A. Credential verification record

Use this record for each audit session. Record one line per staff member checked. Enter Y, N or NA as shown in the column heading.