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 is compiled and updated voluntarily by experts on LTC all over the world. Members of the Social Care COVID-19 Resilience and Recovery project are moderating the entries and editing as needed.

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, Pharoah D (eds.) and LTCcovid contributors. 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 quality of long-term care is a common aspiration in many countries, our report reveals a diversity of approaches to defining and measuring quality.

The quality of LTC can be, and often is, approached from various angles, and relevant dimensions often include: the quality of life of the person with care needs, supporting people to have lives that are as empowered and independent as possible; improving, or limiting the deterioration in, medical conditions; protecting people’s human rights or a mixture of all these different elements. Furthermore, different stakeholders, including providers, policy makers, unpaid carers, may understand quality from different angles. For example, there is no formal national definition of long-term care quality in any of the EU Member State and many countries use the existing broad quality definitions applicable to healthcare and social care services. Such approaches to defining quality, however limited, usually apply to formal long-term care, while the quality of informal lcare is even less addressed (Employment, Social Affairs & Inclusion – European Commission (

International reports and sources

EU Report on LTC (2021) covers LTC quality in Member States.

The Aged Care Quality and Safety Commissioner, under the Australian government, is the national regulator of aged care services. It is responsible for approving subsidies for aged care providers, accrediting aged care services, monitoring quality of care, providing education, and handling complaints. Aged care providers must comply with the Aged Care Quality Standards set by the Aged Care Act and the Aged Care Principles (source: Care, Dignity and Respect report).

Last updated: December 22nd, 2021

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 (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (

Last updated: November 23rd, 2021

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 (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (

Last updated: November 23rd, 2021

The LTC quality framework in Croatia is implemented under the by-law on the standard of quality of social services, based on the Social Care Act in force since 2014. Quality standards have become mandatory for all providers of residential and non-residential social services, private and public ones. The Healthcare Quality Act regulates the qualitative framework for LTC in health services (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (

Last updated: November 23rd, 2021

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: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (

Last updated: November 23rd, 2021

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. Current standards of quality focus on processes within institutions and on personnel capacities (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (

Last updated: November 23rd, 2021

While the municipalities are responsible for service and quality assurance they need to comply with standards set by national framework legislation. Quality standards for long-term care apply to public and private providers. The municipalities must ensure full transparency and clear separation between their function as providers and as the authority supervising quality. The municipal quality standards describe in detail the services available at the local level and are intended to be sufficiently objective and transparent to allow users to evaluate the performance of the provider themselves. For general monitoring of providers, municipal governments and the Ministry for Social Affairs and the Interior have developed 23 impact and background indicators as part of the agreement on care for older people. Most indicators are monitored through administrative data and, every two years, user surveys (source:

Last updated: August 2nd, 2021

Following the Estonian Social Welfare Act in 2018 there are quality principles that must be followed in the provision of social services (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (

Last updated: November 23rd, 2021

An important device to monitor the quality of care is the personal care and service plan, which specifies the services and support measures that a client should receive. It is a care contract between the client (or their representative) and the municipal authorities. The care contract is used in residential and home care settings. At the institutional level, the National Supervisory Authority for Welfare and Health (Valvira) and six regional state administrative agencies supervise all the LTC provisions. They give directives and provide licenses to the private LTC producers which fulfil the basic requirements set in legislation, they also process complaints centrally, which enables them to get an overall picture and conduct broader investigations of the LTC facilities. Unannounced inspections are also carried out by the supervisory authorities (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (

Last updated: November 2nd, 2021

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

Quality of LTC has been a government focus, and addressed through different laws, including new procedures for quality assurance and reporting in residential care settings, financing of 13,000 additional posts, LTC pay rates required to be set according to collective wage agreements and the development of a test to calculate adequate staffing levels (Personalbemessungsverfahren) in LTC settings (source:;

Responsibility for quality of services sits with the providers, however they operate in close collaboration with LTC funds and municipalities. Länder and local authorities are responsible for an efficient infrastructure, including that facilities are available and accessible (source:

Last updated: November 23rd, 2021

There is no national or sub-national definition of LTC quality in Greece neither in the context of the healthcare sector nor for the social care sector. There is also a lack of 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). Quality assurance is mainly based on a set of pre-determined 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, while 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: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (

Last updated: October 27th, 2021

There are national definitions of LTC quality provided by the responsible ministries in the form of government decrees or recommendations. Reflecting the dual structure of the LTC system, 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 irrespective of their legal background (private, for or non for profit, or public providers) (source: Employment, Social Affairs & Inclusion – European Commission).

Last updated: November 25th, 2021

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 July 2012, a system of approved service providers has been put in place under home support services. The approved providers must meet a uniform level of national standards. There are some 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 but as of 2021 there was no statutory basis to do so (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (

Last updated: August 2nd, 2021

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. The use of these tools varies according to whether the services are residential/home-based, or alternatively whether they are related to healthcare or social care

Source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (

Last updated: November 8th, 2021

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: Employment, Social Affairs & Inclusion – European Commission).

Last updated: November 25th, 2021

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: December 6th, 2021   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: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (

Last updated: November 3rd, 2021   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 for dependent older people 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 control visits and conduct inquiries when problems are signalled with regards to quality in LTC ; yet it is not responsible for systematically monitoring of service providers or services (source: Employment, Social Affairs & Inclusion – European Commission).

Last updated: November 23rd, 2021

The Spanish LTC system has three instruments to ensure quality: 1) a national and regional regulatory system; 2) formal quality controls; and 3) good practices. The regulation of quality in terms of services and the training of professionals and carers is developed through the Council of the System for Autonomy and Care for Dependency (CISAAD) which sets the minimum criteria for the whole state with respect to minimum carer-to-recipient ratios, staff qualifications, and resources/equipment/documentation applied to all accredited care centres. The CISAAD also establishes essential quality standards for homecare and residential care. Accredited centres can be inspected at the request of a dependent user or randomly by the autonomous community. The formal quality controls of the LTC system (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, the CISAAD 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).

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: November 23rd, 2021

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: September 8th, 2021

Last updated: September 8th, 2021

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: December 4th, 2021

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: December 5th, 2021   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: January 3rd, 2022   Contributors: Daisy Pharoah  |  

Contributors to the LTCcovid Living International Report, so far:

this list is regularly updated to reflect contributions to the report, if you’d like to contribute please email

Elisa Aguzzoli, Liat Ayalon, David Bell, Shuli Brammli-Greenberg, Jorge 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, Stefania Ilinca, Margrieta Langins, Shoshana Lauter, Kai Leichsenring, Elizabeth Lemmon, Klara Lorenz-Dant, Lee-Fay Low, Joanna Marczak, Elisabetta Notarnicola, Cian O’DonovanCamille Oung, Disha Patel, 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, 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.