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How To Guide 7 – The ASES Assessment Report and Quality Action Plan

How To Guide 7 – The ASES Assessment Report and Quality Action Plan

This module outlines what happens after the External Assessment site visit. The main topics covered are:

  • Responding to the Draft External Assessment Report
  • Developing and implementing the Quality Action Plan
  • Receiving the ASES Certificate of Accreditation and logo
  • Example report templates

Responding to the Draft External Assessment Report

The role of the External Assessment Report

The External Assessment Report is an official record of the external assessment of your organisation in relation to the ASES. It includes the evidence submitted with your self-assessment and evidence collected at the site visit by the External Assessor,[1] as well as recommendations for improvement.

The ASES Certificate of Accreditation is granted only when the External Assessment Report and the Quality Action Plan indicate that your service has met all of the ASES Standards and requirements.

Key people in your organisation should review the Draft External Assessment Report and consider whether any feedback is warranted. The time frame for submitting feedback is usually only a week.

The draft report should not present any surprises as Assessors share and test findings as they emerge during the site visit and present a summary of findings at the closing meeting.

Process and time frames for completing the ASES External Assessment Report

The table below outlines the process and time frames for developing and completing the ASES External Assessment Report.

Weeks Step Time frame Report development stage
Week 1* 1. Up to 3 weeks after the last day of the site visit The Assessor provides the organisation with a Draft External Assessment Report outlining the:

  • assessed ratings for each requirement of the ASES
  • the rationale for the rating
  • recommendations for improvement.
Week 2
Week 3
Week 4 2. One week after receipt of the Draft External Assessment Report The organisation reviews the report and may provide evidence-based comments about any areas of disagreement.

If there are no comments, see step 4.

The report is submitted to the SA DHS for a quality check before it is accepted as final.

Weeks 4-5 3. As soon as practicable upon receipt of comments, if any – up to one week The Assessor and the organisation discuss the comments and an agreed position is integrated into the draft report
Weeks 5-6 4. As soon as practicable after the integration of comments, if any – approximately 1-3 days The Assessor provides the draft report to the ASES Team within the SA DHS for a quality check.
Week 6 5. As soon as practicable upon receiving the draft report The ASES Team within the SA DHS undertakes a quality check. Any issues are addressed as soon as practicable by the Assessor. After a final quality check by the ASES Team, the report is approved as final. The osrganisation and the Assessor then work together to develop a Quality Action Plan, if one is required.

* All of the time frames indicated in this section are the maximums allowed for each step.  In practice, most of these steps take less time than indicated here. The SA DHS requires the submission of the External Assessment Report and Quality Action Plan six weeks from the last date of the site visit.

Structure and content of the External Assessment Report

The report headings and structure reflect the report template set by the SA DHS. The main sections are:

  • Cover page
  • Assessment scope and focus
  • Executive summary
  • Summary table of ratings by Standard
  • Recommendations section
  • Detailed findings section.

See the Example Report Templates section below for an example of the External Assessment Report template.

Findings and ratings

All of the findings from the Assessor’s analysis of the evidence are ‘translated’ into one of the three ratings for each requirement:

  • Fully in place (FIP)
  • Partially in place (PIP)
  • Not in place (NIP).

All requirements must be fully in place to achieve ASES accreditation.

Essential and Continuous Quality Improvement recommendations

There report will contain two types of recommendations:

  • Essential Recommendations – a gap has been identified and the organisation is required to implement the recommendation as part of its Quality Action Plan (QAP).
  • Continuous Quality Improvement (CQI) Recommendations – a potential area for CQI that can enhance the performance of the service has been identified. These recommendations are optional.

Most organisations welcome CQI recommendations as opportunities for growth and further development.

Essential and CQI recommendations are identified as such in the report. Essential Recommendations are direct in their language (e.g., It is recommended that …) whereas CQI recommendations are framed more as issues for consideration (e.g., The Board could consider …).

Commenting on the Draft ASES External Assessment Report

You will be invited to comment usually on the Draft External Assessment Report, usually within a week.  If you consider that any of the content is factually incorrect or if there is evidence to support a different finding, you can raise this in writing. Your comments need to be objective, fair and evidence-based.

If there is a fundamental disagreement between an organisation and their Assessor that cannot be resolved through the usual steps, it is important that you raise it with the Assessor first. A large organisation is likely to have processes for escalating issues. If this is not successful or, if the External Assessor is a small service or sole trader, then it is best to seek advice from the ASES Team within the SA DHS. Their contact details are:

Phone: +61 8 8413 9036

Email: serviceexcellence@sa.gov.au

Developing and implementing the Quality Action Plan

When is a Quality Action Plan required?

A Quality Action Plan (QAP) is required only where an organisation has not fully met one or more of the ASES requirements. Most organisations do not achieve 100% compliance when undertaking ASES for the first time and require a QAP.

Like the External Assessment Report, the QAP is an official document involved in ASES accreditation, and it is retained by the SA DHS.

Your organisation and your Assessor are required to submit the QAP to the ASES Team in South Australia within 6 weeks of your last site visit.

What is in a Quality Action Plan?

The QAP is developed using a specific template issued by the SA DHS.

The QAP is populated by all the Essential Recommendations from your External Assessment Report, to address any areas where you have not fully met the ASES Requirements.

You may include CQI recommendations and other planned actions in your QAP, but this is not essential. Your QAP must clearly distinguish Essential Recommendations from other recommendations you choose to include.

How is a Quality Action Plan developed?

The QAP is generated by your Assessor but your organisation needs to detail how you will implement the recommendations, the allocation of tasks and time frames.

The QAP template has six columns for information. The first two are completed by the Assessor and the next four are completed by you organisation.

  1. Category/Standard – Assessor completes
  2. Action required – Assessor completes
  3. Responsible officer – Organisation completes
  4. Executive/Board approval (Yes/No) – Organisation completes
  5. Target date – Organisation completes
  6. Action completed/Status to date – Organisation completes (checked by Assessor).

The final column is checked by the Assessor before the whole QAP is submitted to the SA DHS.   Note that before you submit any work as part of your QAP, you need to have it approved by your Executive or Board, as it is a formal submission for accreditation.

Steps in completing a Quality Action Plan

Your organisation has six months from the last date of the site visit to complete the recommendations and actions in the QAP. However, most organisations aim to complete the actions earlier so that they can achieve ASES accreditation as soon as possible.

The Assessor will provide support as your organisation implements all the Essential Recommendations in the QAP. As you complete each step in the QAP, you need to obtain and note approval, note the action as completed in your QAP (column 6) and provide your Assessor with supporting evidence.

In most cases your Assessor can verify completion through reviewing documents and photographs but in some instances, they may need to visit your service again.Additional visits may incur an extra cost and are generally explained in the Assessor’s service agreement.


If the external assessment found that your organisation did not have a risk management policy the External Assessment Report would recommend you develop such a policy.

After developing the policy you note that on your QAP and provide your Assessor with a copy. Your Assessor will check that the document complies with the relevant ASES Requirements and, if so, will confirm that recommendation as completed, which will be noted on your QAP.

Receiving the ASES Certificate of Accreditation and logo

After you have completed all the Essential Recommendations in your QAP and these have been verified by your Assessor as fully compliant with ASES, the Assessor will provide the QAP to the ASES Team for a final quality check.  The ASES Team sits within the SA DHS.

The SA DHS is the Standards owner and makes the final decision about granting ASES accreditation. The ASES Team checks all of the documentation related to your assessment and, if acceptable, will  grant ASES accreditation and issue your organisation with a Certificate of Accreditation. The certificate is current for three years and is dated from the last day of your site visit.

Separate certificates will be issued for each of the sites within the scope of the assessment so they can be displayed on the premises. The ASES Team will also provide you with the ASES logo with instructions about how it can be used.

You may wish to celebrate this success and reward the staff and volunteers involved. Let your clients and stakeholders know of the successful outcome and thank them for their contribution by:

  • Sending letters to stakeholders and clients
  • Including an item in your newsletter
  • Publishing the news on your website
  • Speaking about the process and the outcomes of implementing ASES at interagency meetings
  • Adding the logo to signature blocks and letterheads, when appropriate.

Example Report Templates

Example: External Assessment Report

The External Assessment Report template is made up of six sections. Screenshots of some sections are provided below with a description of the purpose of each section.

Cover page
The cover page lists the particulars of the assessment, the level and scope of the assessment, the contact details of key organisational staff and key External Assessor company staff.


Assessment Scope/Focus
The assessment scope and focus page describe:

  • The background to the organisation
  • Its current structure and location
  • The services within the scope of the assessment
  • The evidence that was reviewed
  • The interviews that were held
  • The length of the site visit.


Executive Summary
The Executive Summary includes:

  • The key findings
  • A summary of the recommendations
  • Examples of best practice that were noted during the external assessment.


Summary Table
The summary table lists the Standards and identifies the total number of ratings against each Standard. Ratings are:

  • Not in place
  • Partially in place
  • Fully in Place.


Recommendations for action
The recommendations for action are listed by Standard. The list is drawn from the detailed findings in the next table.


Detailed findings against the ASES Standards and Requirements
The detailed findings record the rating for each requirement and the evidence that supports the rating.
Only the first ASES requirement is shown in this example. However, in your report, all 98 requirements will be included (if you are undertaking the Certificate Level).  External Assessment Reports are typically 80-90 pages long.  Where recommendations are applicable to other Standards, they are cross-referenced in the ‘Evidence’ column.
Example: Quality Action Plan template

The Quality Action Plan is essentially a work plan template that records the recommendations, the actions required, who is responsible, who approved the outcome or product of the action, the target date and the status of the action.






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