The QA Self-Assessment Pack

Please note: you need to register for the Pack before you can access any of its resources on the side menu.


Although an increasing number of providers and managers can see the benefits of using a quality assurance (QA) system based on gathering evidence for the CQC’s domains and key lines of enquiry (KLOEs), it is often hard to know what counts as ‘evidence’ in the first place. And it is especially difficult to work out what would be evidence for ‘Good’ or ‘Outstanding’. Furthermore, although the CQC does provide guidance on this, in many ways the amount of possible information that could be included as evidence can seem overwhelming. It is also the case that some types of evidence are ‘stronger’ than others. And having gathered all the relevant evidence, it may not be immediately obvious how best to interpret and report it in a meaningful way.

This is where the QA Self-Assessment Pack comes in. The purpose of this online knowledge resource is to guide you through the whole process of selecting, gathering, analysing and presenting KLOE evidence. There is also a lot of very helpful background information on the wider quality assurance and governance framework. In addition, it includes a simple-to-use but powerful online KLOE audit tool.[1]

The basic philosophy behind the Pack is simple: in order give your service the best possible chance of being rated ‘Outstanding’, you first need to ensure it currently has a solid foundation of ‘Good’, which is essentially the CQC’s ‘baseline’ for quality.  Therefore, the focus is on finding and presenting the essential KLOE evidence for ‘Good’.  Even if your service was rated ‘Good’ at your last CQC inspection, you need to be confident it still deserves this rating at the current time.  Once you have established the ‘Good’ foundation you can then focus on building an ‘Outstanding’ service, which revolves around being innovative, creative and committed to organisational learning. To read more about the thinking behind this approach please click here.

Using the Pack

The Pack comprises three core pieces of guidance plus an additional audit tool:

  • Building a Culture of Quality:  This online e-book is aimed at helping you develop a broader and deeper understanding of quality assurance within your sector.  It also looks at the work of the CQC in relation to QA and the importance of developing a Culture of Quality.  It is highly recommended that you take the time to read this before you begin using the other resources in the Pack.
  • Gathering essential KLOE evidence:  For each key line of enquiry there are many different types of information that can be used to evidence it.  There are no ‘right’ or ‘wrong’ pieces of evidence, but there are certain types of evidence for each KLOE (referred to as ‘essential evidence’ in Pack) that any CQC inspector would expect to find during their inspection of a service.

In the Self-Assessment Pack, such essential evidence is presented in the form of a spreadsheet-type table.  The table lists the 24 KLOEs and for each one displays three pieces of evidence from different sources.[2] The idea is that you use this as a  guide to selecting and gathering your own evidence, using a KLOE audit tool or template of your choice.

  • Writing QA Service Reports: This element of the Pack focuses on how to interpret and report the evidence once it has been selected and collected.  Just as there are no ‘right’ or ‘wrong’ types of evidence, so there are no ‘right’ or ‘wrong’ interpretations. However, as the guidance explains there are a few basic considerations to bear in mind, particularly with regard to how the evidence provided addresses or ‘validates’ each KLOE and, ultimately, each domain.

The guidance takes you through the validation process step-by-step before explaining how to present a summary of the evidence in the form of a QA Service Report, which follows much the same format as a CQC inspection report.

  • Access to Therapeia’s online KLOE Audit Tool: This provides you with a model example of how to collect KLOE evidence.  It is also a fully functioning audit tool for you to use if you do not have already have access to such a facility, or are looking for a more cost-effective alternative to the one you are already using.  The Tool is deliberately designed to be easy to use and learn.  It allows you to sort and select evidence by KLOE and domain, and to record important information such as the type of evidence, a full description of the evidence, its physical location, when it was last updated, and any actions or issues attached to it.

Registering for the Pack

Before using the Pack you will need to register and pay a one-off registration fee.  The registration process is very simple and allows you access to all the resources of the pack.  Once you have registered please return to this page and choose whichever resource you wish to start using by clicking on the appropriate button on the side menu. Register for the Self-Assessment Pack



  1. Please note: although the use of these resources cannot guarantee that your service will receive a high CQC rating from your next inspection, used properly they should significantly increase your chances of doing so. []
  2. For corroboration purposes the CQC recommends having at least three pieces of evidence for each KLOE. []