Self-assessment Exemplar 2

Transcription

1 Self-assessment Exemplar 2

2 XYZ Awards Self-assessment Report & Plan 2015 This document represents the formal submission to SQA Accreditation from XYZ Awards of its 2015 Self-assessment in accordance with 4. S Thomson S Thomson (Accountable Officer) 28 June 2015 SQA Accreditation's 1 The awarding body shall have clearly defined and effective governance arrangements. effective governance arrangements, which support awarding body functions. Consideration should be given to: - key committees and groups, - partnership arrangements, - conflicts of interest, - policies and procedures, - organisational structure. The awarding body must nominate an Accountable Officer and deal with SQA Accreditation in an open and co-operative way and disclose anything which SQA Accreditation would reasonably expect to be made aware. 1. Risk Management Policy - improved risk identification, monitoring and governance Revised Policy introduced March Awarding Body organisational structure New structure in place December ISO 9001 Quality Management System Review and update by Autumn Revised Risk Policy has been introduced to enable improved risk identification, monitoring and management allowing for more effective governance. This improvement was highlighted as a result of wider business planning and governance by the Board. It will enhance the governance of risk across the differing functions. 2. As a result of business planning in 2014 for 2015 it was identified that additional management resources were required in the form of a dedicated Lead EQA. This has strengthened the internal governance of the delivery of our qualifications and the availability of the Quality Manager to focus on other core requirements of the awarding body. 3. It has been identified that a review and amendment of the ISO QMS is required to reflect the new organisational structure and new/revised processes and procedures. This is part of internal governance in helping to ensure the awarding body continues to comply accordingly with its systems, processes and requirements. 1. The Quality Manager will be responsible for ensuring the risk policy is operated effectively within the awarding body, allocating risk owners as appropriate and providing overall management, reporting to the governing body, the Quality Committee, which reports to the Main Board. 2. This appointment was made to mitigate against and reduce the risk of having insufficient resources to achieve the levels of quality assurance, operational and regulatory responsibilities required and overall good practice of which we are committed to. The role and responsibilities of the Lead EQA are detailed within the role profile which form part of the contract of employment. 3. This improvement will make the auditing function more effective and efficient thus further mitigating against and reducing the risk of non-compliance to published systems and processes (including regulatory compliance). 2

3 2 The awarding body shall ensure it has the necessary resources to effectively carry out its operational functions to meet regulatory requirements. that it has effective: - leadership and expertise, - quality management systems and procedures, - technology, - human resources, - financial resources, - and other physical resources, in order to carry out its operational functions. 1. Budget planning, Quarterly Financial Reforecasts Ongoing reviews 2. Development of online membership portal (also maps to RP6, RP7 & RP15) January Annual 2015 budgets for the awarding body were planned and agreed in advance in Quarter in order to meet operational commitments, including regulatory requirements. Additionally, the Quality Manager and Director undertake Quarterly Financial Reforecasts throughout 2015, as part of the finance process, to ensure the awarding body has all the necessary resources required for it to continue to operate effectively and in compliance with all regulation. 2. As a way of improving systems and processes that will benefit both the awarding body and its delivery partners and customers, an online membership portal is in development. This will include a bespoke service for the awarding body and its Approved Centres covering candidate registrations, certification requests, and qualification and assessment team approvals in a secure environment. All of the awarding body staff have been involved in identifying the requirements for the system to operate efficiently and effectively and to regulatory requirements. This advance in technology is a significant investment and evidence of the commitment of the awarding body to continually review and improve the resources and services it offers. The benefits of the system will be to all stakeholders whether this be by increasing efficiencies by reducing bureaucracy, simplified administration processing times and/or providing consistent and accurate audit trails. A pilot is planned for Autumn 2015 with rollout in Regular development reviews and testing is undertaken with the awarding body to reduce the risk of the system not complying with requirements. A pilot will be operated in a controlled environment to mitigate this risk further. The Quality Manager will monitor closely with members of the team to ensure any corrective action identified as part of the pilot can be actioned prior to its launch. Online services have been requested from the awarding body by its Approved Centres. The awarding body consulted with its Centres on their requirements at recent Centre Standardisation meetings and this feedback has been reflected in the development process where appropriate. 3

4 3 The awarding body shall have clearly defined business planning processes which show evidence of management commitment, decision making and ongoing review. The awarding body's objectives must be clearly defined, measurable, show evidence of review and give consideration to SQA accredited qualifications. that it employs robust processes to protect its own business interests, as well as the interests of its providers and learners and have systems in place to manage risk including business continuity and financial planning. 1. Business Planning Meetings (senior managers) Ongoing reviews 2. Directorate and awarding body team meetings Ongoing Reviews 1. Business planning meetings involve the CEO, Directors and all senior staff. The Strategic and Operational Plan (which the awarding body contributes specific strategic and operational objectives) is reviewed providing the opportunity for continuous improvement in management and leadership. In the past 12 months 2 such meetings have taken place (October and April). 2. Team meetings of awarding body products, service levels and its operational activities and responsibilities take place on a routine basis, normally once a month. These meetings include continuous review of activity, systems and processes, regulatory compliance, delivery partner performance, actions, as well as looking at opportunities for further continuous improvement across all areas. 1 & 2. These requirements are managed further by specific objectives to awarding body staff and these objectives form part of individual performance appraisals. 4

5 4 The awarding body shall continually review the effectiveness of its business services, systems, policies and processes. it has systems in place which facilitate continual improvement and show evidence of regular ongoing review and evaluation of its key business activities. The findings from ongoing review must result in an annual self-assessment of the awarding body s operations in relation to SQA Accreditation s regulatory requirements. The awarding body must take appropriate measures to identify business risk and where appropriate take preventative or corrective action. 1. Continuous Improvement Internal Processing Workshops Target Completion Date: August These continuous improvement workshops seek to identify more efficient and effective ways to offer increased customer service. They require the awarding body to identify and question why it undertakes certain processes in the way it does to ascertain whether improvements could be made. This involves ensuring quality assurance/control and that the awarding body conducts its operations ethically and takes account of all relevant legislation, including ensuring regulatory requirements continue to be fully met. 1. The outcomes of these workshops will feed into the new ISO 9001 quality management system (also maps to RP1). These workshops have been identified as part of the business planning activity to ensure systems and processes captured are fully accurate and up to date and have allowed for review to enable efficiency improvements to be identified and implemented. All awarding body staff are involved and it will be the responsibility of the Quality Manager to ensure the team work with the facilitator to enable the workshops to meet objectives. that it conducts its operations ethically and takes account of all relevant legislation. 5

6 5 The awarding body shall provide clear information on its procedures, products and services and ensure that they are accurate and appropriate to SQA accredited qualifications. NB. RPDIR-1, 3 & 4 that its procedures, products and services are clear and that providers are aware of what is expected of them in terms of resources and requirements. that its policies, processes, systems, fees, guidance and publications, including those provided by its providers, make appropriate reference to SQA accredited qualifications and SQA Accreditation. how it effectively promotes SQA accredited qualifications. 1. New Website under development (also maps to RP7) January This is an ongoing project from last year. The new site will have a dedicated area for qualifications covering the awarding body. A number of improvements are being planned for. SQA accredited qualifications will be an important element of the new website. 1. The awarding body is aware that this is an area where significant improvements can and need to be made. The corporate decision to develop a new website and the processes of working towards this has limited changes being able to be made in the shorter term but the outcomes of this investment will ultimately be an improved experience for users of the site. The new site will address the differing audiences and seek to provide information relevant to them in a user friendly format. It is aimed that this will increase customer and stakeholder satisfaction and promote the professionalism of the awarding body. Awarding body staff have been involved in the internal working group to capture requirements. SQA Accreditation's 6 The awarding body and its providers shall maintain accurate documents, records and data. NB. RPDIR-2, 3 & 4 The awarding body must: - demonstrate it has systems in place for the version control of documents, - specify the type of records and data it holds and their associated retention periods including records which must be held by providers, - have robust arrangements and agreements in place with third parties or service providers where applicable, - ensure the accuracy and currency of information shared with SQA Accreditation. 1. Development of online membership portal (also maps to RP2, RP7 & RP15) January As detailed in RP2 (IT improvement). This new system will assist the awarding body in continuing to ensure it meets this RP effectively and efficiently. 1. This investment will assist in reduction of errors such as, for example, submission of incomplete or out of date forms which cause delays in administrative processing. It will also improve data retention and reporting processes. For the first time, Approved Centres will be able to view up to date records at any time of registrations and approvals (qualifications, assessment team personnel) at their Approved Centre which will help them with their records. To manage risk, appropriate authorisations will be allocated which will ensure accountability and that users only view what is relevant to them and submit information as required. 6

7 7 The awarding body shall have effective arrangements for communicating with its staff, stakeholders and SQA Accreditation. NB. RPDIR-1 & 2 how it communicates effectively with staff, providers, learners, external stakeholders and SQA Accreditation. how it promotes an understanding of SQA accredited qualifications and the role of SQA accreditation. 1. Investors in People (IIP) Target date for completion: December Development of online membership portal (also maps to RP2, RP6 & RP15) January New website under development (Maps to RP5) January The awarding body currently has Investors in People (IIP) accreditation. On re-accreditation assessment, our aim is to achieve IIP Bronze Accreditation. Communication with staff is an important aspect of this assessment. The internal working group continues to work towards ensuring better communication within the organisation. 2 & 3 Improved communication has been a key driver behind the decision to invest in these developments. Stakeholder communication is a current priority area for the awarding body and continuous improvement activities going forward will focus particularly on this requirement. While we have received some good feedback on the quality of information that the awarding body does provide, we are aware that we could utilise a greater range of technology, media avenues and promotion activities. SQA Accreditation's 8 The awarding body shall ensure that SQA Accreditation is granted access to all information pertaining to SQA accredited qualifications. NB. RPDIR-2 The awarding body is responsible for ensuring that SQA Accreditation has access to: - awarding body premises and staff, - providers, assessment locations and learners where appropriate, - third parties and service providers where applicable, - documents, records and data, for the purposes of quality assurance. Policies and processes current and valid. No action required at present. N/A The awarding body must also make all providers, delivering accredited qualifications, aware of SQA Accreditation s right of access. 7

8 9 The awarding body shall ensure that it has robust systems and processes for the identification, design, development, implementation and review of qualifications, which meet the needs of users. NB. RPDIR-3 & 4 and Criteria for Accredited Qualifications AC 1.1, 1.2, 1.3, and 1.4 With specific regard to SQA accredited qualifications, the awarding body must demonstrate the application of the following: - identifying the need/demand for a qualification, - designing and developing qualifications which are fit for purpose (including identification of appropriate assessment methods and quality assurance systems), - maintaining and reviewing qualifications. 1. Industry consultation on qualifications requirements (also maps to RP10) Target completion date: March Industry Qualifications Strategy (also maps to RP10) Target Completion date: May The awarding body is presently preparing for a major industry consultation on qualification requirements going forward. This will involve employers, client companies and other stakeholders. Workshops are planned to commence November This consultation will identify what qualifications are required for the industry; what is to be recognised and validated; target audience; and how the awarding body is to deliver the assessment of its qualifications. A key part of the consultations will be identifying the requirements within each devolved nation; the industry requirement for bespoke national qualifications and also what employers are seeking in consistency and comparability across the UK. 5 workshops are planned in Scotland to capture requirements. 2. Following analysis of the outcomes of the industry consultation on qualifications requirements, the awarding body will be submitting a draft Industry Qualifications Strategy to its Governing Body and then the Board for consideration for approval. This will address all the points listed in 1 above. This will be based on industry, client and other stakeholder feedback, including specific requirements within the devolved nations as well as proposals for obtaining consultation outcomes within the requirements of each regulatory body: SQA Accreditation & SCQF framework in Scotland. 1. Engaging with all appropriate stakeholders ensuring the representatives of those stakeholders inputting into each relevant consultation phase process are the most suitably qualified and hold the authority to make the decisions required will be essential. This risk is being carefully planned for and recruitment activities targeted. This will involve the co-ordination of input of a number of differing specialist functions, including Board members, as well as known key employer, client and other stakeholder contacts and external organisations and other relevant bodies. The Quality Manager and Director are accountable for ensuring that, as far as possible, risk is mitigated and reduced. 2. All outcomes that will inform the final draft Strategy will be validated with key senior representatives of the major employers and clients of the industry. 8

9 10 The awarding body shall ensure that it has the necessary arrangements and resources for the effective delivery, assessment and quality assurance of SQA accredited qualifications. NB. RPDIR-1 and Criteria for Accredited Qualifications AC 1.5 and 1.6 To demonstrate the effective delivery of its qualifications the awarding body must develop and implement assessments which are fit for purpose, rigorous and reliable. The awarding body should consider the following: - the type of qualification, - methods of assessment, - conditions of assessment, - resources (including the roles, responsibilities and requirements of the personnel involved in delivery and assessment and also any technical or physical resources required), - evidence requirements (including the type, amount and standard of evidence to be produced), - assessment principles or requirements for the qualification (e.g. assessment strategies, assessment principles/requirements or any awarding body devised assessment criteria or guidelines). it has an effective and appropriate quality assurance system which ensures the quality and consistency of assessment provided over time, at any location and between locations. The awarding body should consider the following: - the type of qualification, - methods of assessment, - conditions of assessment, - resources (including the roles, responsibilities and requirements of the personnel involved in quality assurance and also any technical or physical resources required), - frequency of quality assurance activity, - quality assurance principles or external quality control requirements for the qualification (e.g. assessment strategies, assessment principles/requirements or any awarding body devised criteria or guidelines)." 1. Industry consultation on qualifications requirements (also maps to RP9) Target completion date: March Industry Qualifications Strategy (also maps to RP9) Target Completion date: May EQA Approved Centre s Monitoring Log Implemented January Development of an expert witness advisor guide November As detailed above in RP 9. Assessment requirements are an integral part of this consultation and outcomes from this will inform development and implementation going forward. 2. As detailed above in RP9. The awarding body will include quality assurance and resource requirements when drafting the Strategy. 3. The awarding body has implemented a centralised log of actions raised with its Approved Centres by EQAs. This is monitored and actioned by the Lead EQA and the Log is reviewed at regular team meetings. 4. This is in draft development and will support existing guidelines and information provided to Centres at recent Approved Centre Standardisation meetings. 1. As detailed above in RP9. 2. As detailed above in RP9. 3. The Lead EQA holds day to day responsibilities for compilation and monitoring of the Log and its reporting. The Accountable Officer is responsible for ensuring it delivers on requirements. This was discussed wider as part of internal continuous improvement review. 4. This improvement has been initiated by the awarding body following comments/actions raised by its EQAs across a number of monitoring visits. The ownership of this development is with the Lead Verifier. Review of drafts will be undertaken within the awarding body team, including EQAs. 9

10 11 The awarding body shall ensure that its qualifications and their assessment are inclusive and accessible to learners. how its equality and diversity policies comply with relevant legislation. it has a clear process for reasonable adjustments and special considerations. Policies and processes current and valid. No action required at present. N/A Where appropriate, the awarding body must define any barriers, requirements or conditions which could affect standards. that there are no unnecessary barriers to entry or assessment. SQA Accreditation's 12 The awarding body and its providers shall have open and transparent systems to manage complaints. The awarding body and its providers must deal with complaints on an equitable basis, in line with its published procedures and timescales, and without unreasonable delay. Policies and processes current and valid. (NB. This policy was updated prior to 2014 Selfassessment submission). No action required at present. N/A NB. RPDIR-5 awarding body personnel, providers and learners must be made aware of how and when they can complain to SQA Accreditation. Where a complaint is upheld, the awarding body and/or provider must take appropriate, preventative and/or corrective action. 10

11 13 The awarding body and its providers shall have clear, fair and equitable procedures to manage appeals. The awarding body and its providers must have clearly defined processes to deal with appeals for services that it offers. Consideration should be given to: - how, when and the circumstances under which an appeal can be made, - timescales for appeals, - independent review. Policies and processes current and valid. (NB. Minor updates to this policy were made prior to 2014 Self-assessment submission). No action required at present. N/A SQA Accreditation's 14 The awarding body and its providers shall ensure that it has safeguards to prevent and manage cases of malpractice and maladministration. The awarding body and its providers must have clearly defined processes to deal with malpractice and maladministration. The awarding body must inform SQA Accreditation when any cases, or suspected cases, of malpractice and/or maladministration are discovered. The awarding body and its providers must develop and implement corrective action plans to prevent further occurrence. Policies and processes current and valid. (The awarding body made significant updates to its Malpractice & Malpractice Policy and Sanctions Policy prior to 2014 Self-assessment submission. This resulted in an updated Malpractice, Maladministration & Whistleblowing Policy and Sanctions & Restrictions Policy). No action required at present. N/A 11

12 15 The awarding body and its providers shall have effective, reliable and secure systems for the registration and certification of learners. NB. RPDIR-2, 3 and 4 The awarding body and its providers must maintain systems which hold secure information on learner achievement and progress and comply with relevant legislation. The awarding body must ensure that qualification and Unit certificates (including replacements): - meet SQA Accreditation s minimum requirements, - reflect learner achievement, - are only issued on the basis of a valid claim, - are designed to protect against fraudulent use, - have published timescales for issue, - are revoked where fraud or malpractice has been identified. 1. Development of online membership portal (also maps to RP2, RP6 & RP7) January As detailed in RP2 (IT improvement) and RP6 & RP7. The new IT system is in development and is being structured and built to ensure compliance with this RP. The new system will be in addition to existing systems. 1. Security, reliability and effectiveness of the new system are integral parameters of the development and phased pilot rollout. As part of risk management, the pilot will ensure appropriate manual validation checks. The system will only be rolled out when these have completed to satisfaction and any corrective action identified has been addressed. This will be agreed within the awarding body team with the final 'live' authority provided by the Quality Manager and Director. The awarding body must seek approval from SQA Accreditation prior to processing certificate claims for expired qualifications. 12