Accreditation Canada 2025 Survey Results

CapitalCare welcomed Accreditation Canada surveyors in October 2025. The surveyors undertake a process that happens every four years to review CapitalCare’s practices, policies and everyday life at the organization to ensure it meets internationally set standards for continuing care.  

“We welcome the opportunity to demonstrate our commitment to high quality continuing care that is focused on residents’ unique needs,” says Aileen Wong, COO of CapitalCare. “I want to thank all of the staff who worked diligently to ensure we were prepared as an organization to demonstrate our high levels of care and dedication to community.”   

The Quality, Care and Transformation team worked across the organization to help prepare staff, build resources and review policies and procedures to ensure CapitalCare was ready for this audit.  

“Accreditation is important to ensure quality care is being provided and I want to thank my staff, and all staff across CapitalCare for working to implement that high standard. This helps to build our reputation as a continuing care provider,” says Schmidt.

CapitalCare's Quality, Care, and Transformation team. Carla Halfyard, Manager, Quality, Care and Policy (left), Candace Schmidt, Director, Quality, Care and Transformation (middle), and Anna Litle, Manager, Infection Control, Quality, Standards & Audits (right).

The Accreditation results were released in December 2025 with CapitalCare scoring highly in all areas. Accreditation reviewed eight standards and 18 priority processes across seven sites. CapitalCare was assessed on person-centred care, infection prevention & control, leadership including emergency preparedness, communications and community partners, planning and service design, as well as patient flow, medication management, and service excellence. Service specific assessments were also done for Ambulatory Care, Long-Term Care, Palliative Care, and Rehabilitation Services. 

 “Residents reported feeling listened to and cared for.”  

The surveyors reported there was a strong sense of family and community, and that CapitalCare  maintains a strong person-centred care approach dedicated to resident quality of life. Surveyors documented a “recognition of specialness of the organization and how incredibly grateful residents are to live in the various residences. Residents described their care as compassionate, skillful, and caring.”  

Areas of excellence included:  

Community Partnerships: CapitalCare is a “trusted and valued partner in the community.” Surveyors highlighted strengths in emergency preparedness, communication, as well as principled decision making with strong ethical and policy frameworks that promote integrity and accountability, along with clear procedures for addressing ethical issues that ensure staff, residents and families have structured avenues for consultation and escalation.  

“The organization’s people are a clear strength.” 

Employee development was listed as a strength with a commitment to a structured orientation process and a strong culture of growth and professional advancement.

Patient-flow: CapitalCare is a true partner in helping to address patient flow throughout the system with surge plans in place and the ability to accommodate ALC beds.

Medication Management: Pharmacy team provides comprehensive oversight. There are regular inspections and audits, and strong attention to safe medication practices, cleanliness, and organization.

Ambulatory care: (CHOICE) – Strong commitment to safety, compassion and client-centred care with structured communication and documentation practices. Individualized care plans were highlighted in Long-Term Care demonstrating a strong commitment to resident choice, independence and quality of life.

The volunteer program was listed as a key strength, offering meaningful companionship and support to residents.

“There are vibrant staff at CapitalCare who are all united in their desire to provide compassionate care with dignity for all residents.”

Opportunities to Improve

Accreditation also creates an opportunity for learning and change. It is an opportunity to review what needs improvement.

Quality improvement: Surveyors highlighted the opportunity to create a corporately led and organization-wide quality improvement plan, including the use of data analytics, and strengthening IPC planning and delivery throughout the organization.

Policy and planning: There was a noted opportunity to align operational planning with the budgeting process and strategic plan, and the need to look at policies to ensure they are in line with applicable regulations, current and best practice and changes in provincial legislation.

There is a greater opportunity for huddle boards to be used as a two-way communication tool, encouraging staff dialogue. They also identified consistently implementing performance appraisals across the organization as an opportunity for improvement.

“Overall we are thrilled at the observations of the surveyors who have documented what we know about CapitalCare. We are an organization dedicated to residents, creating community with purpose and belonging and delivering high quality care,” says Aileen.