Health and Safety Audit

Transcription

1 Health and Safety Audit 1. PURPOSE 1.1 The purpose of a Health and Safety audit is to verify the validity and integrity of the health and safety management system, to identify good practice and to identify areas in need of further development. 2. SCOPE 2.1 Faculties, Schools and Departments will be subject to a health and safety audit as per the Audit Plan. The audit system has been developed in accordance with HSE publication HSG 65 Successful Health and Safety Management. The procedure is effective from 11 February DEFINITIONS Audit Team Senior manager School Lower Risk Area Audit Shall comprise a lead auditor from Health and Safety Services and an additional member of the Health and Safety Services team. A place on the audit team, as an observer, will be offered to a relevant Trade Union health and safety representative. For the purposes of this document, senior manager refers to Heads of School, Heads of Department and Research institute Directors. In this procedure the word school is used to mean school or department or area. Office, computer work and teaching are deemed to be Lower Risk areas. Areas with laboratories, workshops and manual activities are deemed to be higher risk areas. An audit is an in depth survey of the Health and Safety Management System, it is procedure and will follow document trails looking for evidence to demonstrate whether or not the management system is functioning properly and the undertakings given in the University s Health and Safety Policy are being met. Inspection An inspection is a tour of the workplace to identify unsafe acts or conditions and checks whether the area s procedures are understood by staff and students and if they are being complied with. 1

2 4. RESPONSIBILITIES Vice-Chancellor 4.1 On behalf of the Council the Vice-Chancellor has executive responsibility to ensure, that the requirements of the health and safety legislation and the University health and safety policy are complied with. The Vice- Chancellor will ensure that responsibility for health and safety is properly assigned and accepted at all levels within the University. Senior Managers 4.2 Heads of School, Department and Research Institute Directors are responsible for complying with any reasonable request for assistance and/or facilities made by the audit team and for ensuring their availability for audit within a reasonable timescale. 4.3 Senior Managers are responsible for ensuring that, based on the audit question set, sufficient documentary evidence is available on the day of the audit to enable an accurate assessment to be made by the audit team. They are further responsible for providing a separate room with sufficient space for the audit team to meet and discuss the documentary evidence provided Lead Auditor 4.4 The Lead Auditor is responsible for contacting the relevant Senior Manager to agree a mutually convenient timetable for completion of the audit. The lead auditor is responsible for ensuring that all of the administrative arrangements are in place to allow the audit to take place according to the agreed timetable. 5. TRAINING 5.1 Lead auditors will receive training as part of the development of the audit system. 5.2 Training for Audit Team members to enable them to undertake this role will be arranged by Staff Development and delivered by Health and Safety Services. Subsequently an annual training programme will be provided for new auditors. 5.3 Union reps need to have attended training before they attend an audit, The TU reps cannot attend audits in their own school/faculty. 2

3 5.4 Information on the audit will be included in the Health and Safety for Managers training course. 6. AUDIT PROCESS 6.1 The decision on the type of audit used will be based on the flow chart below. There are three potential outcomes:- Audited using full question set and also an inspection of a chosen area within the school. For lower risk areas, audit using the shorter question set, there will not be an area inspection. For low risk areas where the Faculty has achieved an average of at least 75%, then the Faculty will have one audit at faculty level using the shorter question set. At this audit it is not a requirement for all Heads of School to be present, but evidence must be available to demonstrate how Health and Safety is managed across the faculty. An Audit plan will be created at the start of each 3-year Audit Programme, detailing when each school will be audited, each year in the plan will run from August to July. The flow chart below shows this decision/outcome process Higher or Lower Risk Area Lower Risk Faculty has Average Audit Score 75% Faculty has Average Audit Score < 75% Audit at Faculty Level Audit each school individually Higher Risk Full Audit and Inspection 3

4 6.2 Each school will be audited once in line with the 2013 / 2016 plan and the scores achieved in the audits carried out in the period of 2009 to 2013 have been used to determine the type of audit they will receive. An area can also be audited where there is a concern regarding the appropriateness of the health and safety management system within that area. 6.3 The lead auditor will initiate audit of the area by writing to the area s senior manager. 6.4 Following agreement of a date and time for the audit, it is recommended that the Senior Manager should undertake a self-audit. It is further recommended that any self-audit is undertaken sufficiently in advance to enable areas of improvement to be identified and action taken before the formal audit. At this stage the relevant Senior Manager should also inform their staff that a health and safety audit is being undertaken and offer them the opportunity to contribute to the process. 6.5 The Audit Team will meet with the relevant Senior Manager and the area health and safety co-ordinator (where appointed) to go through the audit question set. If the school has a research institute, the senior manager should ensure that the research institute director is present with documentary evidence for their area. Documentary evidence provided during this process may include:- Health and Safety statement for the area Annual report and/or checklist Inspections Annual Health and Safety plan Health and safety training matrices Health and safety operating procedures Risk assessments Accident records Any other school health and safety documentation 6.6 As part of this process, for Higher Risk schools, the Audit Team will determine area(s) within the School, which will be inspected at the end of the audit; this inspection can take place at a later date. At the end of this inspection an outline of what the main findings are likely to be will be verbally communicated to the Senior Manager and/or Health and Safety Co-ordinator. 6.7 A report of the audit will be issued by the Lead Auditor, in consultation with the rest of the audit team, to the relevant Senior Manager within three weeks of the audit date. It will include recommendations for corrective actions and a target timescale to achieve these. If the Senior 4

5 Manager wishes to seek clarification or provide corrections in matters of fact on any aspect of the audit report he should contact the Lead Auditor as soon as possible. 6.8 On receipt of the report the Senior Manager will prepare an action plan to address the recommendations in the report and this should be forwarded to Health and Safety Services within 3 weeks of receipt of the report. Health and Safety Services will undertake a review of action plans within 6 months of the audit. Receipt of and completion of action plans will be reported to the Health and Safety Management Standing Committee. 6.9 If the audit score is a C or D then a re-audit of the area will be undertaken within 12 months An annual report summarising the findings of the Audit Teams will be submitted to both the Health and Safety Management Standing Committee and the Health and Safety Consultative Forum The Risk Management Consultant of the University s Insurance brokers will conduct a minimum of two audits per year. 5

6 APPENDIX 1 Ulster University - School / Department Benchmarking Audit For Information Audit Scoring The scoring system comprises separate sections each scored out of a 100 points with questions within each section specifically weighted towards key issues based around best practice and legislative compliance Total Average Score The scores attained in each Section during the Audit have been analysed to calculate a total average score. The scores in each Section and the total average score will be used by Health and Safety Services as a benchmarking tool to compare the various Schools and Departments. The total average score is represented in the bandings below: Total Average Score Banding Less than 60% D Grade 60-70% C Grade 70-80% B Grade 80% + A Grade 6