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 Plymouth City Council 24 th March 2017

2 Table of Contents 1.0 Introduction Scope of the Audit Background Executive Summary Strengths Good Practice Key areas for improvement 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

3 1.0 Introduction 1.1 This is a report on the outcomes of the Food Standards Agency s (FSA s) audit of Food Hygiene Service Delivery, focussing on Service Organisation, Management and Internal Monitoring Arrangements, conducted at Plymouth City Council on the 24 th March 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 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 Authority 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 arrangements for organisation, management, and internal monitoring arrangements with regard to food hygiene law enforcement. Assurance was sought that key authority 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 Plymouth City Council offices, Building 4a Derriford Business Park Plymouth PL6 5QZ. 3.0 Background 3.1 Plymouth City Council is a unitary authority. The city sits in Devon, on the border of the large rural counties of Devon and Cornwall. It has a resident population of approximately 260,000 living in a generally densely developed area of 80 square kilometres. The City s influence over a wider area is reflected in its Travel to Work Area population of 353, Plymouth acts as a regional shopping centre for large areas of Devon and Cornwall, serving a catchment with a population of 465,000. The city serves its surrounding areas with healthcare, education and training, cultural and leisure facilities, business and financial services, media, tourism, and rail, air and sea transport. Plymouth has an active port and a large MOD presence including one of the largest Naval bases in the UK. 3.3 The Council is operated through a cabinet structure (comprised of the Leader of the Council and the Portfolio Holders with specific areas of responsibility). Two Scrutiny Committees oversee the decision making process and one Member holds the portfolio for food safety and standards. The Environmental Health (Food Safety) Team Manager is accountable to the Consultant in Public Health within the Office of the Director of Public Health (ODPH). The latter is directly accountable to the Chief Executive.

5 4.0 Executive Summary 4.1 This audit of Plymouth City Council sought to gain assurance that key authority 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 Authority s service organisation, management and internal monitoring arrangements. 4.2 The Authority had set itself clear service delivery targets in its Food Safety Service Plan despite experiencing a number of office moves, a recent corporate budget review and a subsequent re-structure. However, at the time of audit the Authority had a significant number of food businesses that were overdue a food hygiene inspection/intervention. Being in the early stages of a corporate transformational change programme, there was no evidence that planned arrangements would be sufficient to address the inspection backlog. Strengths: 4.3 The Authority, Public Health Department and Food Safety Team had worked hard to innovate and put in place measures to make efficiency gains within a climate of challenging resources. Mobile working, formalised risk-based triage mechanisms for interventions and complaints, enhanced online registration and Food Hygiene Rating Scheme (FHRS) re-visit charging had all been recently introduced. Further measures were being considered. 4.4 The Authority had an experienced and knowledgeable Lead Food Officer in place and officers had received a broad range of training appropriate to their duties. Good Practice; 4.5 The enhanced online food business registration system operated by the Authority was identified as an area of good practice by auditors. It gathered a large amount of information from new food businesses on the nature of their business to save officer time on telephone interviews and allow more efficient prioritisation of new businesses based on risk. Key areas for improvement; 4.6 The Authority had a significant number of medium and lower risk food premises that were overdue an intervention, some by up to 14 years. Although the Authority had identified the resulting significant risks posed to public health in its risk registers and was in the early stages of implementing a corporate transformational change programme, there was no evidence that these measures would mitigate these risks and

6 lead to the removal of the intervention backlog. 4.7 The Authority had not yet added all food businesses to its database in the form of a number of childminders, but was in the process of doing so. 4.8 Officers had not yet been fully authorised following the recent restructure of the Public Health Department, potentially limiting the powers of the Authority. The Authority was unable to produce some evidence of qualification and training for officers of the Food Safety Team. 4.9 With the exception of corporate appraisals, some 1:1 activity and database monitoring, most internal monitoring activity had temporarily ceased over the last 15 months, in order to prioritise re-establishing operations following the re-structure and office move. Consequently the Authority was unable to provide auditors with recorded evidence of much of the forms of recent qualitative and quantitative internal monitoring described in their procedures. 5.0 Audit Findings 5.1 Service Organisation & Management The food safety service sat within the remit of the Portfolio Member for Safer and Stronger Communities, being part of the ODPH. At the time of the audit, the responsibility for the approval of the annual Food Safety Service Plan was that of the Director of Public Health and the Portfolio Holder, who sat on the Council s Executive The Director of Public Health was responsible for the Environmental Health Manager who managed a team of officers carrying out food hygiene, food standards, port health and other non-food related duties for the Authority. Officers were in the advanced stages of embedding an agile work pattern which incorporated the use of mobile tablets aiming to reduce the need to visit the office as often and thereby make efficiency gains The Authority had made cuts to its budget in 2015 as part of a corporate budget review; these cuts had negatively affected the Food Safety Team budget and staff had been lost to voluntary redundancy. Following the budget review the Authority had implemented a corporate transformational change programme based upon three phases of work: 1. Smart working (incorporating the aforementioned agile or mobile working), 2. A commercial income review, and 3. A channel shift to look at ways of using technology to further digitise customer service.

7 Auditors were advised that the three work streams (smart working, commercial review and customer service transformation / channel shift) had been implemented simultaneously. Smart working phase one was due for completion in May Transformation as a project was due to close in May 2017, but there would still be much work to be done as business as usual. Commercial review was anticipated to be ongoing until at least October The Authority had also established strategic and corporate risk registers The ODPH was committed to these three transformational change principles and had reported Food Safety Team service delivery failure risks to the Portfolio Member both in writing and verbally. These risks had been entered on both the corporate and strategic risk registers The Food Safety Team contributions to the transformational change objectives were the ongoing move to the aforementioned agile (mobile) working, the introduction of Food Hygiene Rating Scheme (FHRS) revisit charges together with an ongoing review to identify further income streams and the introduction of enhanced online food business registration. The Authority envisaged that this work would deliver more efficiency savings to the team The Team reported that it had moved offices twice in the 18 months prior to the audit as part of the corporate change strategy The Food Safety Service budget for the coming year had been settled and was reported to be equivalent to the budget for 2016/17. Auditors were advised that no further budget cuts were anticipated at present. 5.2 Service Planning The Authority had put in place a Service Plan for 2016/17 which identified all the statutory demands placed on it by the Food Law Code of Practice (FLCoP), the Standard in the Framework Agreement and centrally issued guidance. Auditors were advised that the Authority had no Primary Authorities registered within its area The Plan included a detailed but incomplete assessment of the resources required to deliver the Service in accordance with its business plan, and did not explicitly compare the resources required with the resources available to identify the precise shortfall in full time equivalent (FTE) officers. However, the Plan was explicit that the food hygiene service was under-resourced and that it was unable to meet the intervention targets set by the FLCoP.

8 Recommendation 1 - Service Planning - Drafting [The Standard 3.1] The Authority shall draw up its 2017/18 Service Plan in accordance with the Service Planning Guidance of the Standard in the Framework Agreement. The Plan shall include a comparison of the resources required to deliver each part of the Plan with the resources available and identify any resulting shortfall in resources In an attempt to manage the risk created by the reported underresourcing, the Plan set out risk-based triage mechanisms devised by the Authority to apply to overdue programmed interventions, D and E risk rated food businesses, unrated businesses and food and food premises complaints. The objective of the triage mechanisms was to prioritise the targeting of interventions to those businesses within these risk categories deemed high risk by the Authority The Service Plan reported that the entry in the strategic risk register highlighted the ODPH concerns about the unknown risk to health from premises that are trading without an inspection, or those that haven t been inspected for many years Local Authority Enforcement Monitoring System (LAEMS) data indicated that staff resource had declined from 3.6 FTE officers in 2014/15 to 3.4 FTE in 2015/16. The Authority estimated its FTE to be 5.1 at the time of the audit. The Food Safety Service was only available outside of ordinary office working hours (Monday-Friday, 8.30am 6.00pm) in the event of an Emergency via the switchboard. In such an event, auditors were advised that the on-call Director would have the contact details of the Environmental Health Manager The Authority had no formal Key Performance Indicators (KPI) for the Food Safety Team but rather reported performance by exception to the Directorate management team meeting in terms of local risk. Auditors were advised that work was underway to develop possible KPIs for the Team in future. Corporate risk was reviewed by the Senior Management Team The Authority reported that it had carried out a performance review against the previous years Service Plan, but this had not yet been signed off.

9 Recommendation 2 - Service Planning - Review [The Standard 3.2] Submit the documented 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. 5.3 Service Delivery Interventions The Authority was responsible for enforcement at 2298 food business establishments at the time of the audit. The Authority s performance, as seen in table 1 below (data taken from LAEMS 2014/5 and 2015/16), in addressing its backlog of interventions from April 2014 to March 2016 shows a significant increase in the total number of overdue interventions in 2015/16 and the corresponding increased focus on prioritising the completion of high risk interventions before lower risk. Table 1: Recent performance data interventions (source: LAEMS) Premises Risk Rating Interventions Carried out 2014/15 Interventions Carried out 2015/16 Interventions overdue 2014/15 Interventions overdue 2015/16 A B C D E Unrated Total The Service Plan included the planned intervention targets in table 2 (below). Also included in the table are figures indicating the progress the Authority reported against these targets at the time of the audit. Table 2: Planned targets 2016/17 and reported progress at time of audit interventions

10 Intervention categories Percentage of Due Interventions Planned 2016/17 Category A 100% 0 Category B 100% 0 Category C 100% 23 No. overdue inspections at time of audit (to 28 days before audit) Category D 44% (prioritised according to triage approach) 417 Category E 3% (prioritised according 479 to triage approach) Unrated High Risk 100% 170 (all unrated) Unrated Low Risk / Childminders 0% Total Overdue Interventions Auditors acknowledged the Authority s contention that it was too early to evaluate how successful the corporate transformational change strategy would be in addressing the overdue interventions. However it was clear that the Authority was not on target to complete all its due interventions for 2016/17, contrary to the FLCoP An analysis of the food database by auditors prior to the audit indicated that some D and E rated businesses were overdue an inspection by up to 14 years. Some C rated businesses were overdue by up to 2 years. This posed a potential increased risk to consumer protection and the reputation of the Authority due to possible changes in the type and nature of business operation and the food safety management controls in place. Auditors discussed their concerns with officers and outlined two examples of fatal food poisoning outbreaks in the UK in recent years originating at overdue D-rated food businesses The Authority acknowledged that despite implementing its own riskbased triage approach to prioritise overdue interventions, and using some alternative interventions such as sampling, it was not exploiting all the flexibilities in the FLCoP to carry out alternative interventions at certain C and D rated food businesses. However, officers reported that they had considered this option in the past but had determined that employing these additional flexibilities as a matter of policy was unlikely to deliver any efficiency gains. That said, officers indicated that they were willing to review this decision in future.

11 5.3.6 Officers indicated the triage approach utilised their own information on the food business as well as information and intelligence from active liaison with the Licensing Team, Trading Standards Team and some interrogation of social media for keywords that might indicate grounds for significant food hygiene concerns New businesses (unrated establishments) were segmented into high risk and low risk according to factors such as the type of food business and food operations carried out. High risk unrated food businesses were prioritised for intervention over low risk. This segmentation was informed both by officer experience and a formalised telephone interview with new businesses to gather the necessary information. The telephone interview was gradually being superseded by the Authority s enhanced online food business registration system The enhanced online food business registration system was identified as an area of good practice by auditors. It gathered a large amount of information from new food businesses on the nature of their business to save officer time on telephone interviews and allow more efficient segmentation of new businesses for inspection prioritisation, partially mitigating the risk posed by these businesses being overdue their first intervention. Information gathered included detail on staff training, foods handled, presence of absence of high risk food operations, engagement in export and even uploaded documents and photographs The Senior EHO was responsible for risk profiling overdue inspections using the triage approach and allocating them to officers for action. Auditors examined one intervention from February 2016 however the Authority were unable to locate the inspection record. Recommendation 3 Food Establishment interventions [The Standard 7.1] The Authority shall carry out interventions at all food hygiene establishments in their area, at a frequency which is not less than that determined under the intervention rating scheme set out in the FLCoP The Food Safety team were also responsible for food hygiene enforcement (and other duties) at the Port. The Port was a Designated Point of Entry (DPE) to the UK (under the International Health Regulations 2005) for the import of lower risk food and feed. There were no 3 rd country imports and most food from within Europe entered by road transport via regular ferry services form European ports.

12 The Team carried out regular manifest checks on inbound vessels and advised auditors that it had access by to the European Rapid Alert System for Food and Feed (RASFF) The Team administered approximately fifteen Sanitation Certificate requests per annum, were authorised to do so by the Department of Health, and had enforcement responsibility for two approved fishing vessels. 5.4 Database The Authority had put in place a Database Monitoring Procedure for maintaining the food premises database which outlined arrangements to ensure the accuracy of data. Checks included analyses for duplicate premises, some scoring anomalies, business code anomalies, missing database fields (all at the weekly FHRS upload). The Authority advised auditors that premises name and address accuracy checks only took place in relation to returned s and mailshots at the time of the audit. The procedure was brief and did not prescribe all checks carried out as indicated by officers The Authority advised auditors that database monitoring was carried out by the Lead Food Officer (LFO) (mainly database accuracy checks) and the Senior EHO (mainly officer workload monitoring) Auditors examined the database prior to the on-site visit and found it to be generally accurate and reliable. A small number of examples of improper application of the significant risk rating criteria contrary to the scheme in the FLCoP were found which had not been identified through the application of this database monitoring procedure. Recommendation 4 - Database procedure review [The Standard 11.2] Review the documented procedure for maintaining the food premises database to outline the frequency and nature of all database accuracy and reliability checks carried out. Include reference to a check on risk rating anomalies including significant risk scores, to ensure that the food premises database is accurate, reliable and up to date Auditors queried the statement in the Service Plan that not all childminders have been recorded on the database. Officers advised auditors that these businesses were held on a separate spreadsheet and were in the process of being contacted to verify their existence and, where appropriate, placed on the database.

13 Recommendation 5 - Database accuracy [The Standard 11.1] Complete the exercise to add all existing childminders currently recorded on a separate list to the food business database The database was capable of reporting information reasonably requested to the FSA and the Authority was maintaining appropriate backup systems and security measures. These measures were outlined in the Database Monitoring Procedure. 5.5 Staff Training and Authorisation The Environmental Health Manager had been delegated responsibility to authorise officers by the Director of Public Health who was, in turn, authorised by virtue of the Leader s Scheme for Delegation and part H of the Constitution. An Officer Authorisation Procedure and separate Food Authorisation Procedure were in place. The procedures prescribed authorisation of officers based on the competency requirements of the FLCoP together with procedures for revision training (in accordance with the FLCoP) and appraisal. The procedures also made reference to the qualification and training requirements set out in the FLCoP The Authority had appointed a LFO with the necessary specialist knowledge to carry out the role and meet the competency requirements of the FLCoP All officers checked by auditors were found to have a general authorisation, and an annex to those authorisations specifying the additional powers limiting their duties according to their FLCoP competence, particularly in relation to the Food Safety & Hygiene (England) Regulations All general authorisations had been appropriately signed, however the authorisation annex had not, potentially limiting the powers of the Authority. Auditors were advised by staff that sign-off was due in April Officers of the Authority were generally authorised in accordance with their qualifications, training and experience. However, one officer had been authorised for food hygiene formal sampling despite not meeting the FLCoP qualification requirements necessary to exercise this power. The Authority undertook to amend the Authorisation. The Authority itself had not kept a copy of the officer s qualification The Food Service Plan was explicit that the food hygiene service was under-resourced and that it was unable to meet the intervention targets set by the FLCoP. This statement was supported by LAEMS performance figures over the previous two years and an analysis of the

14 database by auditors at the time of this audit. The Authority acknowledged that it was too early to measure the effect the ongoing transformation programme would have on performance. Recommendation 6 Officer Authorisation [The Standard 5.3] (i) (ii) (iii) Complete the sign-off of authorisations in accordance with authorisation procedures and the Constitution to ensure that a sufficient number of officers are authorised to carry out the work set out in the service delivery plan, consistent with the FLCoP. Appoint a sufficient number of authorised officers to carry out the work set out in the Service Plan. Ensure that all officers are qualified in accordance with their duties and authorisation and take action to limit the latter in accordance with the FLCoP if no appropriate qualification has been attained The training records of officers were checked. Most of the officers had received the necessary 20 hours continuous professional development (CPD) training in accordance with the FLCoP. Training undertaken included key topics such as HACCP, E. coli O157 and cross contamination risks and allergens. However, the Authority was unable to demonstrate that one officer had received the required 20 hours CPD, although they were only short by three hours. The Authority believed that this was as a result of training not being consistently recorded. Recommendation 7 Officer Training Records [The Standard 5.5] Records of relevant academic, or other qualifications, training and experience of each authorised officer shall be maintained by the Authority in accordance with the FLCoP. 5.6 Documented Policies and Procedures The Authority had set up and implemented suitable documented procedures for the full range of activities it carried out. This included an enforcement policy, interventions, FHRS, approval of establishments, complaints, incidents, sampling and alerts and enforcement procedures.

15 5.6.2 All procedures were available to officers via a central data drive The Authority s intervention procedure included reference the Authority s own risk-based triage prioritisation mechanism for overdue lower risk establishments. The procedure also made reference to the carrying out of unannounced visits, inspection preparation, record keeping, and revisits in accordance with the requirements of the FLCoP The Authority had an appropriate intervention visit aide-memoire in place, which included prompts to indicate the type of intervention carried out. The aide-memoire also included a text box for the recording of red-flag issues for the attention of the subsequent inspecting officer. There were supplementary forms in place for written correspondence and the notification of the business food hygiene rating. 5.7 Ensuring an Effective and Consistent Service Internal Monitoring According to the Food Safety Service Plan for 2016/17, the Service had established the following monitoring arrangements to assess the quality of the service provided: Documented sign-off procedure for new staff undertaking food duties Regular review of inspection, case and infectious disease paperwork Accompanied inspections Regional consistency exercises Management documentation review The Authority had also put in place the following procedures: GE02 Quality Monitoring Procedure GE04 Database Monitoring Procedure The Authority had a corporate annual appraisal system in place. Auditors were advised that the LFO was responsible for these appraisals, monitoring EHOs and officers qualified to Higher Certificate in Food Control level (or equivalent). The senior EHO was responsible for: monitoring the performance of support officers checking and signing off changes to risk ratings (on a single inspection basis rather than part of broader performance monitoring) checking inspections with a score of 15 for hygiene to ensure they were revisited in accordance with the Authority s policy.

16 5.7.4 The Quality Monitoring Procedure prescribed the use of the following tools to be used for officer performance review, assessment and consistency assurance: Team meetings, Formal two-monthly 1:1 meetings, File / documentation assessment and sign-off for premises where the risk rating has changed, Accompanied visits ( Inspection Evaluations ) twice per annum by Environmental Health Manager / senior EHO, Open peer review exercises at team meetings and Enforcement checks. Auditors observed that the frequency of enforcement checks would benefit from being defined in the procedure. The procedure also made reference to follow up arrangements where either the need for improvement or good practice was identified The Inspection Evaluation Record form was comprehensive and contained prompts for the monitoring officer to evaluate inspection preparation, the approach to inspection, including the officer s evaluation of HACCP, inspection follow up and risk rating. The form was designed to incorporate a degree of reflective learning by including prompts for both monitoring officer and inspecting officer comments. The 1:1 discussion form included prompts to discuss broader performance and training and development needs. The Inspection Paperwork Audit form included an examination of risk ratings over time, justification of FHRS score, inspection requirements including HACCP and follow up actions The Authority also had in place a new, more comprehensive 1:1 discussion form ( One-to-One Meeting Notes ) which included an evaluation of the officer s work plan, complaints, other reactive work (which included internal monitoring of infectious disease complaints) samples taken, enforcement and training and development. However, auditors were advised by the Authority that this form was not yet in use Auditors were advised that the Senior EHO checked authorisations periodically to ensure they contained up to date information. However, considering the findings of this audit (section 5.5 of this report) the Authority would benefit from putting in place a periodic check on the validity of all authorisations considering the qualifications, training, experience and duties of officers Quantitative database monitoring for integrity and accuracy is described under section 5.4 of this report With the exception of corporate appraisals, some 1:1 activity and database monitoring, the Authority advised auditors that most internal monitoring activity had temporarily ceased over the last 15 months, in

17 order to prioritise re-establishing operations following the re-structure and office move. Consequently the Authority was unable to provide auditors with recorded evidence of much of the forms of recent qualitative and quantitative internal monitoring described in their procedures. Recommendation 8 Internal monitoring procedural implementation [The Standard 19.1] Implement all quantitative and qualitative documented internal monitoring procedures, ensuring that they incorporate food hygiene activities at the Port. Recommendation 9 Internal monitoring record keeping [The Standard 19.3] Keep a record of all internal monitoring for at least 2 years There was no specific provision for the monitoring of alerts and incidents. However, the response to incidents was in part accommodated in the prescribed systems for officer workload checks. FSA Food Alerts were received by the food team s enforcement inbox which the LFO had access to outside office hours and away from the office. Auditors conveyed the benefits of signing up to the FSA text alert service for food incidents to support a responsive out of hours service in the event of a Food Alert For Action (FAFA) Enforcement letters from the Agency were monitored and, where necessary, acted upon promptly. Auditors discussed the recent letters from the FSA on the subject of less than thoroughly cooked burgers which required returns from the Authority on both a specific business chain and the undercooked burger business sector. The Authority reported that it had discussed the letters and guidance in team meetings and written to all businesses to which the FSA letters applied. The Authority reported that the two businesses found to be undercooking burgers had voluntarily stopped doing so following discussion with officers. Third Party or Peer Review The Authority had not taken part in any inter-authority audit (IAA) or peer review of food hygiene in the two years prior to the audit In April 2016 the Authority took part in the FVO audit to Evaluate the Food Safety Control Systems in Place Governing the Production and Placing on The Market of Fishery Products. The audit

18 recommendations are incorporated within the recommendations of this audit report (frequency of inspection) Officers advised auditors that the Food Safety Team intended to volunteer for the next round of IAA. Audit Team: Alun Barnes - Lead Auditor Michael Bluff - Auditor Food Standards Agency Regulatory Delivery Division

19 ANNEX A - Action Plan for Plymouth Council Audit date: 24 March 2017 TO ADDRESS (RECOMMENDATION INCLUDING STANDARD PARAGRAPH) Recommendation 1 - Service Planning Drafting [The Standard 3.1] BY (DATE) PLANNED IMPROVEMENTS ACTION TAKEN TO DATE The Authority shall draw up its 2017/18 Service Plan in accordance with the Service Planning Guidance of the Standard in the Framework Agreement. The Plan shall include a comparison of the resources required to deliver each part of the Plan with the resources available and identify any resulting shortfall in resources. Recommendation 2 - Service Planning Review [The Standard 3.2] Submit the documented 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. 14/06/17 Complete the 2017/18 service plan. Ensure that the resources section is complete as recommended by the Agency. 14/06/17 Submit the 2017/18 Service Plan ahead of portfolio holder briefing on 14/06/2017. The Service Plan will be hopefully be approved at the briefing. Submit the 2017/18 Service Plan to DPH ahead of portfolio holder briefing on 14/06/2017. First draft is complete. Portfolio holder briefing has been arranged for 14 June First draft is complete.

20 Recommendation 3 Food Establishment interventions [The Standard 7.1] The Authority shall carry out interventions at all food hygiene establishments in their area, at a frequency which is not less than that determined under the intervention rating scheme set out in the FLCoP. 31/03/18 30/08/18 Short term: 3 6 month project to tackle overdue and lower risk premises. Additional hours payments to existing part-time staff. Medium to longer term: transformational work, including smart working and improvements to online self-service opportunities for customers is ongoing. This should yield efficiencies in time management and administration and increase capacity for increased inspections. The DPH has approved a plan to offer additional hours to current part time staff for a period of 3 6 months to tackle the backlog of overdue premises. We will use an EHO to inspect overdue and lower risk premises. We will use a combination of support staff and an online survey to make contact with the overdue businesses to help prioritise the visits to be done. Achievement of all planned inspections in categories A D should be achievable in 2017/18. Category E s will be dealt with by SAQ. We have secured approval for a team member to take the Higher Food Premises Inspection certificate, commencing September 17. This will increase our FTE food hygiene inspectors

21 Recommendation 4 - Database procedure review [The Standard 11.2] Review the documented procedure for maintaining the food premises database to outline the frequency and nature of all database accuracy and reliability checks carried out. Include reference to a check on risk rating anomalies including significant risk scores, to ensure that the food premises database is accurate, reliable and up to date. Recommendation 5 - Database accuracy [The Standard 11.1] 30/06/17 Include the recommended references in the database procedure. Use of significant risk scores have been discussed with the team and we have carried out consistency exercises since the audit. Complete the exercise to add all existing childminders currently recorded on a separate list to the food business database. 30/06/17 Add childminders to the database. Have asked Early Years for an updated list of childminders.

22 Recommendation 6 Officer Authorisation [The Standard 5.3] (i) Complete the sign-off of authorisations in accordance with authorisation procedures and the Constitution to ensure that a sufficient number of officers are authorised to carry out the work set out in the service delivery plan, consistent with the FLCoP. April 2017 Complete sign-off of authorisations Completed (ii) Appoint a sufficient number of authorised officers to carry out the work set out in the Service Plan. 14/06/17 Project plan for part time staff to undertake additional work. Appraise portfolio holder of action plan at briefing session. DPH has approved the plan. 30/08/18 Also see recommendation 3 regarding medium to longer term plans. (iii) Ensure that all officers are qualified in accordance with their duties and authorisation and take action to limit the latter in accordance with the FLCoP if no appropriate qualification has been attained. April 2017 Authorisation for Anne-Marie Dadge has been amended with respect to food hygiene formal sampling.

23 Recommendation 7 Officer Training Records [The Standard 5.5] Records of relevant academic, or other qualifications, training and experience of each authorised officer shall be maintained by the Authority in accordance with the FLCoP. April 2017 Ensure training records are complete and continuously updated. 1:1 s have been reinstated and CPD is discussed at these meetings Recommendation 8 Internal monitoring procedural implementation [The Standard 19.1] Implement all quantitative and qualitative documented internal monitoring procedures, ensuring that they incorporate food hygiene activities at the Port. April 2017 Reinstate internal monitoring procedures All internal monitoring procedures have been reinstated. Additional we are working on KPI s for the DPH Recommendation 9 Internal monitoring record keeping [The Standard 19.3] Keep a record of all internal monitoring for at least 2 years. April 2017 Keep a record of internal monitoring for at least 2 years Records are being kept

24 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. The following relevant LA policies, procedures and linked documents were examined before and during the audit: Plymouth City Council Environmental Health (Food Safety) Service Plan Position statement of Plymouth City Council s food hygiene service, February 2015 Briefing note regarding food hygiene inspections, September 2017 Cabinet Briefing: Food Standards Agency audit of Food Hygiene service delivery, February 2017 NFHRS procedure, FS02b, 14/10/16 ODPH Strategic Risk Register BRIEFING NOTE ODPH Public Protection Service; Portfolio Holders Briefing 3/8/2016 Food Complaints Procedure, FS03, 17/5/16 Food Inspection Procedure, FS02a, 14/10/16 Public Protection Service Food Intervention Report Visit Report Form Visit Report-Actions Sheet Food Hygiene Rating Notification of Score Intervention report and action plan letter proforma Food Approved Premise Procedure, FS01a, 8/4/16 Food Intervention Report: Approved Premises Cold Stores

25 Food Intervention Report: Approved Premises Egg Packer Approved Premises Inspection Form: Meat Products Food Incidents & Alerts procedure, FS12, 2/3/16 Food Sampling Policy, SA01, v4, June 2015 Food Sampling Procedure, SA02, 10/3/16 Samples Priorities Chart, 2015/16 Report on Food Sampling Data, 2015 Devon and Cornwall Local Microbiological Sampling priorities ODPH Public Protection Service: Enforcement Policy Officer Authorisation Procedure, AU01, 12/1/17 Food Authorisation Procedure, AU02, 16/1/17 Authorisation Summary ODPH, 2017 PPS Schedule of Legislations Database Monitoring Procedure, GE04, 3/1/17 Quality Monitoring Procedure, GE02c, 3/1/17 GE02 Quality Monitoring Appendix 2: Inspection Paperwork Audit One-to-One Meeting Notes Devon & Cornwall Liaison Group Minutes: 28/7/16 Devon & Cornwall Liaison Group Minutes: 19/10/16 Devon & Cornwall Liaison Group Minutes: 10/1/17 (2) A range of LA file records were reviewed the following LA file records were reviewed during the audit: Inspection report Qualification and training records Authorisations (3) Review of Database records:

26 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: Director of Public Health Environmental Health Manager, Senior EHO

27 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 the organisation not related to food and feed

28 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.