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Accreditation assessment process

Providers are assessed on a regular basis to ensure that they continue to meet the required accreditation standards for the specific services they are approved to deliver.

The assessment process varies depending on the level of compliance required. This could include a site visit, self-assessment or due diligence.

Accreditation is required for organisations seeking to deliver social services and is often necessary for contracting. However, accreditation does not give the right to a contract or funding of a service.

Approval Assessor

Your accreditation assessment will be performed by an Approvals Assessor. On some occasions more than one assessor may visit.

Your Approvals Assessor will be able to answer any questions you have about your assessment and the accreditation process.

What is an assessment?

Providers will be assessed at a level of compliance that is indicative of the types of services they deliver. If you provide several different services you will be assessed at the highest level of compliance required.

The assessment considers both organisational capability and service quality to ensure that good business practices are being followed and that people who access services are safe. This includes but is not limited to:

  • Finances — is the organisation able to financially support itself?
  • Vulnerable clients — are they safe and protected from harm and abuse?
  • Staff — are they appropriately trained and supported?
  • Governance — are there good structures in place to support the organisation?
  • Programmes /services — is the organisation providing quality services?

Providers will be asked to supply evidence to demonstrate compliance with the standards. The guidance provided in the accreditation standards provides further information about this. Generally, an Approvals Assessor will review organisational policies and procedures, the environment and the controls in place.

The frequency of the review cycle differs depending on the level of compliance required.

Site assessment

Providers with a compliance level of 1, 2 or 3 in the Approvals Framework, undergo a site assessment.

An Approvals Assessor organises a suitable time to come in and visit the organisation.

Site visits allow an Approvals Assessor to view the organisation in operation. While on site, an assessor may want to view documents that evidence compliance to the standards.

Provider self-assessment

Providers with a compliance level of 4 in the Approvals Framework will need to complete a self-assessment form.

The self-assessment form is considered by an Approvals Assessor to establish that the provider has demonstrated compliance with the Level 4 Social Sector Accreditation Standards.

An Approvals Assessor will not visit the organisation for a Level 4 assessment unless there are exceptional circumstances.

Level 4 providers have a timeframe of four weeks to submit their self-assessments to Social Services Accreditation

Inter-Agency Accreditation assessment

Providers who contract with multiple funders within the social sector may undergo an inter-agency assessment. In order to streamline the assessment process, MSD will coordinate with participating agencies to minimise duplication of accreditation activity and line up the review cycle to reduce the burden of compliance placed on the provider.

The provider may be involved in the coordination process, as their input could determine what works best for them: one visit to cover everything, or closely aligned visits where responsibility is shared.

Due diligence

Providers with a compliance level of 5 in the Approvals Framework do not require assessment by an Approvals Assessor. Instead, the agency staff member will perform checks and contact you if needed.

Assessment outcome

Assessment report and approval letter

After an assessment has been completed, a provider will receive an assessment summary report and accreditation letter.

The accreditation letter will confirm the approval status for the organisation and the assessment report will contain the findings of the accreditation review.

Assessment reports are written in the style of exception reporting. This means that an Approvals Assessor will only focus on problem areas and areas where you are doing particularly well in the report. The report will state any corrective actions that the provider may need to take and/or any organisational strengths.

Corrective actions

If the Approvals Assessor finds areas where the provider does not demonstrate compliance with the required standards, these will be noted in the assessment report as corrective actions.The provider will be given time to address any corrective actions.

There are three different types of corrective action:

  • Critical Actions (previously referred to as remedials)
    A critical action is an improvement the provider must make to mitigate a failure which constitutes a serious safety hazard or an unacceptable level of risk.
    Critical actions are allocated a timeframe dependent on the nature of the risk, up to a maximum period of six weeks.
    Accreditation will not be confirmed with an outstanding critical action.
  • Required Actions (previously referred to as requirements)
    A required action is an improvement the provider must make to mitigate a failure which does not constitute a serious safety hazard or an unacceptable level of risk.
    A specific timeframe can be assigned to a required action, or it can be assessed at the next scheduled review.
  • Recommendations
    Recommendations are improvements the assessment team have identified.
    It is up to the provider whether or not they implement a recommendation.
    A recommendation does not affect the assessment outcome but is offered to strengthen the organisations practice.

Organisational strengths

Any standards that the provider has exceeded will also be noted in the review. Strengths will be noted only where the provider has surpassed the compliance requirements for the standard.

Removing Accreditation

Accreditation for providers doesn’t have an expiry date. There are three main ways a provider’s accreditation status can be removed:

  • Relinquishment
    A provider can ask for accreditation to be removed (completely or to a certain level of compliance).
    Volunteering to relinquish a level of approval does not affect the organisation’s ability to apply for accreditation at any level in the future.
    Find out more on how to relinquish approval
  • Suspension
    The provider’s accreditation status may be suspended in certain circumstances. This might include where there is serious concern about the safety of clients or the provider’s on-going ability to deliver services or where the provider has failed to comply with the accreditation standards over time.The provider will have the opportunity to make a submission to address MSD’s concerns.Suspension of accreditation often means suspension of existing contracted services. In addition no new contracts or funding for services will be considered. Existing agreements will be put on hold until suspension is resolved.
  • Revocation
    MSD may revoke a provider’s accreditation in certain circumstance. This might include for example, where after suspension and consideration of the provider’s submissions, MSD is still concerned about the service.Revocation terminates the provider’s approval with MSD.Without approval, all MSD contracts will often be cancelled. A provider that has had its accreditation revoked might not be considered for future contracts and funding from the MSD.

Social Services Accreditation suspensions and revocations for Level 1, Level 2 and Level 3 are published in the New Zealand Gazette. Providers at Approval Level 4 will not have suspension or revocation notices published.

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