LTCcovid Country Profiles

Responses to 1.05. Quality and regulation in Long-term care

The LTCcovid International Living report is a “wiki-style” report addressing 68 questions on characteristics of Long-Term Care (LTC) systems, impacts of COVID-19 on LTC, measures adopted to mitigate these impacts and new reforms countries are adopting to address structural problems in LTC systems and to improved preparedness for future events. It was compiled and updated voluntarily by experts on LTC all over the world. Members of the Social Care COVID-19 Resilience and Recovery project moderated the entries and edited as needed. It was updated regularly until the end of 2022.

The report can be read by question/topic (below) or by country: COVID-19 and Long-Term Care country profiles.

To cite this report (please note the date in which it was consulted as the contents changes over time):

Comas-Herrera A, Marczak J, Byrd W, Lorenz-Dant K, Patel D, Pharoah D (eds.) and LTCcovid contributors.  (2022) LTCcovid International living report on COVID-19 and Long-Term Care. LTCcovid, Care Policy & Evaluation Centre, London School of Economics and Political Science.

Copyright is with the LTCCovid and Care Policy and Evaluation Centre, LSE.




While providing high quality of long-term care is a common goal in many countries, our report reveals a diversity of approaches to defining and measuring quality.

Different approaches to defining  quality in long-term care

The quality of LTC can be, and often is, viewed from various dimensions including: the quality of life of the person with care needs, supporting people’s empowerment and independence; improving, or at least limiting the deterioration in health conditions; protecting individuals’ human rights. Often quality encompasses a mixture of some or even all of these different elements. Furthermore, different stakeholders, including providers, policy makers, unpaid carers, may understand quality from different perspectives.  Such approaches to defining quality, however limited, usually apply to formal long-term care, while the defining and measuring quality of informal care is often even less addressed. Such a myriad of approaches to quality means that  there is no uniform definition of long-term care quality even in the European Union (2021 Long-term care in the EU).

Attempts to measure quality in long-term care

There are no common indicators of long-term care quality, countries use a number of different indicators to monitor care quality, which are not always specific to long-term care. Aspects of the quality of life are often considered an indicator of long-term care quality outcomes.  For example, adult social care outcomes toolkit (ASCOT) often used in the UK, measures outcomes by comparing person’s perceived outcomes after receiving care with the outcomes they would expect if no care was provided.  Patient-reported outcome measures (PROMs) and patient reported experience measures (PREMs), often used in Germany and Denmark,  collect information directly from people with needs to assess outcomes.  More recently, The Rights of Older People Index (ROPI) has been developed based on structure and process indicators, although collecting relevant data may be more challenging (2021 Long-term care in the EU).

International reports and sources

EU Report on LTC (2021), Volume 1 and 2, cover LTC quality in EU Member States.

Specific reports cover issues around care quality in Thailand, Australia, Vietnam, or Sri Lanka.

The Aged Care Quality and Safety Commission, under the Australian government, is the national regulator of aged care services. It is responsible for approving subsidies for providers, accrediting services, monitoring quality of care, providing education, handling complaints and imposing sanctions. Providers must comply with the Aged Care Quality Standards set by the Aged Care Act and the Aged Care Principles.

The Royal Commission into Aged Care Quality and Safety’s report highlighted instances of sub-standard care, concluding that the current mechanisms of oversight and market shaping have not been able to respond to changes in the provider market, arguing the need for a less centralised regional and local market governance system (Royal Commission, 2021).


Royal Commission into Aged Care Quality and Safety (2021) Final Report: Care, Dignity and Respect, volume 1. Commonwealth of Australia.

Last updated: February 21st, 2022

As of 2021 there is no clearly defined and integrated quality framework, covering the different sectors of LTC. The ‘15a agreement’ on LTC between the Federal Republic and the federal provinces defines general quality criteria and leaves considerable room for interpretation. On the subnational level, the federal provinces enacted more detailed regulation to promote the quality of LTC services. These regulations address the structural and procedural aspects of LTC quality, and usually do not give much emphasis to outcome-related aspects (European Commission, 2021).


European Commission (2021)  2021 Long-Term Care Report Trends, challenges and opportunities in an ageing society. Luxembourg: Publications Office of the European Union

Last updated: February 3rd, 2022

The quality of LTC is ensured through initiatives and laws at different levels of governance and for different sectors or professionals. At federal level, healthcare professionals are regulated through the Ministry of Health and Social Affairs. Overall, quality in nursing homes is ensured through inspections, but also through set standards. In Flanders, the quality standards are related to the quality decree of 2003 setting the framework and quality criteria and indicators covering quality of care, safety, providers and organisation quality, and quality of life (European Commission, 2021).


European Commission (2021)  2021 Long-Term Care Report Trends, challenges and opportunities in an ageing society. Luxembourg: Publications Office of the European Union

Last updated: February 3rd, 2022

The LTC quality framework in Croatia is implemented under the by-law on the standard of quality for social services, based on the Social Care Act (2014). Quality standards have become mandatory for all providers (both in residential and non-residential sector, private and public). The Healthcare Quality Act regulates the qualitative framework for LTC in health services (European Commission, 2021)


European Commission (2021)  2021 Long-Term Care Report Trends, challenges and opportunities in an ageing society. Luxembourg: Publications Office of the European Union

Last updated: February 4th, 2022

There is no quality framework that applies to all LTC services, and no relevant legislation exists to regulate quality standards for all LTC services. However, there is legislation regarding the quality of services in some areas of LTC, such as residential care and day-care centres. Homecare provision is monitored via visits made by social services officers, who are required to follow a specific evaluation/assessment protocol, made up of three competency themes: self-care, household tasks, and mental state. Regarding LTC in residential care and day-care centres, quality is monitored by reference to the minimum standards set out in the respective legislation and through regular inspections of the centres. Residential and daycare providers, either public or private sector, must meet certain minimum quality standards such as: the suitability and qualifications of employees; the ratio of employees to beneficiaries; the suitability and condition of facilities; the bedroom area ratio and shared areas ratio for each beneficiary; hygiene facilities; buildings safety and physical access; the suitability and range of LTC services provided; and the provision of socialisation and entertainment activities (source: 2021 Long-term care in the EU: European Commission).

Last updated: February 10th, 2022

The tools introduced by the legal framework to ensure the quality of formal services in social care sector are the provider’s registration (each provider must be registered to provide services, registration can be withdrawn if quality standards are not met), inspections, and qualifications and training requirements for social workers. Quality standards focus on institutional processes  and on personnel capacities (European Commission, 2021).


European Commission (2021)  2021 Long-Term Care Report Trends, challenges and opportunities in an ageing society. Luxembourg: Publications Office of the European Union

Last updated: February 4th, 2022

The municipalities must ensure full transparency and clear separation between their function as providers and as the authority supervising quality. In accordance, the purchaser-provider model is implemented.

Quality standards for LTC apply to public and private providers. The municipalities are responsible for service and quality assurance. The overall law, the Social Service Act does not contain any specific quality stipulations that prescribe how the local municipalities should frame or even assess quality of care. The only requirement is that needs for care are met. But overall policy principles frame how quality of care is to be interpreted. Amongst other things, this includes that provisions of care should enable older people to remain at home as long as it is feasible. A quality item is also to deliver personalized services and to include the older person in decision-making. In home care, the law also specifically stipulates that care delivery should support the older person in becoming independent of services as is the goal in reablement.

As the national legislation serves as a framework law only, it does not include any national quality standards, neither on staff ratios, nor the required level of education of staff members as long as they have some education in care. However, there are certain quality requirements which the law specifies for the modern nursing homes, such that all rooms must have their own toilet, bath and kitchen facilities and that rooms much be accessible with a wheel chair.

Another way to regulate quality on a national level is to require providers to be accredited or authorized.  Here, an independent agency evaluate the quality of the care provided as well as certain structural elements such as education of staff, size of facilities etc. In Denmark, the private for-profit and non-profit providers that want to enter the market for Friplejeboliger are required to become authorized.

National standards for care are also influencing the curriculum for future care workers when they study. This ensures that the curriculum includes more or less the same subjects across the country. After having finalized the education, it may be possible to achieve authorization. This is the case in Denmark for both nurses and social care assistants (Social- og sundhedshjælper). Again, this makes it possible to set certain national standards as to the content of the education.

There are certain incentives which motivate public as well as private providers to deliver better quality of care. One of these is the introduction of competition where private and public providers compete over customers, in the Free choice of home care provider. Another is the economic incentive for municipalities to ensure that older people discharged from hospital receives the necessary care. Since 2007 municipalities finance 20 percent of the cost for a hospital bed which gives them a strong incentive for ensuring a quick discharge.

Quality control of providers takes place on the local level. The municipality must set up procedures for regular inspection. This includes supervising whether the services are delivered as planned as well as whether changes in needs are reported. Inspection takes place as unannounced as well as pre-announced visits. In nursing homes, the municipality must perform at least one unannounced visit annually. Since 2005, a private provider can carry out the inspection, but the inspection must not be outsourced to the provider also providing the services. The national agency the Board of Health (Sundhedsstyrelsen) also performs annual unannounced visits by a medical trained health officer (embedslæge).

The local standards of quality of care are communicated through the local quality standards (kvalitetsstandarder) which as accessible on-line in all municipalities. Users may also access information about the local quality of services by consulting the statistics which are collected annually and made public at Statistics Denmark as part of the project Elderly Documentation (Ældredokumentation) (source: ). Here local data on for instance user satisfaction can be accessed, however only in comparison with other municipalities, not broken down to the individual provider. There are 23 impact and background indicators. For general monitoring of providers, most indicators are monitored through administrative data and through user surveys.


Rostgaard T. (2012)  Quality reforms in Danish home care – balancing between standardisation and individualisation. Health Soc Care Community. 20:247–54.

Last updated: June 5th, 2023

Following the Estonian Social Welfare Act in 2018, there are quality principles that must be followed in the provision of social services (source: European Commission: 2021 Long-term care in the EU).

Last updated: February 10th, 2022

The National Supervisory Authority for Welfare and Health (Valvira) and six Regional State Administrative Agencies (AVIs) are responsible for supervising Long-Term Care provision. Valvira’s role is to give directives and providing licenses to private providers, processing complaints and conduct major investigations and inspections. The AVIs are responsible for regional supervision and guidance of health care and welfare provision and responding to complaints.

Individuals who use care have a personal care and service plan which constitutes a contract between the client and the municipal authorities. This specifies the services and support a person should receive and responds to the idea of ‘self-supervision’, according to which clients should be involved in monitoring the quality of services. In 2019 serious failings in quality of care were found in some private sheltered care settings, which led to these institutions being closed down. New legislation set minimum personnel ratios in all care homes, as well as the requirement to assess all residents using interRAI by 2023 (EC, 2021 and Ylinen et al, 2021).


European Commission (2021) Long-term care report. Trends, challenges and opportunities in an ageing society. Country profiles, volume II. Joint Report prepared by the Social Protection Committee (SPC) and the European Commission (DG EMPL).

Ylinen, T., Ylinen, V., Kalliomaa-Puha, L. Ylinen, S. (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Finland’, MC COVID-19 working paper 04/2021.

Last updated: February 1st, 2022

No formal, comprehensive definition of LTC quality has been produced by national or local public authorities. Nevertheless, the reforming the social care sector act of 2002 describes the different components of quality and three main dimensions can be identified: 1) The obligation for social care providers to carry out a double evaluation: an internal one carried out by the provider and focused on quality improvement; and an external evaluation (which guarantees renewed authorisation) carried out by an external body; 2) The respect of different basic user right and 3) Multiannual contracts (five years) of objectives and means are signed between social care providers and pricing authorities (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (

Last updated: November 23rd, 2021

There is no definition of LTC quality in Greece neither in the healthcare nor in the social care sector. A general LTC quality framework that would apply to all types of support (residential or home care) and to various providers (public, for-profit, not-for-profit) is also lacking. Quality assurance is mainly based on a set of standards which are included in the different legal regulatory frameworks that govern the licensing and operation of the various types of LTC facilities and providers. Monitoring and control of the operation of the LTC facilities and providers is subject to on-site inspections by the competent services of the regional authorities (source: European Commission: 2021 Long-term care in the EU).

Last updated: February 10th, 2022

There are national definitions of LTC quality provided in the form of government decrees or recommendations. Quality is defined separately regarding home nursing care as well as social care. Quality of services is typically defined by inputs, such as minimal requirements on personnel (number of employees and their qualification), physical conditions, infrastructure and equipment. For some services, procedures such as care planning are also prescribed in the decrees. The quality frameworks are mandatory and apply to all providers (private, for or non for profit, or public providers) (source: European Commission: 2021 Long-term care in the EU).

Last updated: February 10th, 2022

Since 2008, there have been independent, unannounced inspections of all public, private and voluntary nursing homes. These inspections are carried out by the Health Information and Quality Authority (HIQA). Since 2012, a system of approved service providers has been put in place under home support services, which must meet a uniform level of national standards. There are 35 standards including a person-centred approach, autonomy, safeguarding, the promotion of rights and dignity as well as standards in relation to provision and use of resources. It is planned that home care services will be independently inspected, however as of 2021 there was no statutory basis to do so (source: European Commission: 2021 Long-term care in the EU).

Last updated: February 10th, 2022

There is no overall definition of LTC quality either at national or regional/local level. The national government is responsible for quality control at system level, this responsibility is shared with the regions. The latter adopt slightly different solutions and, to varying degrees, have been able to implement quality-assurance measures. Given the absence of a quality framework, LTC quality is assured through the following tools: authorisation and accreditation; the ratio between beneficiaries and different kinds of professional staff; legislation addressing abuses and mistreatment of LTC recipients; and professional requirements for workers employed in the sector. The use of these tools varies according to whether the services are residential/home-based, or whether they are related to healthcare or social care (European Commission, 2021).


European Commission (2021)  2021 Long-Term Care Report Trends, challenges and opportunities in an ageing society. Luxembourg: Publications Office of the European Union


Last updated: February 4th, 2022

There are two different quality-assurance systems for LTC, integrated within either the healthcare system or welfare social services. Some quality requirements are enshrined in national law, while others are defined by municipalities or service-providers themselves including national quality regulations of LTC (e.g. hygiene norms) (source: European Commission: 2021 Long-term care in the EU).

Last updated: February 10th, 2022

The Social Care Standards Authority (SCSA) was set up in 2018 through Act No. XV of 2018. The SCSA is a regulatory body responsible for (a) the issuing of licences and warrants for service providers within the long term care sector, (b) the setting up of regulatory standards in respect of the various areas of social care, assistance and services provided by public and private entities, and (c) inspecting the long term care sector services, ensuring that practices are safe and up to the required regulatory standards for the persons using these services.


Last updated: February 10th, 2022   Contributors: Maria Aurora Fenech  |  

There is no formal quality framework regarding LTC services in particular, though various regulations address the presence of goal and process-oriented measures with respect to quality assurance separately in the healthcare and social sector. In the social sector, standards are set particularly in respect to residential care, covering minimum standards of the room size, access to toilets and kitchen, sanitation requirements, rooms furnishings and equipment, food as well as minimal staff requirements. Community day care services are standardised within dedicated programmes, such as ‘Senior+’ where minimum requirements regarding facilities and staff are set. Standards in home care are set covering broadly the types of services available and staff qualifications (source: European Commission: 2021 Long-term care in the EU).

Last updated: February 10th, 2022   Contributors: Joanna Marczak  |  

The quality of LTC social and socio-medical services is regulated by the law regarding the quality assurance of social services. The Social Policies and Services Directorate is in charge of designing the minimum quality standards for social services  and the accreditation of all public and private service providers. The minimum quality standards cover residential care, community-based care and homecare. The National Agency for Payments and Social Inspection can undertake unannounced  visits and conduct inquiries when problems are voiced regarding the quality in LTC sector; however it is not responsible for systematically monitoring service providers or services (source: European Commission: 2021 Long-term care in the EU).

Last updated: February 10th, 2022

The Spanish LTC system (System for Autonomy and Care for Dependency or SAAD) has three instruments to ensure quality: 1) a national and regional regulatory system; 2) formal quality controls; and 3) good practices. The responsibility for periodically inspecting and evaluating SAAD, along with ensuring that LTC Centres and service providers meet quality standards regarding the rights of service users, lie with the autonomous communities. They are also responsible for sanctioning any organisations that do not comply with quality standards.

The Territorial Council of Social Services and the System for Autonomy and Dependency Care (CTSAAD), formed by representatives of the central and the territorial governments, is responsible for setting common criteria for the accreditation of centres. It is also responsible for setting the common criteria for homecare and residential care quality plans. This is carried out within the general quality framework of the General State Administration. CTSAAD is also required to agree on quality and safety criteria for centres and services, by establishing indicators for evaluation, continuous improvement and comparative analysis of the System’s centres and services. CTSAAD is responsible for issuing guides for good practice, and for services portfolios, ensuring they are adapted to the specific conditions for people with care needs, under the principles of non-discrimination and accessibility.

CTSAAD is required by law to ensure the coherent application of social policies by working with the General State Administration and the Autonomous Communities. This is carried out by the exchange of points of view and the joint examination of any problems that may arise, along with proposing appropriate measures to solve them.

Accredited centres can be inspected at the request of recipients of publicly funded subsidies, or randomly by the autonomous community. The formal quality controls of the SAAD are based on the accreditation systems established by each regional authority. Although there is a common denominator among them, each region has its own specific regulation and quality plan. With regard to good practices, CTSAAD agreed on common criteria to define, develop, and evaluate good practices in 2011, however most regions have not developed tools to evaluate good practice (Rodriguez Cabrero et al, 2018).

On June 28, 2022, CTSAAD approved a new Agreement on Common Criteria for accreditation and quality of the centres and services of the System for Autonomy and Dependency Care (SAAD), which replaces the previous agreement adopted in 2008.

This new text regulates the accreditation processes through which the Autonomous Communities authorize care centres and services to be a part of the SAAD network, after verification of compliance with the established requirements.

Accredited centres and services will be subject to adequate inspection, control and monitoring, performed by inspection services to ensure continued compliance with the requirements.

Specific criteria are also included to ensure quality in employment, and to address the professional qualification and skills of both first and second level direct care staff, along with the continuous training of care staff. Other areas that are covered by the criteria include common hiring criteria, occupational health, or coordination for social and health care, among other aspects related to quality in the SAAD network.

It is worth noting that Leon and colleagues have identified a weak and fragmented regulatory system as one of the factors that contributed to delays in the implementation of measures to prevent COVID-19 in care homes in Spain.


León, M., Arlotti, M., Palomera, D., & Ranci, C. (2021). Trapped in a Blind Spot: The Covid-19 Crisis in Nursing Homes in Italy and Spain. Social Policy and Society, 1-20. doi:10.1017/S147474642100066X

Rodriguez Cabrero G, Montserrat Codorniu J, Arriba Gonzalez de Durana A, Marban Gallego V and Moreno Fuentes FJ (2018) European Social Policy Network Thematic Report on Challenges in Long-Term Care, Spain. European Commission, Brussels.

Last updated: September 1st, 2022

Since 2011 every person or organization, voluntarily or otherwise, that is engaged in the establishment and maintenance of any institution intended for providing residential care to more than five elders must register with the NSE, failure to comply with this requirement is an offense. Nursing care service providers are required to register with the Private Health Sector Regulatory Council (PHSRC) as a private medical institution. Registration must be done annually through the Provincial Director of Health Services (PDHS). The PHSRC will direct unregistered institutions to register. The PHSRC may shut down any institution that fails to comply with the registration requirement. The PHSRC sets guidelines for the operation of in-home nursing care services. The PDHS is required to check that an institution renewing its registration meets the guidelines and is, therefore, responsible for overseeing the quality standards for in-home nursing care institutions (source: Country Diagnostic Study on Long-Term Care in Sri Lanka).

Last updated: February 21st, 2022

The idea behind the universal Swedish welfare system is that services are affordable for the poor, but still attractive for the wealthy. Quality of services is therefore particularly important (source: European Commission / ESPN Thematic Report).

Sweden has seen a transformation of care provision, as the previous monopoly of publicly run services has led to one with a growing share of private organisations (mostly, for-profit companies). However, all long-term care is managed and organised by municipalities, who are also therefore responsible for quality-control – in both the public and private provision of care. Despite this quality control at a municipal level, there has been a growing concern the growth of the private care sector might have negative implications for care quality. A 2017 study by Winblad et al. investigated this, exploring the relationship between care quality and ownership in nursing homes for the elderly in Sweden. Results of the study were mixed and inconclusive. Although public nursing scored better for individual accommodation and staffing levels, those that were privately operated were found to perform better in terms of medication review, screening for falls, and malnutrition. No significant differences were found in quality between private ownership types (for-profit / not-for-profit / private equity companies) (Winblad et al, 2017).


Winblad, U., Blomqvist, P. & Karlsson, A. Do public nursing home care providers deliver higher quality than private providers? Evidence from Sweden. BMC Health Serv Res 17, 487 (2017).

Last updated: February 10th, 2022   Contributors: Daisy Pharoah  |  

Last updated: February 21st, 2022

The Care Quality Commission (CQC) is an executive non-departmental public body of the Department of Health and Social Care and serves as the independent regulator for both health and long-term care.

Last updated: March 8th, 2022

The Care Inspectorate is the regulatory body charged with ensuring that high care standards are met in Scotland. It carries out regular, unannounced inspections of Scottish care homes. Where care fails to meet the expected standards, the Care Inspectorate work with the provider to suggest how improvements in care quality can be made. If a provider fails to improve quality sufficiently, the Care Inspectorate have the authority to close the service down, subject to the decision of a sheriff.

Last updated: February 10th, 2022   Contributors: Jenni Burton  |  David Bell  |  Elizabeth Lemmon  |  David Henderson  |  

Quality in state-run institutional care centres in Vietnam is reputedly poor, which is mostly down to low levels of funding (source: UNDP report). The responsibility for quality assurance in terms of staffing sits at federal level: The Ministry of Labour, Invalids and Social Affairs prescribes professional standards and training care workers. Training is not mandated, but staffing levels are: for low-level care, they are 1:8-10, and for high level care 1:3-4. Nutrition staff (food purchasers and cooks) are mandated at 1:20. All care institutions (private, public, and NGO or religious providers) must submit annual reports to the federal authorities (source: Royal Commission into Aged Care Quality and Safety).

It is unclear whether quality is higher in private care homes. However, it may be worth noting that according to a recent report, 18% of the private residential care centres in 2016 were unlicensed (this suggests that it is quite possible that they have not been submitting any quality control reports to the authorities).

Last updated: February 21st, 2022   Contributors: Daisy Pharoah  |  

Contributors to the LTCcovid Living International Report, so far:

Elisa Aguzzoli, Liat Ayalon, David Bell, Shuli Brammli-Greenberg, Erica BreuerJorge Browne Salas, Jenni Burton, William Byrd, Sara CharlesworthAdelina Comas-Herrera, Natasha Curry, Gemma Drou, Stefanie Ettelt, Maria-Aurora Fenech, Thomas Fischer, Nerina Girasol, Chris Hatton, Kerstin HämelNina Hemmings, David Henderson, Kathryn Hinsliff-Smith, Iva Holmerova, Stefania Ilinca, Hongsoo Kim, Margrieta Langins, Shoshana Lauter, Kai Leichsenring, Elizabeth Lemmon, Klara Lorenz-Dant, Lee-Fay Low, Joanna Marczak, Elisabetta Notarnicola, Cian O’DonovanCamille Oung, Disha Patel, Martina Paulikova, Eleonora Perobelli, Daisy Pharoah, Stacey Rand, Tine Rostgaard, Olafur H. Samuelsson, Maximilien Salcher-Konrad, Benjamin Schlaepfer, Cheng Shi, Cassandra Simmons, Andrea E. SchmidtAgnieszka Sowa-Kofta, Wendy Taylor, Thordis Hulda Tomasdottir, Sharona Tsadok-Rosenbluth, Sara Ulla Diez, Lisa van Tol, Patrick Alexander Wachholz, Jae Yoon Yi, Jessica J. Yu

This report has built on previous LTCcovid country reports and is supported by the Social Care COVID-19 Resilience and Recovery project, which is funded by the National Institute for Health Research (NIHR) Policy Research Programme (NIHR202333) and by the International Long-Term Care Policy Network and the Care Policy and Evaluation Centre at the London School of Economics and Political Science. The views expressed in this publication are those of the author(s) and not necessarily those of the funders.