Related manuals Health & Safety Part 1 Section 1; H&S Part 1 Section 2; H&S Part 1 Section 3 ; Part 2 Section 1; Corporate Services Part 5 Section 1

Transcription

1 H&S01_05_V4 - Page No.1 summary Health and Safety Audit & Review document control Responsible Author Sig for Sig for RB Issue Date Review Date Director CFO/CE ACFO B Hoad July 2013 July 2015 Related documents Management of Health & Safety at Work Regs 1999 Health and Safety Executive Guide HS(G) 65 BS EN ISO 9000:2000 RoSPA Quality Safety Audit ESFA Members Handbook Related manuals Health & Safety Part 1 Section 1; H&S Part 1 Section 2; H&S Part 1 Section 3 ; Part 2 Section 1; Corporate Services Part 5 Section 1 1 Summary 1.1 Regulation 5 of the Management of Health & Safety at Work Regulations 1999 (MHASAWA) requires employers to have arrangements in place to effectively manage health and safety, and identifies that a successful health and safety management system will include reviews. 1.2 The Health and Safety Executive s guide HS(G)65, Successful Health and Safety Management, states that organisations can maintain and improve their ability to

2 summary H&S01_05_V4 - Page No.2 manage risks by learning from experience through the use of audits and performance reviews 1.3 This section of the Health and Safety Manual defines the nature and purpose of a health and safety audit and details the policy and s for conducting audits and reviews.

3 policy H&S01_05_V4- Page No.3 2 Policy 2.1 East Sussex Fire Authority (ESFA) and East Sussex Fire & Rescue Service (ESFRS) recognise the importance of conducting safety audits and reviews of the Health & Safety Management System SMS). This supports the Fire Authority s strategic objective Maintain and improve the standards of health, safety and welfare of our staff and provide a safe and secure workplace. 2.2 This commitment is stated in the Health and Safety Strategy, as published in the ESFA Members Handbook, which commits the Service to audit the Health & Safety Management System on a regular basis to ensure that the organisation is effective. 2.3 This approach follows the principles and good practices in HS(G) 65, Successful Health & Safety Management. The purpose of audits and reviews is normally to identify findings and non-conformities to inform continuous improvement in health and safety performance. However, regard will be given to positive safety practices that are considered noteworthy for wider adoption. These will normally be matters that are making a positive contribution to health and safety performance. 2.4 ESFRS has adopted the Royal Society for the Prevention of Accidents (RoSPA) Quality Safety Audit system as an externally recognised standard for audits and reviews of the H&S SMS. ESFRS will maintain a suitable number of competent personnel trained and accredited to the relevant standards in order to undertake audits and reviews of the SMS. This manual details the management arrangements and s required to comply with the QSA standard. 2.5 The use of a structured and accredited audit system will enable ESFA to actively analyse and review the effectiveness of its SMS, demonstrate improving performance, benchmark performance with the UK Fire & Rescue Service and against other industries and occupations.

4 policy H&S01_05_V4- Page No Health and Safety audits and reviews will be programmed and managed through the Performance Management Framework. The exact frequency of audits will be determined in accordance with the Fire Authority s 5 year Value for Money / Business Assurance Audit & Review Strategy, as approved by the Scrutiny and Audit Panel, and updated annually. 2.7 Regulation 5 of the MHASAW Regulations 1999 requires periodic reviews of the whole SMS. Normally full audits / reviews of the ESFRS SMS will be undertaken at not more than 3 yearly intervals. 2.8 Other periodic business audits and reviews of specific elements of the SMS or individual activities will be programmed at the request of the Fire Authority, Corporate Management Team, or Health, Safety and Welfare Committee. These will normally be programmed within the Annual Audit and Review plan, however, it is recognised that there may be a requirement to undertake such audits / reviews on a dynamic basis within a business year, i.e. to verify compliance with a specific Health and Safety regulation or ESFRS policy /, or following a safety event. 2.9 Regard will be given to the Chief Fire Officers Association (CFOA) South East Region programme of Health & Safety Audits. ESFRS will contribute trained auditors to participate in inter-frs audits in accordance with the programme agreed by the CFOA South East Health & Safety Group. ESFRS may invite suitably accredited safety auditors from other FRSs in the CFOA SE Group to assist internal audits of the SMS Audits and reviews of the SMS will normally be based on the RoSPA Quality Safety Audit or similar standard. The exact system to be used will take account of available good practices from relevant bodies such as the Health and Safety Executive (HSE), The Institution of Occupational Safety and Health (IOSH), The International Institute of

5 policy H&S01_05_V4- Page No.5 Risk and Safety Management (IIRSM), and including recommendations from CFOA South East Health & Safety Group It should be noted that this policy and falls within the overall framework provided by the Value for Money Review (VFMR), Business Review (BR) and Business Audit (BA) model and associated manual note Auditing, reviewing and associated activities such as driving ESFRS vehicles and making visits outside ESFRS are subject to activity risk assessments and controls available on the ESFRS risk register This policy will be subject to periodic monitoring, audit and review as detailed at paragraphs 3.99 to 3.95.

6 H&S01_05_V4- Page No.6 3 Procedure This section defines the purpose of audit and review, identifies concise levels of responsibility and provides a for conducting audits / reviews of the full SMS, in accordance with the requirements of external standards, such as RoSPA QSA. The also provides the basis for conducting audits / reviews of specific individual elements of the SMS. 3.1 All audit reports will be subject to ESFRS document control and archiving policies. Standard audit / review reporting templates are provided on the Service intranet. All trained auditors will be made aware of the requirement to use these templates. 3.2 Health and Safety Audit 3.3 HS(G) 65 defines audit as: The structured process of collecting independent information on the efficiency, effectiveness and reliability of the total health and safety management system and drawing up plans for corrective action. 3.4 Health and Safety Review 3.5 HS(G) 65 defines review as: A process of making judgements about the adequacy of performance and taking decisions about the nature and timing of actions to remedy deficiencies. In practice, feedback on performance is received from a range of processes across the Service, as listed at sections 3.88 to These include active and reactive

7 H&S01_05_V4- Page No.7 monitoring measures, audits and reviews, corporate and local performance plans, performance indicators, and performance reports. 3.6 Why Audit and Review? 3.7 The following principal reasons reinforce why the Service should be the subject of regular audits and reviews: To check compliance with legislative requirements e.g. Statutory H&S duties To check compliance with relevant good practices e.g. HS(G) 65 To check compliance with the Service s own policies and s To assess the extent to which the Service has been successful in establishing a positive safety culture To recognise positive achievements, as well as areas for improvement To identify training / developmental needs To provide for internal, and in certain circumstances, inter-frs comparisons and benchmarking against performance in other industries / occupations To ensure that management control systems do not erode with time; and To provide a possible defence in the event of civil litigation and / or enforcing authority action. 3.8 Audit Objectives 3.9 To be successful an audit must: Determine the extent of conformity or non-conformity of the safety management system with the s, standards and requirements specified in paragraph 3.4 Provide an opportunity for the Service to improve its safety management system; and Provide management information on the Service s performance against its defined objectives, standards and requirements.

8 H&S01_05_V4- Page No Requirements of the Audit System 3.11 To be effective the audit must: Be planned and systematic Have full support from Corporate Management Team (CMT) Have clearly defined objectives that have been agreed with CMT Be carried out by competent auditors trained in the audit system to be employed Carry sufficient authority within the Service Produce clear results which are easily communicated to the management of the Service; and Result in action plans being drawn up by the Service Appointment and Responsibilities of the Health & Safety Auditors 3.13 All Health and Safety auditors will receive appropriate training and development. Auditors will be required to attend initial and periodic refresher training, in liaison with the Head of Learning & Development (HoL&D). Nominations will take into account the requirements in paragraphs 3.14 to 3.18 inclusive The good practice approach adopted by CFOA South East is to accredit Health and Safety auditors to the RoSPA Quality Safety Audit Lead Auditor or Team Auditor status. All appointed audit team members for audits and reviews of the full SMS will be QSA trained in accordance with RoSPA requirements A minimum of 4 QSA trained auditors will normally be required to undertake a full QSA audit within ESFRS H&S Auditors will normally be nominated from H&S practitioners with suitable accreditation (i.e. NEBOSH certificate or equivalent), having a suitable level of practical experience and underpinning knowledge of interpreting H&S legislation and developing policies and s at Service level. However, in order to ensure

9 H&S01_05_V4- Page No.9 independence, auditors will not audit their own specific areas of responsibility. Therefore nominations for the QSA team will also be sought from other personnel having similar H&S accreditations and trained and experienced in Business auditing For other VFMR, BR and BAs of individual health and safety related matters and in accordance with general audit practices, a minimum of 2 trained auditors will be appointed. The exact size of the appointed audit / review team will take into account the scope of the audit / review and timescale required. The Head of Performance Management will ensure that sufficient team members are appointed, having appropriate levels of accreditation, experience and independence. Accredited QSA H&S auditors will normally be appointed to lead such audits / reviews. However, members of the trained ESFRS Performance Management auditor team may be appointed as team members. These auditors are trained in management auditing and review techniques, in accordance with good practices agreed within CFOA South East A Lead Auditor should be appointed to oversee and co-ordinate all audits / reviews, and to assume ultimate responsibility for its delivery within the agreed scope. The Lead Auditor, in addition to being trained in the audit system to be employed, should be an experienced manager and will have authority to make final decisions regarding the conduct of the audit and the way in which its findings are reported. On full audits / reviews of the ESFRS SMS, the Lead Auditor will normally be a suitably trained and accredited member of another FRS within CFOA SE Region Lead Auditor - Additional responsibilities The designated Lead Auditor shall comply with the responsibilities listed at 3.19, plus: Agree with CMT the scope and extent of the audit (CMT may delegate this task to the Health Safety & Welfare Committee) The selection of other audit team members, should this be deemed necessary Prepare the detailed audit plan and programme Request prior documentation and records

10 H&S01_05_V4- Page No.10 Arrange and take a lead role at the opening and closing meetings Ensure that auditors are not programmed to review their own specific area of responsibility Identify relevant risk assessments and controls, particularly for higher risk areas / activities and brief the audit team, including provisions for ensuring the safety and welfare of visiting external auditors. Liaise with relevant ESFRS Managers to ensure appropriate supervision and safety controls for the Audit team, including during site visits and observations of activities. Brief and supervise the audit team Where the scope and scale of the audit necessitates, to designate members of the audit team to take a lead role on individual elements of the audit Monitor progress during the audit / review and provide interim progress reports Brief the Project Manager regarding any urgent non-compliances / safety critical matters arising Represent the audit team with CMT, to further consider the issues raised Submit a final audit report to CMT / HS&WC Arrange a follow-up audit / review, if requested In liaison with the Head of Performance Management provide a summary report for consideration by the Fire Authority, following approval by CMT All Auditors - responsibilities All designated Auditors shall: Comply with the requirements of the audit system and work within the agreed scope Comply with safety requirements including controls from relevant risk assessments. Undertake dynamic risk assessments before and during audit and review activities Liaise with relevant Managers to ensure appropriate supervision for the Audit team i.e. during site visits and observations of activities Lead on agreed elements of the audit Plan and carry out the audit effectively and efficiently

11 H&S01_05_V4- Page No.11 Document the audit observations Report the audit results Retain and archive documents relating to the audit in accordance with Corporate Services Manual Part 5 Section 1 Ensure such documents remain confidential Treat privileged information with discretion Co-operate with and support the Lead Auditor Comply with ESFRS document control policies and s. Only agreed business assurance documentation will be used to record and report audit and review activities. Maintain a record of time spent on audit / review activities 3.21 Auditors should remain free from bias and influences that could affect objectivity. In accordance with good practices, Auditors will not be programmed to review their own normal areas of activity. The Audit team for full audits of the SMS will include at least one trained Auditor external to the Health and Safety team, in order to provide for independence when examining the specific responsibilities of that section Service management and personnel should respect and support the independence and integrity of the auditors ESFRS will invite Representative Bodies to nominate a suitable observer to participate in audits and reviews of the full SMS. Observers will work under the supervision of the Lead Auditor and be required to comply with audit requirements, including confidentiality and safety controls Safety and Welfare provisions for Auditors 3.25 All Auditors shall comply with requirements from relevant ESFRS risk assessments. These have identified specific controls for audit and review activities. These controls should be reinforced at all times by dynamic risk assessment, particularly when

12 H&S01_05_V4- Page No.12 auditing unfamiliar workplaces and areas such as appliance bays, workshops, plant rooms or observing operational and other safety critical work activities. Close liaison should be maintained with relevant workplace managers and supervisors to ensure that auditors do not enter risk areas without appropriate supervision and other controls Where agreement has been given for designated ESFRS Auditors to assist with an external CFOA H&S Audit programme, all relevant ESFRS s and activity risk assessments i.e. for audit and review activities, use of Service vehicles and for working outside of ESFRS must be complied with. In addition, there must be formal liaison with the designated Lead Auditor and host FRS to agree appropriate controls for visiting auditors undertaking audit activities Where ESFRS is to be assisted by external auditors it is the responsibility of the designated Lead ESFRS Auditor to identify appropriate controls to ensure their safety and welfare, and to brief all team members regarding these arrangements Responsibilities of Corporate Management Team 3.29 The Health and Safety Strategy specifies that CMT is responsible for policy development, reviewing performance and agreeing plans for improvement to develop the SMS. Therefore CMT will receive briefings from the Audit team at the opening and closing meetings CMT will approve and initiate corrective actions based on the audit report, and publish an action plan. (This task may be delegated to the Health Safety & Welfare Committee) CMT will determine the level of reporting to the Fire Authority. Reports on the full Audit of the Service s SMS will be presented to the Scrutiny & Audit Panel of the Fire Authority and a summary report will be forwarded to the full Fire Authority.

13 H&S01_05_V4- Page No Responsibilities of Directors In addition to the responsibilities described in paragraphs to 3.31, Directors shall: On reasonable request, provide suitable levels of resources to enable the audit / review of the SMS and other safety audits / reviews. Relevant Directors will co-operate with any such audit / review, provide in advance any documents or other relevant information requested by the Lead Auditor, and act upon / comply with approved recommendations / actions arising from the findings, following approval of the improvement / action plan. Directorate Heads will brief in advance all relevant employees about the audit, its timetable, objectives and scope. It must not fall to auditors to explain and / or justify the audit to interviewees. Directorate Heads will provide access to relevant documents, records, facilities or other evidential material requested by the auditor(s). Directorate Heads will identify relevant key people i.e. responsible managers or persons to liaise with and suitable person(s) to accompany the auditor(s), particularly where any higher risk areas and / or safety critical activities are within the scope of the audit Responsibility of the Health, Safety & Welfare Committee The HS&WC shall: Consider any recommendations made by the audit / review team Monitor implementation of any action / improvement plan Request follow up reviews or audits to verify that the expected outcomes have been achieved.

14 H&S01_05_V4- Page No Head of Performance Management The Head of Performance Management (HoPM) will: Ensure that health and safety audits / reviews are programmed in the 5 year and annual BVR, BR and BA plans, in accordance with agreed policies Manage requests for other in year audits / reviews Ensure that suitable resources are available to deliver BVRs, BRs and BAs Agree the scope for audits / reviews in liaison with the designated Project Manager Act as Lead auditor on appropriate audits / reviews (if trained and accredited) Report to ACFO on progress and outcomes of audits / reviews Maintain a regional / national approach to developing audit methodologies in accordance with good practices in liaison with the Strategic Health & Safety Advisor. Ensure that health and safety audit / review is an integrated element of the Performance Management framework Once approved by CMT / ESFA, publish outcome reports, including on the Service intranet Ensure that relevant Equality Impact Assessments are completed and act on outcomes Ensure that all audit and review documentation complies with ESFRS document control policies and s Ensure that completed audit reports and supporting documents are archived in accordance with Service policy 3.35 Strategic Health & Safety Advisor The Strategic Health & Safety Advisor (SHSA) shall: Review and develop Health & Safety policy Provide specialist advice on matters relating to the continuing development of health and safety audit and review, and improvement planning in liaison with HoPM Act as team auditor (if trained and accredited)

15 H&S01_05_V4- Page No.15 Instigate an improvement plan to implement the agreed corrective action arising from audits / reviews, as part of the overall H&S Performance Plan Report progress with implementation of improvement plans to HS&WC Liaise with HoPM and HS&WC regarding the CFOA South East programme of inter- FRS H&S audits Liaise with HoPM and HS&WC regarding requests from CFOA South East Health & Safety Group to provide auditors for inter-frs audits Inform HoPM and HoL&OD regarding developments in good H&S audit and review practices, including the training and accreditation of auditors 3.36 Head of Learning & Development The Head of Learning & Development (HoL&D) shall: Provide suitable and sufficient trained and accredited Health and Safety auditors to ensure the effective delivery of programmed health and safety audits / reviews Provide refresher training to ensure that trained auditors maintain competence Liaise with the Quality Assurance Manager to ensure effective succession planning 3.37 Responsibilities of Managers / Supervisors / other staff Release trained Auditors from their areas of responsibility on reasonable request, to ensure that the Fire Authority s BVR, BR and BA programme is delivered All personnel will co-operate fully with the auditor(s) to permit the audit objectives to be achieved Act on / comply with approved recommendations / actions from health and safety audits / reviews and associated improvement plans The Audit Scope and Plan

16 H&S01_05_V4- Page No A formal scope for all audits and reviews will be agreed sufficiently in advance of the programmed audit period to allow for effective pre-planning For full audits of the SMS a written scoping document will be agreed and signed by the ACFO as the designated Principal Officer with day-to-day responsibility for coordinating Health & Safety and as Chair of the HS&WC, and by the HoPM The scope for other periodic audits / reviews i.e. of individual H&S policies / s will be agreed with the relevant Project Manager i.e. ACFO as Chair of HS&WC, or Directorate Head or HoPM or SHSA, and by the designated Lead Auditor All scoping documents will specify terms of reference for the audit / review, including: The designated Client requesting the audit / review (this may be a Corporate Committee such as CMT or the HS&WC, or an individual Director or other manager, such as HoPM) Name of a Project Manager who will provide a single point of contact and strategic direction to HoPM and to the Lead Auditor, and receive feedback, including any urgent matters arising during the audit / review. For full audits / reviews of the SMS the project manager will normally be the ACFO. Names of the designated audit team, including a Lead Auditor Outline of the background link(s) to relevant Business / performance plans or action points i.e. minutes, safety event reports, action plans The standard or criteria against which performance will be reviewed Main areas for audit / review, including specific key business questions The scope for audits of the full SMS must include all key elements of the safety management system Verification that corrective actions from previous audits or reviews have been carried out

17 H&S01_05_V4- Page No.17 Evidence from relevant performance data, trends, reviews, annual reports, including internal and external benchmarking Key people i.e. Directors and Managers responsible for relevant policies, plans, s, & activities Where relevant, a designated contact to accompany auditors, particularly in higher risk areas / activities Key documents & records, including those required in advance of the audit / review Arrangements to brief relevant staff groups in advance of the audit / review Timescales for the completion of the audit / review, and availability of final report Dates, times and venues for the opening and closing meetings 3.43 For full audits of the SMS the scope will also identify the risk control performance indicators (RCPIs) required by the RoSPA QSA system, and / or other criteria as agreed at the CFOA SE Health & Safety Group. The RCPIs will examine compliance with specific H&S regulations, such as PUWER and COSHH Audit Programme 3.45 The audit plan / programme for a full audit of the H&S SMS should be prepared by the Lead Auditor and be presented to CMT at the audit opening meeting. Certain elements of the plan will have been agreed in advance with the ACFO, following an initial scoping meeting For other smaller scale Business Audits of H&S matters, the Lead Auditor will plan an opening meeting with the Project Manager and relevant Director or Lead Manager for the activity under review The plan, which should be designed to be flexible in order to permit changes in emphasis based on information gathered during the audit, should include:

18 H&S01_05_V4- Page No.18 The objectives, scope and extent of the audit, covering all key elements of the SMS. This will include agreement of the specific risk control performance indicators (RCPIs) to be reviewed as required by the full RoSPA QSA process. Identification of individuals having significant direct responsibilities relating to the objectives and scope of the audit Identification of reference documents, (orders, manuals, s, etc.) to be referred to Identification and qualifications of audit team members The audit timetable Identification of Directorates, Sections, Staff Groups, workplaces, activities to be audited The expected time and duration of each major area of audit activity; and The proposed distribution of the audit report and the expected date of issue Confidentiality 3.49 The auditors general responsibilities in respect of confidentiality are listed in paragraph 3.20 above. Confidentiality requirements also apply to observers Upon completion of a draft final report, the Lead Auditor will circulate copies to the Project Manager and individual members of the audit team. The draft report will be marked as strictly confidential. Auditors may only discuss its content with the senior management of the Service and other members of the audit team. Document control requirements are detailed at paragraphs 3.74 to Circulation of the final report on audits / reviews of the full SMS will be at the discretion of CMT, but will include all members of the audit team and the HS&WC. A summary of the final report will be submitted to the Fire Authority as part of the annual Health and Safety report.

19 H&S01_05_V4- Page No Circulation of reports from audits and reviews will be at the discretion of the relevant Project Manager and Directorate Head in liaison with the HoPM and the Lead Auditor Opening Meeting 3.54 All audits / reviews should commence with an opening meeting between the Auditor(s) and the Manager(s) of the area(s) of the Service being audited. For a full audit of the SMS, this will be CMT. The meeting should be minuted and should include the following items on the agenda: A review of the objectives, scope and extent of the audit A brief summary of the audit system to be employed Detail of the agreed lines of communication between the audit team and the relevant managers Confirmation that the documents and records required by the audit team are available Confirmation of the date and time of the closing meeting and any interim meetings to be held if appropriate; and Confirmation of the audit plan Timescale for the availability of the final report Arrangements to provide interim progress reports Arrangements to report urgent non-compliances / safety critical findings Gathering evidence during an audit / review 3.56 During the course of the audit / review, auditors shall: Remain within the scope of the audit Exercise objectivity Collect and analyse sufficient relevant evidence to enable conclusions to be drawn regarding the systems being audited

20 H&S01_05_V4- Page No.20 Remain aware that certain evidence gathered may dictate that more extensive auditing/ review is required Report any issues that impact upon the ability of the auditors to effectively perform their audit role to the relevant manager(s). Treat all information and findings with confidentiality, keeping evidence secure. Comply with safety requirements and controls in relevant risk assessments Comply with requirements of the externally accredited audit / review system in use (e.g. RoSPA QSA) 3.57 The audit system to be employed will indicate to the auditors the areas from which evidence is to be gathered. Evidence should be collected through examination of documents, interviews with personnel at various levels of the Service and observation of activities and conditions in the areas being audited. Wherever possible, evidence extracted from documents should be verified by interviews and physical checks and vice versa The extent of sampling and reality checks will be sufficient to allow objective findings. It should however give consideration, for example, to sampling across different staff groups or different shifts from the same staff group undertaking a common activity to verify if relevant risk controls are being consistently applied During the course of the audit, the Lead Auditor may make changes to the audit plan, should this prove necessary, to ensure the achievement of the audit objectives If it appears to the audit team that it may not be possible to achieve the pre-determined and agreed objectives of the audit, the Lead Auditor should report the reasons to the appropriate Manager(s) without delay All significant observations and findings of the audit should be documented accurately whether or not they suggest non-conformity.

21 H&S01_05_V4- Page No All evidence gathered during an audit should be treated as confidential. If any documents / records are retained by the Audit team these should be stored securely until returned to the Auditee Urgent non-conformities / safety critical findings Auditors will take appropriate action to avoid potential safety occurrences. Local managers / supervisors should be informed of safety critical matters arising, for example, during visits to workplaces or observations of activities. Auditors will also report apparent legal non-compliance and safety critical non-conformities (for example, perceived deficiencies in policy or s) to the Lead Auditor at the earliest opportunity, who will, in turn, inform the appropriate Director / Lead Manager(s) immediately. These matters will be included into the audit report Positive Health and Safety practices The focus of audits and reviews is normally to identify findings and non-conformities to inform continuous improvement in health and safety performance. However, Auditors will also give active regard to positive safety practices that are considered noteworthy for wider adoption. These will normally be matters that are making a positive contribution to health and safety performance Agreement of Findings 3.66 After all areas of the audit / review have been completed, the audit team should review all observations made in order agree findings, including which are to be reported as positive practices, non-conformities and / or safety critical matters. The audit team members must communicate these to the Lead Auditor in a clear, concise manner and

22 H&S01_05_V4- Page No.22 support them with objective evidence. Non-conformities should be identified in relation to the specific requirements of the regulations, standard(s) policies, s or other criteria against which the audit has been conducted Closing Meeting 3.68 At the conclusion of the audit / review, the audit team should meet with those Managers present at the opening meeting. The meeting should be minuted and should commence with a brief review of the main items covered in the opening meeting The Lead Auditor should present a summary of the main findings of the audit, then detail the observations noted in each of the areas covered by the audit. Individual Auditors will present findings for individual areas on which they took the lead role The presentation should highlight: Positive practices that are contributing to health and safety performance Areas of improvement, including in relation to previous audit / review findings Areas where there is opportunity for improvement, or performance has reduced in relation to previous audits / reviews Non-compliances and / or safety critical findings 3.71 If the audit / review system employed (eg RoSPA QSA) provides a performance rating or audit score, this should be communicated at the closing meeting, and supported with relevant data and analysis The audit team may make positive recommendations for improvement to the Service s systems and s. Production of an action plan may be discussed, but will

23 H&S01_05_V4- Page No.23 remain the responsibility of the CMT and HS&WC, or the relevant Director for smaller scale Business Audits Final Audit / Review Report 3.74 The final audit report should be prepared under the direction of the Lead Auditor, who will be responsible for its accuracy and completeness. The structure of the report will normally reflect the headings in the HS(G) 65 model. Full audits / reviews of the SMS will cover all RoSPA QSA criteria The audit / review report should reflect both the tone and content of the audit and should be dated and signed by the Lead Auditor. Intellectual ownership / authorship of the original final audit report rests with the designated Audit team. The original final report agreed by the Lead Auditor must be retained for future reference and clearly marked, normally as v.1. Any subsequent additions to the report must be agreed with the Audit / Review team and reflected into an amended version in which the amendments will be clearly identifiable. A different version number (i.e. v1.1, v1.2 etc) must be used to allow for document control requirements and to provide an audit trail for future reference When highlighting non-conformities, and when making recommendations, the Lead Auditor should divide these into three distinct action categories, i.e.: High - where there are apparent legal non-compliance(s) or safety critical issues Medium - where there is non-compliance with the Service s own policies and s Low - where action(s) to be taken are considered desirable and will improve the overall effectiveness of the safety management system.

24 H&S01_05_V4- Page No.24 Note: The Lead Auditor may exercise discretion and recommend a higher priority where considered appropriate The final audit report should include: An executive summary An introduction A description of the audit system employed Audit results, conclusions and recommendations presented in a logical sequence An audit performance rating, (or score) if this is appropriate A summary of recommendations A disclaimer* *In accordance with audit practices it is appropriate to include a disclaimer to reflect that the audit is a representative sampling exercise. A disclaimer must be included in opening and closing meetings and the final report to the effect that The auditors cannot guarantee identification of all breaches of statutory duties placed on the Service. Absence of comment on any particular feature must not be taken to indicate compliance with any statutory obligations 3.78 Improvement Planning, Corrective Action & Follow-Up 3.79 Auditors are only responsible for working within the agreed scope to identify the nonconformities and providing objective findings, including good practices, to assist relevant Managers with improvement / action planning ACFO is responsible for identifying and implementing appropriate corrective actions necessary to address the issues raised in the audit, in liaison with the HS&WC The SHSA is responsible for managing the improvement plan as part of the overall H&S Performance Plan, and reporting progress to HS&WC

25 H&S01_05_V4- Page No A copy of the Service s improvement / action plan will be forwarded to the Lead Auditor as soon as it is available The HS&WC will, after allowing a suitable implementation period, determine whether a follow-up audit or review is required to verify that the corrective actions identified in the action plan have been initiated and the desired outcomes achieved. The scope for the follow up audit or review must be clearly defined Where a follow-up audit or review is undertaken, the designated Lead Auditor will provide a follow-up report, which will be subject to the same degree of confidentially as the original final audit report All audit reports will be subject to ESFRS document control and archiving policies. Standard audit/ review reporting templates are provided on the Service intranet. All trained auditors will be made aware of the requirement to use these templates Health and Safety Review 3.87 Regulation 5 of the Management of Health & Safety at Work Regulations 1999 describes review as involving: Establishing priorities for necessary remedial action that were discovered as a result of monitoring Periodically reviewing the whole of the SMS to ensure that the whole system remains effective 3.88 In accordance with the Health and Safety Strategy, ESFRS has established arrangements for health and safety review policies and processes within the Performance Management framework i.e.

26 H&S01_05_V4- Page No.26 Active monitoring, including Workplace Inspections, Dynamic and Analytical Risk Assessments, Operational Quality Assurance monitoring at incidents and exercises, Reactive monitoring, including the Management of Safety Events, and maintenance of records and data to enable performance indicators and trend analysis within the performance management framework Performance Management audits and reviews Health and Safety audits and reviews Health and Safety Performance plans and indicators ESFRS Annual Plans Health and Safety Annual Report Quarterly Reports to HSWC 3.89 Responsibilities for these policies and processes are detailed in the ESFA Members Handbook, relevant ESFRS Manual notes and associated performance plans Formal reviews of the SMS, or elements of the SMS, will follow the principles and s required in this manual note Monitoring, Audit and Review of this Policy 3.92 Monitoring, Audit and Review are key elements in the HS(G) 65 model and are fundamental to the SMS and performance management framework within ESFRS Delivery of the audit and review plan will be monitored by the HoPM, who will maintain a tracking document indicating the status of all programmed and completed audits and reviews. Progress on Health and Safety related audits and reviews will be reported to the HS&WC and WSRC. CMT will determine the level of reporting to the Fire Authority.

27 H&S01_05_V4- Page No The effectiveness of this policy and will be subject to systematic audit and review, via full 3 yearly audits and reviews of the SMS as programmed in the Fire Authority s 5 year Value for Money/ Business Assurance Audit & Review plan In addition, other periodic business audits and reviews of specific individual Health and Safety activities will be programmed at the request of the Fire Authority, Corporate Management Team, or Health, Safety and Welfare Committee. These will normally be programmed within the Annual Business Assurance Audit and Review plan. However, it is recognised that there may be a requirement to undertake such audits / reviews on a dynamic basis within a business year, i.e. to verify compliance with a specific Health and Safety regulation or ESFRS policy/, or following a safety event.

28 H&S01_05_V4- Page No.28 appendices 4 Appendices There are no appendices with this document.

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