Languages Canada Accreditation Handbook
Accreditation to the Languages Canada Quality Assurance Scheme
Who this handbook is for
This handbook is intended to be used by educational institutions and language program personnel who:
- Handle the Languages Canada application and membership for their program
- Oversee the Preliminary submissions and the On-site and/or Maintenance audit process
In some language programs, different personnel may be responsible for each of the components of the audit. This guide is intended to help everyone involved make the audit more successful, efficient, and useful for the entire program.
We hope that you find the audit process useful, not only to obtain or maintain Accreditation, but to stimulate and assist with program review and continuous improvement, complementing the processes you already use.
Introductory Information
The Languages Canada Quality Assurance Standards Scheme
Quality Assurance Is a Critical Priority for Languages Canada
The purpose of the LC Standards is to ensure that the best interests of students studying or planning to study English and/or French in Canada are met. As a condition of membership with Languages Canada, all member programs must be accredited, confirming that they have met the rigorous Standards set out in this Scheme.
The Accreditation Scheme maintains the integrity and rigour of the standards in six key areas:
- Student Admissions
- Academic Staf
- Student Services, including Accommodations, Activities and
- Curriculum
- Marketing and Recruiting
- Administration
Accreditation Advisory Board
Provide guidance, when needed, to Languages Canada on changes needed to the Standards
Resolve disputes and recommend best practices to the membership
*For disputes, please refer to LCP01 Accreditation Advisory Board Appeals Policy and Procedure.
The Standards
The structure of the Languages Canada Quality Assurance Standards is broken down into the following:
| Accreditation Standards | Standards Interpretation Updates | |
|---|---|---|
| Languages Canada Quality Assurance Scheme – Standards And Specification | The Accreditation audit process requires that evidence is produced to satisfy all the requirement of the standards. Your Auditor will check each Standard and each Additional Specification. How the standards are fulfilled may vary slightly depending on whether your program is a Private Institution or a part of a larger Public Institution (such as a University or a Community College). |
| Published / Sanctioned Interpretations | The Languages Canada Quality Assurance Standard itself is a living document and is updated as needed, via a formal input and review process. Final approval of updated versions of the standard are voted on and approved by the Languages Canada membership. Sanctioned Interpretations exist to provide a single focal point for all questions and changes related to the standard, between formal revisions to the standard. Programs seeking accreditation must meet requirements of both the current Quality Assurance Standard and any published interpretations. The Standards and the current Sanctioned Interpretations of the Standards can be found on the Orion Canada website: https://www.orioncan.com/en/portalLC/). |
Summary of the Accreditation Process
| Audit Stage | Process Action & Requirements | |
|---|---|---|
|
| Application | After Languages Canada has successfully vetted the educational institution for potential membership, an Application for Accreditation must be submitted to Orion Assessment Services. This includes the application and deposit. |
| Stage 1 / Preliminary Review | This audit is conducted to identify any major gaps prior to the On-Site/Remote Audit. The applicant is provided with Preliminary Review Submission Requirements detailing information that must be submitted for review. The applicant will then receive or discuss a Preliminary Review Report, detailing strengths, areas for improvement, and areas of concern to be addressed during the audit meetings. An Audit Plan, confirming the details for the site/ remote visit, including the proposed date and daily schedule, will be forwarded by the auditor prior to the audit meetings. |
| Audit | The audit is conducted to ensure the processes and documents examined during the Preliminary Review and discussed in meetings are in use as reported. The auditor will meet with staff, students and faculty and review documentation. The applicant will receive an audit report, detailing strengths, opportunities for improvement, any issues standing in the way of accreditation, and a timeline for resolution of the issues. Once the issues have been resolved, a recommendation will be made regarding accreditation. |
| Accreditation Review / Certificate Issuance | The results from the audit are reviewed internally, by Orion’s accreditation team, to ensure a proper recommendation has been made. At this point, approval is given to accredit, not accredit, suspend, or terminate the program. |
|
| Maintenance Assessments | Accreditation is a four-year cycle. Mid-way through the second year after the initial accreditation, an off-site maintenance review is conducted to record changes and ensure all requirements of the standards continue to be met. A Maintenance Review Report will be generated detailing any findings from this review. |
| Risk And Random Based Compliance Assessment | The intent of these visits is to ensure continued compliance between regularly scheduled visits. Programs reviewed will be determined based on either a random selection or through a risk-based criterion. The risk-based criteria consider items such as a programs audit history, if there have been changes in key positions, the addition of new programs, fact driven complaints or noncompliance concerns. Programs selected are given 24 hours’ notice and must ensure a resource is available. Failure to allow Orion auditors in may result in immediate suspension or termination of accreditation. |
Applying for Accreditation for the First Time
The Scope of Accreditation Is Defined by Three Attributes:
| Audit Requirement | Standards & Compliance Details | |
|---|---|---|
|
| Legal Name of the Organization Offering the Program | For colleges and universities, it may be the name of the institution followed by the department. For example, University of ABC, English Language Department. |
|
| Location of the Program | An organization may have several locations but only seeking accreditation at one. In these cases, all marketing and advertising material must clearly identify the accredited program and not imply all locations are accredited. |
|
| Scope Statement | Typically, all programs/courses offering English or French language instruction must be included if they fall under points 1) and 2). |
Application Process
Apply to Languages Canada for Membership
All Programs (corporations or other legal entities with the primary purpose being the provision of training in English or French as a second/foreign language) applying for membership with Languages Canada must submit:
- A Languages Canada Application Membership Application
- Two (2) references from current Languages Canada members
- A pdf or hard copy of most recent brochure
- A bank reference and an appropriate credit report, or a Chartered Accountant’s statement of solvency based on professionally prepared financial statements; or, in the case of a public program, a statement of solvency from the Institution’s Chief Financial Officer
Please refer to Languages Canada for the most recent process for obtaining membership.
These documents will be submitted to the Languages Canada secretariat for review and approval. Once these conditions have been satisfied, the Program will be referred to Orion Assessment Services to commence the accreditation process.
Upon notification of the successful accreditation of the specific program submitted for accreditation or all of its locations, facilities, branches and operations that the Program owns or operates, or shares common branding with, the Program(s) will be accepted as Full, Listed or Assisted Members and the Board and membership will be advised accordingly.
Exclusions to the Standard
LC Members must comply with all requirements of the standard unless they fall under one of the following allowable exclusions:
- If the LC member is entirely remote, D.3 Activities, D.4 Accommodation, H.7 Facilities may be exclusions.
- If the LC member does not offer accommodation services, D.4 is an exclusion. However, if the LC Member recommends a third-party provider and has any type of referral services, the LC member is still responsible for ensuring that all the standard requirements are met.
- D.5 Care of Junior Students is an exclusion if the LC member does not cater to junior students.
The following provides an overview of the accreditation process.
Member types
- Have operated an ESL / FSL program for a minimum of 3 years
- Have a designated ESL / EFL program
- Pay all application, Accreditation and other fees as may be prescribed by the Board
- Adhere at all times to be bound by the By-laws, Code of Conduct, Membership Policies and Quality Assurance Standards of LC
- Successfully complete the Accreditation process.
Upon receiving notification of successful accreditation, a Program may apply to the Board for “Assisted Member” status, requesting a subsidized membership by reason of one or more of the following:
- Not having a significant annual student enrolment;
- Possessing operations that are seasonal;
- Operating in a remote location; and/or
- For any other reason that makes the cost of Full Member status an unaffordable expense.
Such organization shall set out sufficient reasons for requesting Assisted Member status. The decision to grant Assisted Member status shall be at the sole discretion of the Board. Applications for Assisted Member status must be renewed annually.
- Have operated an ESL / FSL program for between one and three years;
- Meet the requirements outlined in the Conditions of Membership;
- Pay all application, Accreditation and other fees as may be prescribed by the Board
- Successfully complete the Accreditation process; and
- Provide a financial guarantee in an amount and form which meets the requirements established by the Board from time to time.
- Additional locations or language programs which are owned or operated or share common branding with a full, novice, or assisted member.
- Listed Members are non-voting
- Listed Member locations are listed on the LC Website
Apply to Orion Assessment Services of Canada for Accreditation
Once your program has been deemed eligible for membership by Languages Canada, you may apply for accreditation directly to Orion, using the Application Form found on the Orion website.
The Application form asks for information to determine the size of your program (number of students registered at different times of the year, number of teachers, classrooms, satellite locations). The fees you pay for the accreditation are based on this information. It also lays out the responsibilities of each party and the nature of the contractual agreement.
Once the application has been received, Orion will process your application and send you a welcome letter identifying the auditor assigned. Your auditor will then contact you to explain the process and establish dates for the Preliminary Review process in preparation for an Audit.
The Audit Process
hereThe Orion auditor will contact the person listed on your application as “Primary,” sending the documents described below, the first three of which are to be completed and returned. All are also available from the Orion Canada website here.
Stage 1 Preliminary Review
1. Documentation Review - Submission Requirements
Please review this list carefully. It is set up as a checklist for your convenience. You may submit your documents or website references through an upload link provided by Orion or submit the documents directly to your auditor by email.
If you are unsure as to whether a document you have is the correct one to meet the requirements, please contact your auditor.
2. Teaching Qualifications Summary (TQS for short!)
It is very important to the success of your audit that the Teaching Qualifications Summary be completed fully and correctly. Your auditor will use it as a checklist to verify that your teaching staff, including the Academic Leader(s), meet the LC Standards in a number of categories.
NOTE: It is in your best interest to go through the following steps at the time of hiring and have the copies available for compliance procedures.
It may take some time to gather the documents from your Academic Team, so please inform them about what is required as soon as you receive the form!
You will need to:
- Collect the educational and professional qualification documents from Academic Leaders and all teachers for all language programs (including full time, part time, contract, seasonal, etc.). This includes the degree and TESL certificates and an assessment by a recognized body, such as WES, ICAS, IQAS, etc. if the degree is obtained outside of Canada.
- Photocopy or scan them
- Initial them verifying that you have seen the original and that this is a true copy.
To determine exactly which documents specific teachers and staff must bring in, please consult the educational and professional requirements per the LC Standards, which can be found on the Orion Canada website here.
LCS02 Academic Staff Qualification and Specification
In most cases, two documents will be required:
Evidence that Academic staff hold a Bachelor’s Degree (or equivalent, if from a non-Canadian University). If they also hold graduate degrees, those documents, along with the Bachelor Degree should be collected and the information added to the TQS. Acceptable documents include:
Copy of the original document, showing degree granted, major/subject area, institution, and date. Ensure that you record the location of the institution if it is not displayed on the document.
An official transcript from the Institution, indicating completion of the degree requirements as well as all the above information.
If the instructor has recently completed the requirements but has not yet received the degree, Orion will accept a letter on official letterhead from the Dean/Director of the program, indicating successful completion of the requirements and the date that the degree will be conferred.
If a degree was earned outside of Canada, an assessment must have been done to ensure equivalency to a Canadian credential and must be included with the other documents. Ontario uses WES and CES; IQAS covers Saskatchewan, Alberta and the Yukon; British Columbia uses ICES; Manitoba’s is WES and CEFAHQ (Centre d’expertise sur les formations acquises hors du Quebec) does these for Quebec.
Evidence the Academic staff holds the professional qualifications for teaching English/French as a second languages, as required by the Languages Canada Standards (equivalent to 100 hours Methodology + 20 hours of practicum in Institutions offering TESL Training). In the case of Academic Leaders, evidence of TESOL-Q qualifications or equivalence must be documented and submitted.
TESL professional associations in many provinces provide accreditation for instructors as a condition of membership. Evidence of such membership does not satisfy the LC requirements; your auditor will need to see the actual certificate, diploma, or transcript from the educational institution.
If your instructors are certified teachers in your province’s public program system, they must still have a TESL Certification that meets Language’s Canada’s requirement. Records generated from your province’s College of Teachers qualifications website may not provide all of the information needed: please have your instructors bring in the required documentation from the educational institutions.
LCFO8 Teacher Qualification Summary (TQS)
This will take some time, but once it is done, this document will be used in all future audits and you will only have to update it periodically, preferably annually when you conduct your internal review. No template other than this one will be accepted for review. Please do not change the form to another format, size or software application. Do not delete any columns. Do not remove entries already approved; your auditor may do that on the final version if necessary.
Ensure that you have completed all fields with all details and return it to your auditor. If the information is incomplete, your auditor will return it to you with notes.
Filling in the TQS Chart:
| Audit Requirement | Standards & Compliance Details | |
|---|---|---|
| Names | In the first column, list the teachers’ full names. For Academic Leaders, include those personnel who directly supervise language teachers, and who are therefore required to possess a minimum of TESOL-Q (or an equivalent combination of TESOL-I with documented relevant and ongoing professional development) as prescribed in the Languages Canada Professional Development Specifications. | |
| Full or part time | In some programs, these categories may overlap with permanent vs. casual employment status of instructors. In others, all instructors are employed on limited-term contracts, regardless of the number of hours per week that they teach. For the purposes of this chart, please indicate here as Full-time (F), those instructors who normally teach what is considered to be a full teaching load in your program, and as Part-time (P) those instructors who teach less than a full teaching load. if an instructor has full-time employment status but only a partial teaching load due to other duties (curriculum development, leadership, etc.) indicate that person as full-time. | |
| Employ date | Please indicate “original date of hire” and not just the period covered by this report. In future updates, you can also indicate here the date that person left your employment. | |
| Juniors | Some programs, especially in the summer, hire personnel for special programs for students under the age of 16: “Juniors.” These instructors, depending on the nature of the program, may not be required to meet all the of the LC educational and professional standards for ESL instructors. In this column, please just indicate with “Y” or “N,” whether the instructor teaches only Junior students; this will help the auditor to determine if their qualifications meet the standard. As well, Languages Canada requires that any staff responsible for students who are 15 years of age are under, provide a Criminal Record Check AND the completed Declaration Regarding Suitability to Work with Minors. Please note that all Academic staff who teach or otherwise take responsibility for Junior students (e.g., on activities, trips, etc.) must have these documents in their file. | |
| Undergraduate degree | Record this information from the original documents for each person: a) ABC University b) Toronto, Ontario c) 1996 d) BA, Eng/Fr. If the instructor or Academic Leader has been awarded an equivalency from another jurisdiction, enter the Canadian equivalency and granting agency information below this information. | |
| Type of tesl | Enter the name of the TESL Certification, e.g., “TESOL Diploma,” “ESL Part 1 Additional Qualification,” “TESL Courses 479 & 489”, CELTA, DELTA, TESL Canada Level 1, etc. | |
| Tesl institution | Follow the format to include the Name of Institution, the location and date | |
| Years experience | For the TESL Certification named in the previous column, indicate the instructor’s total years of ESL teaching experience, not only their teaching experience at your program. | |
| Other qualifications, advanced degrees | Any other relevant educational and professional qualifications may be recorded in this column, including those from other jurisdictions, whether or not a Canadian equivalency has been granted. | |
| Evaluator comments and verified | Leave the last two columns blank. They will be completed by your auditor. At the site /remote visit, the auditor will check the records to confirm the information that has been provided on the TQS and will indicate in the “Verified” column, whether or not the person’s educational and professional qualifications meet the LC standard. This completed version of the TQS will be returned to you with the On-Site/ Remote report. |
3. Audit Plan
Your auditor will send you an audit plan detailing the logistics for the audit. Included in the plan will be suggested times for meetings, areas or topics being covered along with any other resources required. During these meetings, the auditor will ask questions to confirm the points on the Audit Checklist (see below) and will review relevant documents.
Please review this document when you receive it, make changes as indicated below, and return it to your auditor.
Assign your program’s personnel, with their appropriate titles, to the pertinent sections.
Review the suggested meeting times and adjust, in communication with your auditor, to suit your program’s schedule. (For example, many programs find it most convenient to schedule Teacher and Student focus groups around the lunch break; certain administrative personnel may be available only before versus after lunch.) It doesn’t matter when the meetings occur, just that they do.
Indicate if any sections are N/A, e.g., if your program does not offer a Homestay service, or a Juniors Program (see Exclusions).
4. Audit Checklist
This detailed document will form the basis for the audit. Your auditor is required to verify in the Y or N boxes, whether evidence has been provided that the standard is being met. Some of this is done during the Preliminary Review of documents, and will be so indicated, but the auditor will still need to see and discuss the ‘hard’ evidence for these sections.
The Audit Checklist contains instructions and advice for the auditor. As the audit is a transparent process, you can see what the auditor is required to ask for and double-check. This can help you to be prepared with the appropriate evidence and documentation.
You will notice that there are some comments, in blue-coloured font, that pertain only to Public Sector institutions (typically universities and colleges). They guide the auditor in taking account of the various ways in which larger educational institutions may provide evidence of standards being met, authority over which may not rest with the English or French Language Training program itself. Private Sector programs may ignore these comments.
It is highly recommended that you distribute the checklist, or the relevant sections of it, to the staff responsible for the various components of the standards, so that they are able to prepare well for the audit visit. In some cases, the Standards refer to Codes and Best Practices Documents with which program staff are expected to be familiar.
Please provide them with these, or direct them to the Languages Canada website, before the day of the audit!
Submitting the Documents for Preliminary Review
Complete the TQS
Upload/Return
Reserve
the required rooms or times for focus groups,
auditor’s work/meeting space if necessary, and
opening and closing meetings
You Will Receive or Discuss:
- Preliminary Report identifying any areas which should be focused on during the audit meetings
- The finalized Audit Plan constituting the schedule for the audit meetings
Audit
Audits are conducted to ensure that the program or organization conforms to standard requirements and is capable of continued compliance. To do this, auditors must collect objective evidence through interviews, observation, reviews of documents, records, policies and procedures, analyze the information and make a recommendation. Note that auditing is based on sampling process, so the recommendations are only based on the evidence sampled. The following steps outline the audit process.
Things to make sure of:
Documents
Staff
All of the relevant staff are available and ready to address the auditor.
LC Codes of Ethics
Opening Meeting
The day of your audit should begin with a brief meeting with the auditor, the program Director and possibly any key people involved in the audit. The purpose of this meeting is:
- To make introductions
- To explain the auditor’s goals and the audit process
- To explain what the outcomes of the day will be
- To confirm the resources and logistics (times of meetings, room, etc.)
- To answer questions about the process
Facilities Tour*
The best time for the tour (on-site or remotely) of the program facilities is usually right after the opening meeting. On this tour, the auditor will need to see:
- Some classrooms
- The teachers’ room / work area and resources available
- Fire /emergency exits and signage
- Washrooms
- Location of student records and confidential files
- Student and teacher library / resource rooms
Meetings with Staff Members
At a minimum, your auditor will need to meet with the people responsible for the following areas, to discuss:
| Department | Responsibilities |
|---|---|
| Academic Program | Sections E: Academic Staff and F: Curriculum of the Audit Checklist |
| Student Admissions | Section C of the Audit Checklist |
| Student Services |
The people responsible for:
The auditor will require access to the active homestay files to draw a sample, checking for appropriate documentation and communications per the Audit Checklist. Please make paper or electronic file storage available to the auditor. The auditor must select the sample files; do not pre-select files for the auditor to view. |
| Junior Programs D.5 | The auditor must be shown the job descriptions and Declaration of Suitability for Working with Minors and a CRC for personnel with responsibility for junior students (15 years or younger) |
| Marketing / Recruiting | Please ensure all clauses noted for agent agreements are included in your agent contract. |
| Administration | The auditor will need to meet with the Director or a senior administrator of the program, who can answer questions about leadership structure, human resources policies and practices, program review, facilities. |
The auditor will require access to the active homestay files to draw a sample, checking for appropriate documentation and communications per the Audit Checklist. Please make paper or electronic file storage available to the auditor. The auditor must select the sample files; do not pre-select files for the auditor to view.
Focus Groups
The purpose of the Focus Groups is to gather the students’ and teachers’ perspectives on aspects of the standards. They will be asked about their knowledge and experience with a range of program policies and procedures, about the support they receive, problem resolution, resources available, and will be given the opportunity to voice their views of the program’s strengths and areas for improvement.
The contributions of students and teachers in focus groups are kept confidential. General points are summarized in notes at the end of the On-site Report, but statements attributable to one particular individual are not included.
6 – 10 people is a good size for both the teachers’ and students’ focus groups. The groups should be representative of both ‘older’ and ‘newer’ students and teachers, those in different levels, and full / part-time (if applicable). Many programs find it convenient to schedule the focus group during the lunch period. Others find a time to release teachers and/or students from their classrooms for the half-hour of the focus group.
Your program may or may not choose to provide lunch / snacks for the focus group participants. You should make whatever arrangements will facilitate the best, most representative participation of the students and teachers in your program.
Lunch
Some auditors may choose to work through lunch in order to meet the timelines of a one-day audit. Others may schedule a lunch break. You needn’t provide lunch for the auditor.
Closing Meeting
- Discuss the findings of the audit in each area, including strengths, opportunities for improvement, and issues identified, (if any
- Explain what will be required to resolve the issues and the timelines
- Present the auditor’s recommendation (to accredit or not to accredit)
- Explain the next steps in the process (production of on-site/ remote report, resolution of issues, final report, technical review, issuance of certificate
- Address questions
The Report
1. Summary and Recommendations
| Strengths | Areas of the Standards in which your program’s practices are exemplary or very successful will be highlighted here. |
| Issues | Here you will see a number, indicating how many Issues the auditor has found that indicated nonconformance with the LC Standards, and that must be resolved before a recommendation can be made to accredit. |
| Opportunities for improvement | Specific standards, identified during the Audit and documented as per the numbering in the audit checklist, will be noted in which your program’s practices have met the minimum requirement, but in which opportunities exist to do so in a more efficient, thorough, or sustainable manner. If you chose not to address these, your accreditation will not be in jeopardy, but it may improve your services to students and staff. |
| Recommendation | The auditor’s conclusion as to whether the LC Standards have or have not been fully implemented, and whether accreditation is recommended. If significant issues are identified with accredited members, this may include a recommendation to suspend or revoke accreditation. |
2. Assessment Details
This section lists the date and other data from the on-site/ remote audit.
3. Issues
This section of the report will provide details on the number of issues identified in Section 1. The results are presented in Table format.
| Issue # | This is simply a numerical list. The number of Issues identified in this column should match the number of Issues reported in Section 1. | |||
| Area/element | This will identify by letter and number as per the Audit Checklist, the Standard and the Additional Specification (If any) to which your program’s practice does not conform. | |||
| Issue | This column states what the Issue is, specifying in what way your program’s practices do not meet the standard. | |||
| NCR classification | Depending on the nature of your findings, the issue will be classified as either a Major nonconformance (NCR) or a Minor nonconformance. | |||
| Major NCR’s |
Typically occurs when:
| |||
| Minor NCR | Typically occurs when there is a minor breakdown of the system, control or procedure. | |||
| Closure due date | This will give the latest date by which the Issue must be resolved. |
| Verification by evaluator | In this column, the auditor will note how your program has resolved the Issue, and what evidence has been supplied. The auditor will indicate the date and will initial to indicate that the evidence has been verified. |
2. Additional Information
A. Areas Reviewed:
This is a listing of the sections and sub-sections of the Standards, indicating that all have been reviewed.
B. Student Focus Group
C. Teacher Focus Group
Here, the number of people who participated in each Focus Group will be noted, and the main themes of the discussion will be briefly summarized.
In order to keep the discussions confidential and frank, no information will be presented that would identify an individual’s specific contribution.
Resolution of Issues
Issues identified during the Pre-Assessment / Documentation Review must be resolved within the timelines specified in the Report.
As you submit evidence resolving the Issues, the auditor will track this on the table in Section 3 of the report. The completed table will be submitted to Orion Assessment Services as part of the Final Report.
For new LC Members, you should have up to 14 weeks to resolve Issues, unless you have requested a delay in the date of your audit, later than originally suggested by your auditor. This is based on the typical timespan required for an instructor to obtain an LC-approved TESL Qualification.
No extensions will be provided for the resolution of Issues, if by your own request you delayed the date of your audit, leaving you fewer than 14 weeks to resolve the Issues.
Issues identified during the audit must be resolved within the specified timeframe. If follow-up visits are required to resolve these issues, the LC member will be charged accordingly.
| Major NCR’s | Within 30 days of the last day of the audit, LC Member must complete the Orion’s Nonconformance form detailing the correction, root cause and the steps taken to prevent reoccurrence. Afterwards, new LC Members have 120 days to prove the issue is resolved, whereas existing programs have 60 days. Programs that don’t address the nonconformances within the given timeframe may have their accreditation status suspended or terminated. |
| Minor NCR | For minors NCR’s, the LC Member has up to 30 days to close the issue(s). The NCR will be upgraded to a Major nonconformance if not closed within the given timeframe. Members do not need to complete Orion’s Nonconformance form. |
NOTE:
Please note that, if you have completed a reAccreditation audit, the Closure Due Date for resolution of Issues will generally be up to four weeks before the expiration of your program’s Accreditation Certificate.
Time is required, after the resolution of the Issues has been verified by the auditor, for the Final Report to be prepared, submitted for Technical Review, and for the Recommendation to Re-accredit to be issued.
Please do not count on having until the date of your program’s Certificate expiry to resolve issues!
A second visit by the Auditor may be required to verify the resolution of some Issues. You will be notified by Orion about additional charges that may apply in this case.
Final Report
Once all of the Issues have been resolved, the auditor will so indicate in Section 3 of the report, will revise the number of Issues to ‘0’ and change the Recommendation to Accredit in Section 1, and will submit the changed report as a Final Report to Orion Assessment Services.
Technical Review
A second Orion auditor will review the Final Report to confirm that the audit has been properly conducted and sufficient objective evidence collected to support the accreditation decision. If any errors are discovered, your auditor or another member of the Orion team may contact you to clarify any concerns.
Issuance of Accrediation Certificate
After the report of the Technical Reviewer has confirmed the auditor’s recommendation to accredit or not to accredit, this recommendation will be forwarded to Languages Canada.
Note that aside from your accreditation recommendation, the specific results of your audit are confidential and will not be shared. At this stage, a copy of the final report will be emailed to you.
1. If your program is accredited:
If your program is a Full Member of Languages Canada, you will be authorized to use the Languages Canada logo in your promotional material and on your website, subject to the terms and conditions set out by Languages Canada. Orion will also send you a pdf copy of your Accreditation Certificate, which you may proudly display at your program premises
2. If your program is not accredited:
The reasons for the decision not to accredit should be clear as a result of the audit process. Your program may work on resolving the identified issues and may re-apply for accreditation after twelve (12) months. This will be treated as a new Accreditation application, and the regular accreditation processing fees will apply.
A second visit by the Auditor may be required to verify the resolution of some Issues. You will be notified by Orion about additional charges that may apply in this case.
Complaints/Appeals
Audit
| If your program is not accredited | Suspension is typically recommended when significant non-compliance issues are identified. The reasons for the suspension and the timeframe to close the issues should be clear as a result of the audit process. A maximum of 30 days will be given to resolve the issues. When suspension is recommended, Languages Canada will be notified of this decision and will then take any necessary actions. During this timeframe you must refrain from marketing or promoting your accreditation until the suspension has been lifted. You may also choose to appeal the decision. The process for filing an appeal is described in the Appeal / Complaints section. |
| If your program is terminated | The reasons for the decision will be clearly communicated. If the termination occurred because you were not able to address the issues identified in your audit, you may re-apply for accreditation after twelve (12) months. This will be treated as a new Accreditation application, and the regular accreditation processing fees will apply. If the termination occurred due to lack of payment, significant safety concerns for students or to unethical behavior, Orion may choose to not accept future applications for Accreditation. A program that has been denied accreditation has the right to appeal the decision according to the procedures outlined below. Any dispute or appeal referring specifically to Orion Assessment Services of Canada (Orion) and not to the content of the program audit will be reviewed by Accreditation Advisory Board. |
Procedure to Set Up an Appeal:
| Written notice | A program wishing to appeal an accreditation decision is required to send written notice of the intent to appeal to Languages Canada within fifteen (15) working days of receiving official notification of its status from Orion. To file an appeal, you may either contact Languages Canada or file your appeal through the dispute resolution request process on www.orioncan.com |
| Review of the appeal | Languages Canada will review the nature of the appeal, determine ownership of the appeal process and allocate to the appropriate body, either Languages Canada or Orion Assessment Services, as noted above. |
| Programs and fee | Members are required to send complete details pertaining to the appeal, along with the fee specified in the Accreditation Appeal procedure within fifteen (15) working days of sending their notice of intent to appeal. For rejected appeals, the fee shall be retained by Orion to be used to compensate the new evaluator and to cover the costs associated with the Accreditation Advisory Board review. Where an appeal is upheld, the Appeals fee will be refunded. |
| Evaluation | Upon receipt of the details of the program’s appeal of the accreditation decision or process and the applicable fee, the President of Orion Assessment Services will appoint an evaluator not involved in any part of the initial review, to review the file and determine the accuracy of the initial accreditation decision. |
| Examination of documents |
In reviewing the file, the evaluators will examine emailed copies of:
|
Please Note: Reports from other accrediting bodies will not be considered.
Review by the advisory board
The independent evaluator will forward the report to the Accreditation Advisory Board for review and consideration within 15 days of receiving the emailed documents from the program.
Decision
The Accreditation Advisory Board will inform you of the decision, in writing, within fifteen (15) working days of receipt of written report from the evaluator.
NOTE:
With respect to a previously accredited program that is under appeal, the program maintains its status as an accredited program during the appeal process. Should the appeal be rejected, the program is immediately deleted from the LC list of officially accredited programs and must cease to use the LC logo in its publicity materials and marketing.
All rejected programs may re-apply for accreditation twelve (12) months following the appeal. Please note that the application will be deemed to be a completely new application and will be charged full accreditation processing fees.
Accreditation Advisory Board decisions regarding appeals are final.
Maintaining Accreditation
Two Year Maintenance Reviews
In order to ensure that all accredited programs continue to maintain the standards, every accredited program is subject to a Maintenance Review two years after the initial On-Site/Remote or Re-accreditation visits.
This consists of an update report on selected areas of the standards that you can complete and submit electronically. An on-site visit is generally not necessary for a Maintenance Review. Just prior to the two-year anniversary of your initial Accreditation date, you will be contacted by an Orion Assessment Services auditor, asking you to complete an information update form and to submit certain documents.
This will consist of six sections:
| Table Header | Table Header | Table Header | Table Header |
|---|---|---|---|
|
Overview of Program Changes |
List any programs that your program has added, or ceased to offer, in the last two years (including Junior programs). This might include, for example, test preparation programs, programs with a special focus such as English for Academic Purposes or ESL Literacy, or special summer programs. |
||
|
Enrollment |
Fill in the number of classrooms and teachers you currently have, and indicate your program’s % increase or decrease in student enrollment over the past two years. |
||
|
Staff and Career Development |
A. Teaching Qualifications Summary Using the form that you submitted as part of your initial Accreditation, update it with information for all new hires, even if they have come and gone within the two years. Please also submit scans of the degree, TESL and assessment body’s review of foreign degrees (if relevant) documents that provide evidence that these new hires meet the LC educational and professional qualifications standards. Tip: Have new hires bring in their documents at the time of hiring, copy and initial them and keep them in their personnel files. Indicate which Academic staff are no longer working for your program by entering the last date of their employment and termination in the ‘Employ Dates’ column. B. Professional Development List all academic and non-academic staff professional development opportunities provided or funded by your Program in the past two years. This could include: in-house workshops, conferences that staff have received support to attend, other on-the-job development (e.g., hosting student teachers, conducting action research). It does not include activities that staff undertake on their own initiative and expense, nor as part of their regular duties (such as orienting a new employee). |
||
|
Reports of Annual Internal Review, Curriculum and/or Operational Reviews |
Briefly summarize, providing dates, the latest annual internal review, curriculum or organizational and area review undertaken by your program. |
||
|
Follow-up |
Opportunities flagged for further review as a result of your initial Accreditation or ReAccreditation audit may be listed here. |
||
|
Other Items |
In this section, you may add any other developments or changes relating to your program’s operations and the Standards; for example, if you have ceased to offer your own homestay services and have begun to use a Homestay Provider company; if you have gone through a facilities renovation, etc. You will receive a Maintenance Review Report containing your information, and indicating if any new Issues have been identified as a result of the review (for example, if a newly hired teacher lacks the LC-approved credentials). |
If there are any Issues to be resolved, they will be indicated in the report. The auditor will set a date for the resolution of these issues, in consultation with your program. It should be as soon as practically possible in order not to risk revocation of your accreditation.
An on-site visit for the two-year Maintenance Review may be occasioned by:
- Evidence arising from the Maintenance Review Report that an Issue has been identified and not addressed (e.g., failure to submit evidence of approved credentials for new hires)
- Inability to confirm a requirement has been met via the remote review
Internal Audit
As a Languages Canada Member, you must conduct your own internal audit annually. The purpose of this audit is to ensure the program is effectively implemented, maintained, and conforms with requirements of LC Standards as well as your program’s own requirements.
The criteria for conducting the audit are to be planned and carried out by competent auditors independent of the activities being reviewed.
Records of the audits should include:
- Date of Audit
- Auditors
- Areas Reviewed
- Results of the audits (positive aspects / deficiencies and areas for improveme
The results of the audit are to be communicated to the person responsible for the program and serve as input to the Operational Review. A suggested approach for your internal audit is to follow the guidance for “Preparing for an Audit”.
Risk-Based Compliance Visits (Spot Checks)
These visits are used to:
| Ensure compliance | is maintained by a random selection of member programs for spot checks. |
| Investigate complaints | from students, agencies, or government regarding members not respecting standards between audits (e.g., to overcome staff shortages during Summer programs). |
| Follow-up | to support programs who experience recurring issues arising from accreditation, or newer programs that require additional reviews as they become more familiar with the quality requirements. |
| Ensure compliance | is maintained when major changes have been made to resources, premises or programs. |
| Track compliance | with specific standards, support government compliance mechanisms and support continuous quality improvement. |
Programs selected for review will be based on a combination of random sampling along with a riskbased methodology to determine priorities. As an example, a program with a formal and verified documented proof of non-compliance, history of re-occurring issues or newer programs may be considered a higher risk and subject to a potential inspection.
The spot check is not a full inspection and auditors will not look at all areas covered by the criteria but will concentrate on specific areas based on the risk assessment or previous audit history. Twentyfour hours notice is provided to ensure the proper resources are made available for the auditor. Upon arriving on site, the auditor will conduct an opening meeting with the person responsible for the program, explain the focus of the review and the resources and records to be reviewed. After the review is complete, an overview will be provided detailing any findings, positive aspects, or areas for improvement.
This will also be documented in an Audit Summary Report. After, the results of the investigation will be sent to the Orion management team to review and determine a course of action, if any. If there are major issues, the program may be suspended until the issues have been addressed or withdrawn. If subsequent visits are required to resolve any issues, the program will be charged at the current day rate plus any out-of-pocket expenses.
Special Circumstances
Termination of Accreditation
Termination of Accreditation is one of the conditions specified under the Terms and Conditions agreed to between Orion and the accredited program.
Termination of Accreditation may result from:
- Failing to resolve Issues identified during the Onsite, Maintenance, or random/risk-based sampling audits, or to present verifiable evidence to the auditor that the Issue(s) has/have been resolved
- An unsuccessful appeal of an audit decision not to re-accredit
- Breach of the Terms and Conditions for Accreditation
- Unethical behavior or any situation that may potentially place student safety at risk.
- Misrepresentations and falsification of statements, records or other evidence
Should this situation occur, your accreditation status will terminate immediately, and Languages Canada will be informed of the decision. At this point you must refrain from marketing or promoting your accreditation in any fashion. This includes removing your accreditation status from any electronic or hardcopy-based media and informing those who rely on your accreditation status (e.g., agents) that your accreditation has been revoked.
Should you wish to appeal the decision, you may file an appeal per the Complaints / Appeals procedure.
Transfer of Ownership
(This process is also summarized in the Transfer of Ownership Scheme document on the Orion Canada website).
When a program or organization is sold to another firm, the accreditation status is not necessarily transferable. Organizations often undergo key changes to management and operations when changes in ownership occur.
The transfer of ownership process is broken down into two steps which include an accreditation review and a financial review. To start the process, you will need to inform Orion of the transfer, including the name and address of the program or programs along with the contract details for the purchaser. Orion will then provide you with an engagement letter outlining the costs of the accreditation review. At the same time, your information will be sent to Toronto CA Solutions, so they can prepare the engagement for the financial review.
A transfer review is required to ensure:
- The new management is committed to Languages Canada and the Accreditation Scheme.
- The transition is properly planned and managed.
- The accreditation requirements remain intact.
- The new ownership is fiscally sound to protect the liability of Languages Canada, its members, and students.
- Key staff fully understand the requirements imposed on them.
Termination of Accreditation
A transfer plan must be submitted to Orion in writing which includes:
- New or proposed organization chart
- A training plan to ensure the new ownership understands their responsibilities and the Languages Canada Accreditation requirements
- Changes to any processes
- Timing of transition
Orion will review the transition plan to ensure there will be no major potential impacts on the accreditation requirements. If there are, a formal letter will be issued outlining any concerns. If the plan is acceptable, within 4 to 8 months after the ownership transfer, Orion will conduct an Audit to ensure requirements of the Languages Canada standard are being met, along with the action items stipulated in the submitted plan.
A report will be issued including:
- On-Site Review Report detailing Strengths, Issues, and Opportunities for Improvement.
- The recommendation regarding accreditation.
Financial Review
Toronto CA Solutions, a professional accounting firm, will assess the financial stability of the acquirer as well as the financial sustainably of the entity as a whole. The main purpose is to ensure the purchaser has the required resources to ensure continued operations of the program. A report detailing any issues, and a recommendation will be provided.
As part of the financial review, the following information will be requested.
1. From Acquirer
- Most recent externally prepared financial statements
- In-house financial statements for the current period
- Post-acquisition balance sheet
- Cash flows and financial projections
- Business Plan
2. From Acquired Program:
- Most recent externally prepared financial statements
- In-house financial statements for the current period
- Cash flows and financial projections
- List of current registrants and forecasted registrants
- Any lending agreements from financial institutions (lease agreements, promissory notes, lien agreements, and agreements which will disclose priority claims over assets.)
3. From Languages Canada:
Financial statements of at least 3 programs which have been operating successfully for the past 3 to 5 years.
From these financial statements we will be able to determine the benchmark ratios (debt to equity, working capital, etc.) against which the new owner’s financial statements will be measured.
Fees
Current information about fees can be found in the Application documents at Orion Canada’s website, or by inquiry to: info@orioncan.com.
Confidentiality
The confidentiality of your audit results and recommendation, the documents, processes, and conversations that form part of the audit, and of communications between you and your auditor, are assured. To ensure your audit is confidential and free of any conflicts of interest, the Orion teams, including contractors, are bound not only by the confidentiality requirements in our Nondisclosure agreements with all staff, but also our Privacy Policy, Gift Policy and Statement of Impartiality.
Details are as follows:
Information considered confidential and proprietary includes:
- Audit data (e.g. results of reviewing documents,
- Unpublished goals, forecasts or initiatives that are marked as confidential
- Data entrusted to the company by external parties
- Documents, processes or other elements explicitly marked as confidential
- Any other knowledge acquired by employees during their employment
In the course of their employment, Orion employees and contractors have various levels of authorized access to confidential information so as to conduct their business. When they do so, the following rules strictly apply:
- Information will not be disseminated to anyone outside of the organization
- The disclosure of information will be limited to those with authorized access and legitimate reason to require that information
- The information will not be used for the personal benefit or profit of the employee or any other except the company
- The employee will have access only to the amount and type of information required for the completion of their job responsibilities and no more
- Information collected during audit reviews will be limited to what is necessary to validate the implementation of a particular requirement
- Employees must limit to a minimum the occasions when they take confidential information out of the office
- When perusing or sharing information through electronic means, all precautionary safety measures must be in effect
- Confidential information must not be left unattended or unlocked
- All copies of confidential documents must be shredded when no longer needed
- Upon separation of employment all confidential information must be returned or deleted from the employee’s electronic devices.
Orion will take measures to ensure that confidential information is well protected. Those measures include but are not limited to:
- Electronic information will be encrypted
- Computers or portable equipment carrying confidential information must be password protected. Unattended devices must be locked and not accessible
- Databases will be protected with all available security measures
- Paper documents will be safely stored and locked (if any)
- Authorization of access will be carefully controlled, usually by senior management
- Employees and contractors must sign a non-disclosure agreement (NDAs) as a condition of employment.
- Confidential information as described abovemay occasionally have to be disclosed for egitimate reasons, e.g. upon request of a regulatory body or for business purposes. In such cases, a strict procedure must be followed that includes the explicit consent of parties involved (unless they are faced with criminal charges) and the disclosure of only relevant information and no more.
Disciplinary Consequences
The company places great importance in this policy. Any non-conformity will bring about disciplinary and, possibly, legal action. The company is prepared to terminate any employee who willfully or regularly breaches the confidentiality guidelines for personal profit. Serious offenses such as theft of information, illegal disclosure of sensitive data etc. will be grounds for immediate for-cause dismissal and may also involve legal consequences.
Any unintentional breach of this policy will be thoroughly investigated and will be punished appropriately depending on its magnitude and seriousness. This policy is binding even after separation of employment.