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Implementation of requirements

Legislative frameworks

Implementation and monitoring of the requirements: inspections

Residential care facilities have to comply with the regulatory requirements at the time of registration, and are monitored after registration. In Europe, inspections are the most common way of assuring minimum quality standards (Interlinks, 2010).

In the majority of the cases, the body responsible for such inspections is a national body (e.g. Bulgaria, Croatia, Czech Republic, Netherlands, Ireland, Luxembourg, Malta, Netherlands, Portugal, Slovenia, Turkey and the UK). In Finland, two different bodies exist: Valvira and AVI. Valvira is the national supervisory authority of welfare and health, and provides permissions to health and social care service providers with services in more than one region. The service providers that work in smaller regions apply permits from a local Regional State Administrative Agency (AVI). In addition to the inspections, in Finland, all the service providers have to develop a self-monitoring plan and provide a yearly report to the regulatory body.

In terms of the frequency of inspections, overall in all countries, an inspection would take place if a complaint has been filed. In several countries, no specific time frames are listed in legislation and thus, the visit and inspection can occur at any time. In some countries (e.g. Croatia, Ireland, UK–Scotland), facilities which give raise to concern are inspected more frequently. Table 5 shows examples of provisions regarding the frequency of inspections.

In some countries, (e.g. Czech Republic, Ireland, UK), in addition to reviewing the relevant paperwork and records and visiting the care facility, inspectors talk to different stakeholders including: people using the service, their representatives and families, staff and managers. In England, users or interested parties can report examples of poor care, abuse and/or neglect they have experienced (or know about) in health and social care services. This can be done directly to Care Quality Commission (CQC) or through the ‘share your experience’ or the Healthwatch tools. In Scotland, anyone can make a complaint, anonymously if needed, to the Care Inspectorate which has the powers to investigate.

In several countries, support to implement the regulated requirements and/or standards is provided to residential care facilities. However, differences are found in the type and intensity of such support. Some examples of the support provided include:

  • Development of guidance documents on a number of relevant topics to support providers in the implementation of the regulated requirements (Finland, Ireland, Portugal, UK). Interestingly, in Northern Ireland, guidance documents have been developed also for members of the public.  
  • Provision of advice to the residential care facility at request (Germany, Finland, Ireland)
  • Training on implementing of the requirements (Netherlands, Portugal and Slovenia).
  • In the Czech Republic, when the national standards were launched (in 2006) some regional authorities provided support to social care facilities (e.g. onsite visits, support with methodological aspects etc.).
  • In Malta, some standards will be phased in gradually for existing homes.

After an inspection, care facilities have to remedy any deficiencies identified. In some cases, there can be financial consequences for the facility if requirements are not addressed, as for example in Belgium (Flanders), Greece, Italy or Turkey where the facility may not receive funding from the health system, or in the Czech Republic, Malta, Romania, Poland and Portugal where the facility can be fined if the facility does not meet or comply with the regulated requirements and standards.

In England, after an inspection, the CQC produces a report which also includes a rating to show the overall judgment of the quality of care (outstanding, good, requires improvement or inadequate). By law, care providers must display the ratings the CQC gives them in the places they provide care, so that the people who use the services can see them, as well as on their website if they have one. In Belgium (Wallonia), the Government has developed a charter about quality of care according to which, and in order to improve the quality of life of the residents, facilities for older people should focus on the needs and expectations of the residents and respect them. Care facilities that adhere to the charter are included in a list published by the Government and are given a “quality label”.  Residents are informed about this.

In Scotland, in recent years, the Care Inspectorate has shifted the focus of its work on social care and social work services, from one based on an approach primarily concerned with compliance and inputs, to an improvement-focused approach which provides assurance about care quality and looks to improve the experience and outcomes for people who use care services. Quality is assessed by the extent to which care supports positive outcomes, not compliance. Scrutiny becomes a diagnostic tool which evidences what is working well and what needs to improve. An example of this change lies in changing inspection approaches. For example, where managers of services may have previously identified improvement needs within their services, (and there are robust plans to address the shortcoming), this would now be considered a management strength, rather than necessarily a service failure. Whilst inputs are not being removed completely, significantly more emphasis is being placed on the experience of the person using the service. This form of scrutiny does not mandate how improvement must take place – that is owned by local care leaders. The model provides independent evidence on whether improvement activity has been successful. In exceptional circumstances where services refuse to comply or do not improve, the Care Inspectorate can take legal action through the courts to have a service closed down, however, this is a measure of last resort.

In Wales, while the standards included in the National Standards are qualitative (i.e. they provide a tool for judging the quality of life of service users) they are also measurable. Regulators look for evidence that the requirements are being met and a good quality of life is enjoyed by service users. The involvement of lay assessors in inspections helps ensure a focus on outcomes for and quality of life of service users.

Example of registrations:

Cyprus [19]

Residential care homes have to be registered (Law 222/91 on Long-term care residential facilities for the elderly and the disabled and the Regulatory amended Law 213/2006). In order to be registered, residential care homes have to pass a Social Welfare Services (SWS) notified inspection, which will prove that the facility complies with the law regulations. After registration, these facilities undergo unannounced inspections by an SWS officer at 6 months intervals. The inspector gives a report using an inspection tool, which was developed based on the law regulations and which is divided into the following requirements: personnel qualifications, level of care, facilities, comfort, security, level of health care, quality of foods and nutrition, behavioural treatment of the residents and their families, indoor and outdoor cleanliness, furnishings and infrastructure sufficiency, amusement and occupational therapy, contacts with relatives and the community, general atmosphere in the premises and compliance with the regulations (e.g. fire, hygiene etc.).

Luxembourg [20]

In Luxembourg, the provision of private residential services is restricted to organisations approved by the Ministry of Family Affairs based on the fulfilment of certain quality standards and after adhesion to a framework contract with the National Health Insurance, which determines the rights and obligations for executing the nursing care services. By the end of 2014, 52 nursing homes and integrated homes for older people with a mix of dependent and less-dependent residents were registered.

UK - England

When registering care providers, the Care Quality Commission (CQC) checks whether they meet a number of legal requirements including the fundamental standards of quality and safety. They also assess and make judgments about whether the services look suitable, whether there are enough staff with the right skills, qualifications and experience, the size, layout and design of the place they intend to provide care, their policies, systems and how effective they will be and how they are run and how they plan to make decision. After a service is registered, they are continuously monitored with reference to five key questions: are they safe; are they effective; are they caring; are they responsive to people’s needs and are they well-led.


[19]This text has been reproduced from: Loizou, C (2010).

[20] This text is an excerpt from the Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability, 2016, National report for Luxembourg.

Table 5: Frequency of inspections.


Minimum frequency of inspections

Belgium Wallonia



According to the plan adopted by the executive director of Social Assistance Agency.


1 - 2 inspections per year.


Every 6 months.

Czech Republic

Inspections for quality standards every 3-5 years.[21]




At least once in a three-year cycle.

Inspections can also be carried out at other times as informed by the centre’s risk profile.


At least once per year.


Every two years.

(“extra” visits may occur if necessary).


Every 6 months.


At least once every three years.


Annual visits and online grading on e-BHKS system (Quality Standards Care Services Online System).

UK - England

Depends on the service.

UK - Wales

Every year.

UK - Scotland

At least once every year, but using a risk basis, so services which give rise to concern are inspected more frequently.


[21] This is not included in the law, this was described in the 2008 Recommendations.

Examples of monitoring quality and inspections

Belgium - Flanders

The Flemish Indicator Project helps residential care facilities to assess themselves and improve their quality policies; inform the residents and general public; allow the government to use the results for inspections and accreditation assessments; and compare various facilities (benchmarking). The residential care facilities measure indicators related to care, safety, care providers and the organisation. They provide the data to the Flemish Care and Health Agency twice a year.

The Residential Care Helpline provides information and handles complaints about care services for older people

Belgium - Wallonia

In Wallonia, nursing and residential care homes must be accredited before opening. Then, approximately once a year, they receive an inspection (specific or global). They have to meet a series of requirements relating to the building, safety, health care as well as the quality of their support for people who are 60 years or older. 

The implementation of, and the compliance with, the requirements are monitored in a special program (only available to the public administration) which is used to prepare a biennial report where the results of this sector are analysed.

If an institution does not meet one of the standards, an inspector designated by the Government and working for the public service, will inform the direction during the visit and give the manager a warning. If too many standards are not met, or if there concerns regarding the security and dignity of the residents, the administration can propose to the Ministry of Health to close the institution.

Germany [22] 

In Germany, residential care facilities have to ensure the quality of the care they provide. In the contracts between the Federation of providers and the regional branches of the LTC insurance, it is stipulated that care providers are expected to meet the requirements and federal provisions (type of services provided, staff ratios and skills etc.), use a quality management system and use existing expert standards (e.g. related to medical and nursing care).

The Medical Advisory Boards of long-term care insurance funds, carry out the external monitoring / auditing of residential care facilities. In addition, the Local Residential Home Authorities ensure compliance with Land regulations. This includes inspections of the physical environment (e.g. rooms, living area, etc.), relevant activities and the care status of the residents.

If inspections are not successful, the Medical Advisory Board of sickness funds (MDK) may cut payments or exclude the provider from funding entirely.


[22]  Summary from OECD /European Commission report, 2013






Last Updated: Friday 31 January 2020


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