Corrective Action Plan (CAP) Submission by: Corrective Action and Root Cause Analysis

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Loraine McDaniel
5 years ago
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The CAP Submission date (shown above) is the 28 day deadline for corrective action and root cause to be forwarded to PAI s office. 3.

1 Visit Reference: Audit Date: Client Name: Corrective Action Plan (CAP) Submission by: Corrective Action and Root Cause Analysis 1. Detailed in the tables below are the non-conformities identified during your BRC Evaluation Assessment visit. 2. The CAP Submission date (shown above) is the 28 day deadline for corrective action and root cause to be forwarded to PAI s office. 3. Please submit Corrective Action Evidence and Root Cause Analysis to sheila.robson@thepaigroup.com 4. Each CAP document submitted as objective evidence must be identified by a specific Non-Conformance (NC) Number and Clause/ (E.g. MINOR NC-06 Clause 2.2.1). The identification of the objective evidence submitted aids the close-out process. Please note that under the BRC Global Standard, it is a requirement that all non-conformities must be closed out within a 28 day calendar period following the audit. If satisfactory evidence is not provided within the 28 calendar day period allowed for submission, this means that certification will not be granted. The company will require a full re-evaluation in order to be considered for certification. For this reason, clients are strongly advised to submit their corrective action and root cause information well before the 28 day deadline, in case further information is required to close out the non-conformity. Following the identification of any non-conformity the company must undertake corrective action both to remedy the immediate issue and to undertake an analysis of the underlying cause of the non-conformity (root cause) and thereby develop a corrective action plan to address the root cause. Clients have the right of Appeal against either the information contained in Kiwa PAI Assessment Reports or the recommendations arising from Assessment Reports. The Appeal must be made in writing to Kiwa PAI within 2 weeks of receiving the information on which the Appeal is based. Page 1 of 5

2 Example of Root Cause Analysis: Whys approach - Asking Why? a number of times will get to the reason why the non-conformity occurred in the first place. e.g. Non-conformity: Operative seen wearing necklace in contravention of the company hygiene rules 1. Why was he wearing it? Nobody had told him he couldn t 2. Why had nobody told him? New employee 3. Why wasn t he informed of the rules? Not included in induction given to new staff 4. Why had no-one identified he was wearing it? Nobody checks staff are complying with rules So the root cause of the problem was that the hygiene rules were not included in the induction given to new staff and the immediate corrective action is to train him in the rules. The corrective action plan going forward is to monitor staff in respect of the site hygiene rules to avoid this non-conformity occurring again. Suggested evidence required for this example: 1. Training record for this operative 2. Details of what is now included in the induction 3. Details of the checks on staff - daily/weekly monitoring record 4. Include any new documents which have been issued along with evidence that the new documents are now in use e.g. Completed check sheets Summary of Corrective and Preventative Action Taken 1. A summary of the Corrective and Preventative action taken, including root cause analysis should be completed and typed into the tables below. 2. Please note the certification process cannot be completed without Root Cause Analysis for each Non-conformity. Certification Process 1. On receipt of the CAP document and the supporting objective evidence to close out the non-conformances, a technical review is carried out of the assessor s notes, assessor s report and the CAP submitted by you. The decision to award certification is made following this review. 2. The full typed audit report will not be available until the technical review has been completed. 3. The completion of the review process and issue of certificate/report is usually around day 42 following the assessment. 4. A PDF version of the certificate and report will be issued by PAI Ltd. A hard copy of the certificate will be posted. 5. The BRC Directory website will also send notification of your site s certification. Page 2 of 5

3 Total Number of NC s Raised at this audit: Critical / Major against a fundamental Critical Major Minor Acceptance of Non-conformities Auditor Auditor number: Auditor Signature: Name: Client Name: Position: Client Signature: Critical or Major Non-Conformities Against Fundamental s Critical or Major? Anticipated re-audit date Critical Anticipated re-audit date Page 3 of 5

4 Major Corrective action taken Root cause analysis and proposed action plan Evidence provided document, photograph, visit/other Minor Corrective action taken Root cause analysis and proposed action plan Evidence provided document, photograph, visit/other Page 4 of 5

5 Minor Page 5 of 5

Critical 0 Major 0 Minor 0. Certification Body name and address

Critical 0 Major 0 Minor 0. Certification Body name and address Audit Report Global Standard for Agents and Brokers Issue 1: January 2014 1.Audit Summary Company name BRC Site Code BRC Site code 2.Scope Operation Services Scope of audit Product categories Select Operation