Re-accreditation and annual audit

This page includes application and guidance forms for Baby Friendly re-accreditation and annual audit, and details of the re-assessment process.

Once your organisation has passed Stage 3, it will be accredited as Baby Friendly. The initial accreditation typically lasts for two years; after this, re-assessments will take place on a regular basis to ensure that the standards are being maintained and to explore how the service is building on the good work it has already done.

All accredited facilities must collect infant feeding statistics and must audit their implementation of the standards. The results of the audit should be used to ensure that high standards are being maintained and improved and annual audit forms (see below) should be sent to the Baby Friendly Initiative office every year.

Re-accreditation will consist of interviews with mothers, staff and managers to check audit results and discuss how the standards are being maintained. Internal audit results and outcomes such as breastfeeding initiation, continuation and exclusive rates and supplementation rates (where applicable) will be reviewed.

Evidence of additional work to improve care for mothers and babies related to the standards will be reviewed and added to the overall picture at re-assessment, with the aim of encouraging facilities to build upon the achievements of their original accreditation, and continue to improve.

How we will assess the standards

More detailed information on how to meet the standards is in our Guide to the Baby Friendly Initiative standards. Our Guide for health professionals to working within the Code will give you useful advice on avoiding inappropriate promotion of breastmilk substitutes within your facility.

As part of the  assessment you will be asked to send details of the staff on duty and you can use the Staff lists and interview timetable template to prepare this information.

Progress monitoring visits

The Baby Friendly Initiative occasionally carries out progress monitoring visits in order to support facilities in maintaining and improving their standards. A suspected drop in standards could lead to an accredited Baby Friendly facility being re-assessed on one or more standards at any point. As a last resort, the award could be withdrawn.

Achieving Sustainability

At re-assessment stage, services can also opt to be considered for an Achieving Sustainability assessment, leading to the Gold Award. This is not compulsory; if services to do not wish to go for Gold, they will undergo continued re-assessment every three to five years.

Annual audit forms

Re-assessment forms

Telephone number grids

Sample mother consent form – see guidance document for further information

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Achieving Sustainability: Health Services

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Guide to the Baby Friendly Initiative Standards

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