Audit of Food Hygiene Service Delivery Audit of Food Hygiene Service Delivery focusing on Focusing on Service Organisation, Service Organisation,

Transcription

1 Audit of Food Hygiene Service Delivery Audit of Food Hygiene Service Delivery focusing on Focusing on Service Organisation, Service Organisation, Management and Internal Management and Internal Monitoring Monitoring Arrangements Arrangements LA name Lambeth London Borough Council 28 th September 2017

2 Table of Contents 1.0 Introduction Scope of the Audit Background Executive Summary Audit Findings Service Organisation & Management Service Planning Service Delivery Database Staff Training and Authorisation Documented Policies and Procedures Ensuring an Effective and Consistent Service Internal Monitoring Third Party or Peer Review ANNEX A - Action Plan for Lambeth London Borough Council ANNEX B - Audit Approach/Methodology ANNEX C - Glossary

3 1.0 Introduction 1.1 This is a report on the outcomes of the Food Standards Agency s (FSAs) audit of Food Hygiene Service Delivery, focussing on Service Organisation, Management and Internal Monitoring Arrangements, conducted at Lambeth London Borough Council on the 28 th September The audit was carried out as part of a programme of audits on local authorities (LA) in England. The report has been made available on the Agency s website at: Hard copies are available from the FSA by ing the FSA at LAAudit@foodstandards.gsi.gov.uk or telephoning The power to set standards, monitor and audit local authority feed and food law enforcement services was conferred on the Food Standards Agency by the Food Standards Act 1999 and the Official Feed and Food Controls (England) Regulations This audit was undertaken under section 12(4) of the Act as part of the Food Standards Agency s annual audit programme. 1.3 Regulation (EC) No. 882/2004 on official controls performed to ensure the verification of compliance with feed and food law, includes a requirement for competent authorities to carry out internal audits or to have external audits carried out. The purpose of these audits is to verify whether official controls relating to feed and food law are effectively implemented. To fulfil this requirement, the Food Standards Agency, as the central competent authority for feed and food law in the UK has established external audit arrangements. In developing these, the Agency has taken account of the European Commission guidance on how such audits should be conducted. [1] 1.4 The Council ( the Authority ) was included in the Food Standards Agency s programme of audits of local authority food law enforcement services because of the relatively low percentage of planned interventions achieved based on data submitted by the Service to the FSA via the Local Authority Enforcement Monitoring System (LAEMS). 1.5 For assistance, a glossary of technical terms used within the audit report can be found at Annex C. [1] Commission Decision of 29 September 2006 setting out the guidelines laying down criteria for the conduct of audits under Regulation (EC) No. 882/2004 of the European Parliament and of the Council on official controls to verify compliance with feed and food law, animal health and animal welfare rules (2006/677/EC)

4 2.0 Scope of the Audit 2.1 The audit examined the local authority s (LAs) organisation, management, and internal monitoring arrangements with regard to food hygiene law enforcement. Assurance was sought that key Service food hygiene systems and arrangements were in place and effective, including suitable arrangements for the internal monitoring of official controls delivered by the Service. The on-site element of the audit took place at International House, 6 th Floor, Canterbury Crescent, Brixton, London SW9 7QE. 3.0 Background 3.1 Lambeth borough is approximately 3 miles (4.8 km) wide and 7 miles (11 km) long. At the last census the population was 303,000 and the ethnic mix is a broad one, presenting a diverse range of community needs. Brixton is Lambeth s civic centre. The largest shopping areas are (in order of size) Streatham, Brixton, Vauxhall, Clapham and West Norwood. In the northern part of the borough are the central London districts of the South Bank, Vauxhall and Lambeth. In the South of the district there are wards with both suburban and urban elements with differing levels of prosperity. Vauxhall and South Lambeth are central districts in the process of redevelopment with high-density business and residential property. 3.2 At the time of the audit, the Authority was operated through a cabinet structure with a Council Leader and a Mayor. The Council was focused on economic development, and auditors were advised that many of the discussions between officers and members took place in that context.

5 4.0 Executive Summary 4.1 This audit of Lambeth London Borough Council food safety service (the Service ) sought to gain assurance that key Service food hygiene law enforcement systems and arrangements were effective in supporting business compliance, and that local enforcement was managed and delivered effectively. The audit focused on the Service s organisation, management and internal monitoring arrangements. 4.2 The Service (within the Food, Health and Safety team) consisted of a small, dedicated team of officers who generally operated a risk-based approach to service delivery within the limitations of their resources. The team engaged in a number of business support activities and had demonstrated the ability and willingness to carry out a range of enforcement options, where necessary, to protect public health. In the last year, officers had dealt with a major national infectious disease outbreak and complex issues around the sale of less than thoroughly cooked burgers, in addition to their planned workload. The Authority reported that a recent prosecution of a national food business by the food safety service had led to a fine of 120, The Service had lost a number of staff members over the last year. This had a significant impact on the number of due food safety interventions carried out, putting at risk consumer protection and the reputation of the Authority. However, the Authority was in the process of recruiting to two recently vacated posts; recruitment to a third post was being considered. 4.4 The Food, Health & Safety Service had engaged in limited food hygiene delivery peer review activities in the form of the national Food Standards Agency (FSA) Food Hygiene Rating Scheme (FHRS) consistency exercise. Key areas for improvement 4.5 The draft Service Plan for 2017/18 did not provide a detailed estimate of the resources required to run the Service compared to the resources available to form a basis for its business planning to meet Food Law Code of Practice (FLCoP) requirements. It also failed to include the significant backlog of overdue food hygiene interventions in the work plan for the year. The Plan did not seek to meet the national intervention frequencies prescribed by the Food Law Code of Practice (FLCoP), nor did it identify a strategy to tackle the resulting shortfall. 4.6 The Service had a significant number of medium and lower risk food premises that were overdue an intervention. The increasing number of overdue interventions at these establishments posed a potential risk to consumer protection and the reputation of the Authority as a result of the possibility of those businesses changing the nature of their business operations to higher risk activities without the knowledge and support of

6 the Authority. A significant number of the overdue medium risk (C-rated) businesses were last due an intervention 5 years ago. 4.7 Performance reports to the Council Cabinet did not compare performance against the national intervention frequency standards set out by the FLCoP. As a result Service performance and the associated risks to consumer safety were not as transparent as they could be. 4.8 Officers had not yet been authorised for the Trade in Animal and Related Products Regulations 2011, limiting the Service s ability to respond quickly in the event of an incident involving illegally imported foods. 4.9 Qualitative checks on service performance had been neglected as a consequence of the prioritisation of officer time on tackling the large amount of operational work due. 5.0 Audit Findings 5.1 Service Organisation & Management The Food, Health and Safety Manager (who was the technical lead for the Food Safety Team and Lead Food Officer) was accountable to the Head of Community Safety. The Head of Community Safety was in turn responsible to the Strategic Director of Neighbourhood & Growth The Food, Health and Safety Manager managed a team of officers carrying out food hygiene, health and safety, infectious disease investigations and other non-food related duties for the Authority The Food Safety Service ( the Service ) had seen a reduction in professional posts since 2014, from 7 to 5 full time equivalent officers (FTE) in 2016/17, according to Local Authority Enforcement Monitoring System (LAEMS) figures submitted by the Authority. The Authority had reported a corresponding reduction of 0.5 FTE in administrative staff over the same period. At the time of the audit, the Food, Health and Safety Manager reported that the service had a professional FTE of 3. In addition, the team had reportedly suffered the unplanned absence and the loss of two staff in 2016 and The Service reported that it had committed all of its resource for a number of weeks to an infectious disease outbreak associated with a national restaurant chain in November This had also had an additional impact on the LAs performance against planned food business interventions No cuts to the service were anticipated at the time of the audit; the Authority was in the process of advertising to fill two recently vacated

7 posts. The Food, Health and Safety team was considering funding for a third post At the time of the audit the Food, Health and Safety Manager was overseeing the training of an officer from another enforcement team in the Authority to carry out a wider range of food enforcement work Auditors discussed the degree to which Members were aware of the risks posed to public health and the reputation of the Council by the increasing number of overdue food hygiene interventions at lower risk food businesses. Auditors discussed the potential that businesses remaining without an intervention from food safety officers, could change the nature of their operation to one that posed a higher risk to the public The Authority advised auditors that members had been made aware of these risks verbally, but that they had not been documented. The corporate risk register did outline the risk of outbreaks, but would benefit from identifying the potential for an increase in this risk as a consequence of increasingly overdue interventions at lower risk businesses. The Food, Health and Safety Service Plan was not subject to a review process by elected Members Although the Service had reported performance through a system of Key Performance Indicators (KPIs) in the past, there was no KPI reporting system in place at the time of audit. Auditors were advised that one graph of combined food, health and safety inspections carried out by the team was reported to the Council Cabinet monthly (a copy was provided). No specific food enforcement performance information was reported Auditors concluded that service performance and the associated risks to public health of increasingly overdue lower risk interventions could be made more transparent to elected Members, by regularly documenting and reporting food service performance against the national benchmarks prescribed by the FLCoP in the explicit context of those risks. 5.2 Service Planning The Service had put together a draft Food, Health and Safety Team Service Plan for 2017/18. The Plan was drafted in part in accordance with the service planning guidance of the Framework Agreement, but intervention targets for the year did not include the backlog of interventions (the Authority indicated that they had recently found this anomaly to have been the result of their database reporting only that year s overdues during the drafting of the plan). There was no comparison of the resource required to deliver the Service with the resource available, nor an outline of the strategy to deal with any shortfall The Plan did not set out to meet the intervention frequencies set out in the FLCoP. The Service had prioritised higher risk food businesses for intervention, but had no documented targets or strategy to deal with

8 compliant C-rated, D and E-rated, overdue and unrated businesses. The Food Safety Team manager did have a risk-based strategy in mind for organising interventions at category E premises as well as at overdue and unrated premises, but auditors acknowledged that the Service wanted to retain some flexibility until the outcome of the ongoing recruitment exercise was known Also absent from the plan were the organisational structure, an outline for the process of performance review (despite the review itself being present within the Plan) and an indication of the resource required for risk-based internal monitoring across all service activities The Plan indicated that the Service had a total FTE figure of 5 for food and feed A performance review had been included in the Plan but performance against targets had not been completely documented. The review had not been submitted for approval to either the relevant Member forum or the appropriate delegated senior officer. The Plan also stopped short of identifying how the variance in meeting the previous service plan targets would be addressed by the Authority in 2017/18.

9 Recommendation 1 - Service Planning [The Standard 3.1] Draw up, document and implement the 2017/18 Service Plan in accordance with the Service Planning Guidance in Chapter 1 of The Framework Agreement on official Feed & Food Controls by Local Authorities ( The Framework Agreement ). The Plan should include: (i) (ii) The number of all due food interventions in each risk rating category as specified by the FLCoP, together with an estimate of the number of unrated premises due (including any existing backlog). A comparison of the resources required to deliver each part of the Plan with the resources available and any resulting shortfall in resources, together with the corresponding strategy for delivering the service plan. [The Standard 3.2 & 3.3] (iii) (iv) Submit a documented 2016/17 service plan performance review for approval to either the relevant member forum or, where approval and management of service plans has been delegated to senior officers, to the relevant senior officer. Address any variance in meeting the Service Delivery Plan in the subsequent 2017/18 service plan. 5.3 Service Delivery Interventions The Service was responsible for enforcement at approximately 3321 food business establishments at the time of the audit. The Service s performance, as seen in table 1 below (data taken from LAEMS 2015/16 and 2016/17), from April 2015 to March 2017 shows a reduction in the number of interventions carried out at medium and lower risk establishments and a significant increase in the total number of overdue interventions. There had been a corresponding increase in the number of businesses in the Borough over that time.

10 Table 1: Recent performance data interventions (source: LAEMS) Premises Risk Rating Interventions Carried out 2015/16 Interventions Carried out 2016/17 Interventions overdue 2015/16 Interventions overdue 2016/17 A B C D E Unrated Total However, auditors carried out an analysis of the Authority s database prior to the audit which indicated that the actual number of overdue interventions was considerably higher at the end of March 2017 than the figures reported through LAEMS. Auditors reminded the Authority that all overdue interventions should be reported through LAEMS, including any backlog The Authority advised auditors that business turnover in the Borough was high. Recommendation 2 - Database procedure [The Standard 6.3] (i) The database should be operated such that all overdue interventions are reported through LAEMS, including any backlog The draft Service Plan for 2017/18 included the planned intervention targets in table 2 (below). Also included in the table are figures for overdue interventions at the time of the audit. Table 2: Planned targets 2016/17 and reported progress at time of audit interventions Intervention categories Percentage of Due Interventions Planned 2016/17 Category A 100% 0 Category B 100% 5 No. overdue inspections at time of audit (accounting for 28 day tolerance period)

11 Category C (noncompliant) Category C (compliant) 80% 402 No target Category D No target 691 Category E No target 592 Unrated No target 463 Total Overdue Interventions The increasing number of overdue interventions posed a potential increased risk to consumer protection and the reputation of the Authority due to the potential for changes in business activity and key personnel over time. A significant number of the overdue medium risk (C-rated) businesses were last due an intervention 5 years ago Auditors were advised that the Authority was intending to prioritise overdue and unrated interventions by higher risk activity and the length of time since their last intervention. The Service also acknowledged that despite implementing its own risk-based approach to prioritising overdue interventions, it was not proactively exploiting all the flexibilities in the FLCoP to carry out alternative interventions at certain C and D rated food businesses. However, despite this, the Service had determined that it did not have the capacity to meet the intervention frequencies laid down in the FLCoP. It was also clear that the situation had worsened over the past year with the reduction in professional food enforcement FTE officers to three and a corresponding increase in the number of overdue interventions Auditors welcomed the current recruitment exercise (which was intended to bring new staff into post by December 2017 at the earliest) whilst advising the Authority to base any further recruitment on an informed assessment of the resource required to meet the service delivery requirements of the FLCoP. Recommendation 3 Food Establishment interventions [The Standard 7.1] Carry out interventions at all food hygiene establishments in the area, at a frequency which is not less than that determined under the intervention rating scheme set out in the FLCoP.

12 5.3.8 Officers advised auditors that once successful recruitment had taken place, it was the intention of the service to put in place an appropriate strategy to deal with the backlog of overdue interventions in a risk-based manner. The Authority was considering desk-top risk rating some businesses; auditors discussed the importance of adhering to the requirements of the FLCoP, particularly with regard to limiting risk-rating to an on-site inspection, partial inspection or audit only In the meantime, the Authority advised auditors that it had allocated 400 interventions to four contractors, prioritising overdue interventions. These inspections were due to be completed by 31 st March Auditors were also advised that a data cleansing exercise had also taken place for registered home caterers, childminders and chemists using a system of questionnaires. 5.4 Database The Service had set up and was implementing a database of the food establishments in its area The Lead Food Officer and Business Development Manager were jointly responsible for monitoring quantitative performance against work plan targets for interventions, service requests and infectious disease reports. However there was no corresponding documented database management procedure in place and officers did not have a formal system for checking database accuracy and reliability Database checks carried out by auditors prior to the audit confirmed that the database was generally accurate and reliable. There were a small number of additional database anomalies, which the Authority believed were officer data entry errors. Officers undertook to investigate these further. Recommendation 4 - Database procedure [The Standard 11.2] (ii) Set up, maintain and implement a documented procedure to ensure that the food database is accurate, reliable and up to date The database was capable of reporting information reasonably requested to the FSA and auditors were advised that the Service was maintaining appropriate backup systems and security measures.

13 5.5 Staff Training and Authorisation The Strategic Director Neighbourhood and Growth had been delegated responsibility to authorise officers within the Food, Health and Safety Team. There was a documented authorisation procedure in place which prescribed the authorisation of officers based on the competency requirements of the FLCoP. The procedure also made reference to the qualification and training requirements set out in the FLCoP The Service had appointed a Lead Food Officer with the necessary specialist knowledge to carry out the role and meet the competency requirements of the FLCoP. The Lead Food Officer was responsible for assessing officer competency Auditors checked officer authorisations, the management scheme authorisation matrix and two competency assessments. Auditors found the following non-conformities: There was a single group authorisation for all food officers which, in effect, extended the powers of some beyond their competencies. Auditors discussed the benefits of linking the management scheme to the authorisation procedure and new authorisations, as at the time of audit its purpose was not clear. No officers were authorised under the Trade in animal and Related Products (TARP) Regulations 2011, limiting the Service s powers to remove inland illegally imported food from the market in an emergency Officer competency assessments did not fully reflect the competency framework prescribed by the latest edition of the FLCoP published in Competency assessments did not show any evidence of assessment or decision by the Lead Food Officer. Auditors discussed the need to record and sign-off this decision making process for each officer, making it clear for each competency whether or not the officer had been deemed competent The Service subscribed to a corporate annual appraisal scheme which formed part of the training needs assessment led by the Lead Food Officer Discussions with officers indicated that one officer newly returned to food safety enforcement had recently undergone a programme of training and monitoring by the Lead Food officer which was in accordance with the requirements of the FLCoP The training records of two officers were checked. Both officers had received the necessary 20 hours continuous professional development (CPD) training in accordance with the FLCoP.

14 5.5.7 Although appropriately qualified and registered with the Environmental Health Officers Registration Board (EHORB), officers had not received any certificated HACCP training (although it had been included in their professional qualification). Auditors discussed the benefits of prioritising additional significant HACCP training, if necessary. With the presence of approved fishery products premises within the Borough, auditors discussed the benefits of prioritising the relevant specialist products training for the relevant officer/s Generally, records of qualifications, training and experience of officers and support staff had been maintained by the Service. However, some training certificates could not be located. Recommendation 5 Officer Authorisation [The Standard 5.3] (i) (ii) (iii) Ensure all officers are appropriately authorised in accordance with their individual competencies and the individual regulations of the Food Safety & Hygiene (England) Regulations 2013 and TARP 2011 to respond to food incidents involving illegally imported food and to carry out the work set out in the Service Plan. Ensure the Service has a sufficient number of officers to carry out the work set out in the service delivery plan (including meeting the intervention frequencies prescribed by the FLCoP). Ensure that competency assessments and authorisation documents make clear whether or not officers are competent and authorised under particular competencies and powers respectively. [The Standard 5.5] (iv) Records of the training, including certificates, of each authorised officer and appropriate support staff shall be maintained by the Authority in accordance with the FLCoP. 5.6 Documented Policies and Procedures The Service had set up and implemented suitable documented procedures for the activities it carried out. This included an enforcement policy (including procedures), approved establishments procedure, complaints procedure, authorisation procedure, sampling policy, programme and procedure and food incidents and alerts procedure. The sampling

15 procedure would benefit from a review to remove references to out of date Codes of Practice The enforcement policy was undergoing a review and auditors discussed how it would benefit from the inclusion of references to enforcement sanctions absent from the existing policy, namely Remedial Action Notices and the certification of food procedure of regulation 29 of the Food Safety and Hygiene (England) Regulations The Procedure for Food Hygiene Enforcement interventions was generally appropriate and included reference to food safety management system assessment and inspection preparation, conduct, recording and reporting. However, auditors indicated that it would benefit from inclusion of the Alternative Enforcement Strategy procedure once this had been determined by the Authority Officers used a detailed aide-memoire for food hygiene inspections, which included reference to a range of regulatory requirements reflective of the FLCoP, including prompts for the evaluation of food business food safety management systems The Service had a sampling policy and documented sampling programme for 2017/18. The policy and programme incorporated a consideration of regional programmes, approved establishments and other locally prioritised risks. 5.7 Ensuring an Effective and Consistent Service Internal Monitoring The draft Food, Health and Safety Team Service Plan for 2017/18 made reference to the Authority s system of annual staff performance appraisal and monthly staff one-to-one meetings. In addition, the Service had put in place a Food Safety and Infectious Disease Control Internal Monitoring Procedure which covered most areas of food enforcement (sampling and authorisation checks were not mentioned). The Food, Health and Safety Team Manager was responsible for carrying out all qualitative monitoring checks. The procedure prescribed the following qualitative performance monitoring checks: File reviews as part of corporate appraisal process Officer risk-rating reviews and follow-up action reviews as part of corporate appraisal process Four file checks to be carried out per officer per year Minimum of one accompanied inspection per officer per year (but risk-based if further visits deemed necessary) All hygiene improvement notices and a sample of other enforcement notices to be checked Two complaint files per officer per year to be checked

16 Business questionnaires to be sent to a percentage of food businesses every quarter As a result of the Lead Food Officer having to carry out additional operational work to cover staff absence, the Authority acknowledged that the internal monitoring procedure had not been fully implemented for some time. Auditors were advised that contractor paperwork checks and some accompanied visits were still taking place (as part of or in addition to the new officer monitoring previously mentioned), but were not being recorded. No evidence of recent qualitative performance checks was available at the time of the audit. Auditors discussed reviewing the procedure to focus resource on those areas where past performance indicated the greatest monitoring need (risk-based internal monitoring). The Authority was keen to re-start full qualitative performance checks following successful recruitment to the empty posts It was clear that the Service engaged in discussions of technical food safety matters such as less than thoroughly cooked burgers at team meetings, South West Sector Food Group meetings and London Food Coordinating Group sub-group meetings (regional meetings). These discussions in themselves represented a form of team and regional consistency management The Authority also carried out some checks on FHRS data during the regular upload to the FSA website, however a data analysis carried out by the FSA prior to the audit found a number of possible anomalies in this data. The Authority undertook to review this analysis and take any necessary action to resolve any anomalies verified Quantitative monitoring of database accuracy is covered under section 5.4 of this report. The Lead Food Officer issued inspections to officers on a monthly basis, reporting performance against these targets to the Business Development Manager also on a monthly basis.

17 Recommendation 6 Internal Monitoring [The Standard 19.1, 19.2, 19.3] (i) (ii) (iii) Review and implement the Food Safety and Infectious Disease Control Internal Monitoring Procedure in accordance with Article 8 of Regulation (EC) 882/2004 and the FLCoP. Verify the conformance of the Service with all aspects of The Standard, relevant legislation, the FLCoP and relevant centrally issued guidance. Make a record of all internal monitoring and keep it for at least 2 years Enforcement letters from the FSA were received by the Service and team meeting minutes indicated that the Team were aware of, and had actioned, the recent advice from the FSA on less than thoroughly cooked burgers, and the need to return certain information on associated food businesses to the Agency. Third Party or Peer Review The Service had not taken part in any external or internal reviews of food hygiene in the two years prior to the audit, or any regional peer review or inter-authority audits The Authority had taken part in the recent FSA FHRS national consistency exercise. Audit Team: Alun Barnes - Lead Auditor Aranzazu Sanchez - Auditor Food Standards Agency Regulatory Delivery Division

18 ANNEX A - Action Plan for Lambeth London Borough Council Audit date: 28 th September 2017 TO ADDRESS (RECOMMENDATION INCLUDING STANDARD PARAGRAPH) Recommendation 1 - Service Planning [The Standard 3.1] BY (DATE) PLANNED IMPROVEMENTS ACTION TAKEN TO DATE Draw up, document and implement the 2017/18 Service Plan in accordance with the Service Planning Guidance in Chapter 1 of The Framework Agreement on official Feed & Food Controls by Local Authorities ( The Framework Agreement ). The Plan should include: (i) The number of all due food interventions in each risk rating category as specified by the FLCoP, together with an estimate of the number of unrated premises due (including any existing backlog). (ii) A comparison of the resources required to deliver each part of the Plan with the resources available and any resulting shortfall in resources, together with the corresponding strategy for delivering the service plan. [The Standard 3.2 & 3.3] (iii) Submit a documented 2016/17 service plan performance review for approval to either the The service plan for 2017/18 will be amended to show:- (i) (ii) (iii) All food interventions due with risk rating including the number of unrated premise and existing backlog The resource required to deliver the interventions will be included showing any shortfall in funding to deliver the plan. The service plan will in future be presented for sign off by Director of Environment Service plan is being reviewed in light of the audit finding

19 TO ADDRESS (RECOMMENDATION INCLUDING STANDARD PARAGRAPH) relevant member forum or, where approval and management of service plans has been delegated to senior officers, to the relevant senior officer. BY (DATE) PLANNED IMPROVEMENTS ACTION TAKEN TO DATE Address any variance in meeting the Service Delivery Plan in the subsequent 2017/18 service plan. Recommendation 2 - Database procedure [The Standard 6.3] (i) The database should be operated such that all overdue interventions are reported through LAEMS, including any backlog. Recommendation 3 Food Establishment interventions [The Standard 7.1] Carry out interventions at all food hygiene establishments in the area, at a frequency which is not less than that determined under the intervention rating scheme set out in the FLCoP We have been informed by Idox that there was a system error, an issue which was highlighted by the FSA where they believed that the number of missed interventions was being underreported due to the returns only including interventions due from the current reporting period. This has now been corrected and all outstanding interventions will be included in 2018/19 LEAMS returns Food hygiene interventions will be planned to ensure that all risk inspections are inspected in accordance with the FLCoP. Alternative enforcement will be used where appropriate for low risk businesses. This will be clearly identified in the service plan for 2018/9 The LEAMS return for 2017/18 will reflect the correct overdue and backlog of inspections. A list of all overdue and backlog of inspection has been compiled and external contractors are being assigned to inspect them. High risk inspections to be carried out in accordance with FLCOP and appropriate use of alternative enforcement to be carried out.

20 TO ADDRESS (RECOMMENDATION INCLUDING STANDARD PARAGRAPH) Recommendation 4 - Database procedure [The Standard 11.2] (ii) Set up, maintain and implement a documented procedure to ensure that the food database is accurate, reliable and up to date. BY (DATE) PLANNED IMPROVEMENTS ACTION TAKEN TO DATE Procedure to be written. Currently using Uniform guidance and only one officer is responsible for database management. Recommendation 5 Officer Authorisation [The Standard 5.3] (i) Ensure all officers are appropriately authorised in accordance with their individual competencies and the individual regulations of the Food Safety & Hygiene (England) Regulations 2013 and TARP 2011 to respond to food incidents involving illegally imported food and to carry out the work set out in the Service Plan Procedure to be amended and officers to be authorised in accordance with individual officer competencies and deploy accordingly. Authorisation matrix and procedure to be amended according to officer competencies. (ii) Ensure the Service has a sufficient number of officers to carry out the work set out in the service delivery plan (including meeting the intervention frequencies prescribed by the FLCoP) Neighbouring local authorities have recently advertised for food safety/eho posts and have not been able to recruit, as there is generally a shortage of suitable trained officers. HR to look at recruiting suitable candidate and re advertise the existing vacant post. We successfully recruited to 1 post internally. No suitable external candidates applied to the advertisement and there is a 1 vacant post.

21 TO ADDRESS (RECOMMENDATION INCLUDING STANDARD PARAGRAPH) (iii) Ensure that competency assessments and authorisation documents make clear whether or not officers are competent and authorised under particular competencies and powers respectively. BY (DATE) PLANNED IMPROVEMENTS ACTION TAKEN TO DATE Competency assessments and authorisation document to be amended to reflect officer s competencies and powers. The authorisation matrix now linked to the authorisation procedure. [The Standard 5.5] (iv) Records of the training, including certificates, of each authorised officer and appropriate support staff shall be maintained by the Authority in accordance with the FLCoP. Reviewed and ongoing Copies of CPD are now stored for each officer by the manager. Copies of all officers CPD now stored centrally. Recommendation 6 Internal Monitoring [The Standard 19.1, 19.2, 19.3] (i) Review and implement the Food Safety and Infectious Disease Control Internal Monitoring Procedure in accordance with Article 8 of Regulation (EC) 882/2004 and the FLCoP. (ii) Verify the conformance of the Service with all aspects of The Standard, relevant legislation, the FLCoP and relevant centrally issued guidance /8/18 Food safety and infectious disease control monitoring procedure will be reviewed and a plan drawn up for monitoring and the records will be kept for 2 years. Staff 121 and appraisals to be resumed and will be used to ensure staff conformance to service standards. (iii) Make a record of all internal monitoring and keep it for at least 2 years. 1/8/18 Monitoring and the records will be kept for 2 years

22 ANNEX B - Audit Approach/Methodology The audit was conducted using a variety of approaches and methodologies as follows: (1) Examination of LA plans, policies and procedures, Including the following relevant LA policies, procedures and linked documents were examined before and during the audit: Draft Food Safety Service Plan Procedure for the Authorisation Officers in the Food Health & Safety Team Food, Health and Safety Team Enforcement Policy, July 2017 Food, Health and Safety Team Procedure Note For Food Complaints Procedure for Food Hygiene Enforcement Interventions Procedure for the Approval of Products Specific (Animal Origin Food Business) Establishments Food Safety Sampling Policy (2014), procedure and programme (2017/18) Internal Monitoring Procedure South West Sector food group minutes: o 27/9/16 o 13/12/16 o 11/4/17 Food Team Meeting Minutes: o 13/1/17 (2) A range of LA file records were reviewed the following LA file records were reviewed during the audit: Qualification and training records Authorisations

23 (3) Review of Database: To assess the completeness and accuracy of the food premises database To assess the capability of the system to generate food law enforcement activity reports and the monitoring information required by the Food Standards Agency. (4) Officer interviews the following officers were interviewed: Head of Community Safety Food, Health and Safety Manager Technical Business Support Officer

24 ANNEX C - Glossary Authorised officer Brand Standard Codes of Practice County Council District Council A suitably qualified officer who is authorised by the local authority to act on its behalf in, for example, the enforcement of legislation. This Guidance represents the Brand Standard for the Food Hygiene Rating Scheme (FHRS). Local authorities in England and Northern Ireland operating the FHRS are expected to follow it in full. Government Codes of Practice issued under Section 40 of the Food Safety Act 1990 as guidance to local authorities on the enforcement of food legislation. A local authority whose geographical area corresponds to the county and whose responsibilities include food standards and feeding stuffs enforcement. A local authority of a smaller geographical area and situated within a County Council whose responsibilities include food hygiene enforcement. Environmental Health Officer (EHO) Food Safety Management System Feeding stuffs Food hygiene Full Time Equivalents (FTE) Officer employed by the local authority to enforce food safety legislation. A written permanent procedure, or procedures, based on HACCP principles. It is structured so that this requirement can be applied flexibly and proportionately according to the size and nature of the food business. Term used in legislation on feed mixes for farm animals and pet food. The legal requirements covering the safety and wholesomeness of food. A figure which represents that part of an individual officer s time available to a particular role or set of duties. It reflects the fact that individuals may work part-time, or may have other responsibilities within

25 the organisation not related to food and feed enforcement. HACCP LAEMS Service Plan Unitary Authority Hazard Analysis and Critical Control Point a food safety management system used within food businesses to identify points in the production process where it is critical for food safety that the control measure is carried out correctly, thereby eliminating or reducing the hazard to a safe level. Local Authority Enforcement Monitoring System is an electronic system used by local authorities to report their food law enforcement activities to the Food Standards Agency. A document produced by a local authority setting out their plans on providing and delivering a food service to the local community. A local authority in which the County and District Council functions are combined, examples being Metropolitan District/Borough Councils, and London Boroughs. A Unitary Authority s responsibilities will include food hygiene, food standards and feeding stuffs enforcement.