Health and Safety Practice Guidance Note SAFETY INSPECTION AUDITS Date issued Issue 1 Oct 12 Issue 2 Nov 15 Issue 3 Jul 16 Issue 4 Dec 16 Issue 5 Jun 17 Planned review Dec 2017 Responsible officer Tony Gray HS-PGN-12 Part of NTW(O)20 Health and Safety Policy Section Content Page No 1 Introduction 1 2 Why we need audits 2 3 Who are safety representatives 2 4 What is the function of a safety representative 2 5 Audit programme schedule 3 6 Arranging the audit 3 7 Audit paperwork 3 8 Audit guidelines 3 9 Completing the audit paperwork 4 Appendix 1 Appendix 2 Appendix 3 Appendix 4 Directorate Audit Schedule Audit of Area 1. INTRODUCTION Audit Guidelines Appendices Health and safety improvement notice 1.1 Health and Safety auditing is described as an ongoing process involving critical examination of an organisations activities against a set of specific and attainable standards. It is a tool used to identify the strengths and weaknesses within a working environment and covers elements such as policy, staff attitudes, training, personal protection and emergency procedures. 1.2 A set of Recommendations are normally produced on the day of the audit which informs the responsible manager of improvements to be made or where remedial action is to be taken. 1
1.3 This document will clarify the process of staff side safety auditing within (the Trust) and the function of the staff side representatives involved. It will identify the responsibilities of managers in ensuring a safe place of work for their staff. 2 WHY WE NEED AUDITS 2.1 Staff side safety representatives have the right under Regulation 5 (1) of the Safety Representatives and Safety Committee Regulations 1977, to carry out inspections in accordance with Regulations 5, 6 and 7. 2.2 Staff side representatives are entitled to inspect the workplace or a part of it if they have given the Trust or their representative reasonable notice in writing of their intention to do so and have not inspected it, or that part of it, as the case may be, in the previous three months; and may carry out more frequent inspections by agreement with the Trust. 2.3 The Trust has a duty to permit those safety representatives such time off with pay during the employee's working hours as necessary for the purpose of carrying out those functions as may be reasonable in all the circumstances'. 3 WHO ARE SAFETY REPRESENTATIVES 3.1 They are persons appointed by a trade union, the union giving the Trust written notification of their appointment. Safety representative shall so far as is reasonably practicable either have been employed by the Trust throughout the preceding two years or have had at least two years' experience in similar employment. 4 WHAT IS THE FUNCTION OF A SAFETY REPRESENTATIVE 4.1 The function of the safety representative is a wide ranging one as detailed below, however they have no more duty imposed on them than any other employee as described in section 7 and 8 of the Health and Safety at Work etc act 1974. 4.2 In order to fulfil their functions under section 2(4) of the Act safety representatives should keep themselves informed of: the legal requirements relating to the health and safety of persons at work, particularly the group or groups of persons they directly represent; the particular hazards of the workplace and the measures deemed necessary to eliminate or minimise the risk deriving from these hazards, and the health and safety policy of their employer and the organisation and arrangements for fulfilling that policy; Safety representatives are entitled: to investigate potential hazards and dangerous occurrences at the workplace (whether or not they are drawn to his attention by the employees he represents) and to examine the causes of accidents at the workplace; to investigate complaints by any employee he represents relating to that employee's health, safety or welfare at work; 2
to make representations to the employer on general matters affecting the health safety or welfare at work of the employees at the workplace; to represent the employees he was appointed to represent in consultations at the workplace with inspectors of the Health and Safety Executive and of any other enforcing authority; to attend meetings of the health and safety committee; to carry out inspections in accordance with Regulations 5, 6 and 7; 5 AUDIT PROGRAMME/SCHEDULE (Appendix 1 - Directorate Audit Schedule) 5.1 A full audit programme/schedule will be drawn up between staff side and management to identify those areas to be covered. The audit frequency will be dependent upon the high risk nature of activities within the units departments or facility. Which will mean that those areas determined as high risk will normally be audited on an annual basis and other areas defined as low risk every 18 months or in some cases alternate years? 5.2 The auditors retain the right to inspect areas where concerns may be raised by their members again with notice to the Trust. 6 ARRANGING THE AUDIT 6.1 Safety Representatives are required to contact the manager of the unit, ward, department or facility by telephone and standard letter at least one week prior to the scheduled date to arrange the audit. The manager or representative is required to be present during the audit to ensure the accuracy of information and effectiveness of remedial actions. In the event of unforeseen circumstances of either party every effort should be made to inform of the cancellation. 7 AUDIT - PAPER WORK (Appendix 2 Health and Safety Audit of Area) 7.1 The Audit paper work consists of a front page 1 of 4 and contains sections to identify where and when the audit was conducted, who the auditor was and the manager of the area being audited 7.2 The audit overview page 2 of 4 is an aide memoir to the auditor and covers items such as Policy and procedure, Risk assessment, training and the work environment. 7.3 Pages 3 and 4 of 4 are for identifying issues which need addressing and their risk potential. These pages can be added to if the auditor raises a significant number of issues. 8 AUDIT GUIDELINES (Appendix 3 Health and Safety Audit Guidelines) 8.1 The Auditors are supported by Audit Guidelines drawn up directly from Health and Safety Legislation and provide guidance on information from specific Directives 3
such as Health and Safety Welfare arrangements, Personal Protective Equipment, Control of Substances Hazardous to Health, Food Hygiene, and Estates guidance. 9 COMPLETING THE AUDIT PAPER WORK Front Cover Page 1 of 4 The Auditor should include the following information: The Directorate Unit Ward, Dept or facility name where the audit is being conducted The Number of Concerns or issues raised The Total Number of pages used in the audit The Auditors name and manager s name The date of the audit and the date the last audit was carried out The Audit should be given a unique reference, consisting of the unit name and year of audit i.e. Stephenson Court SC2007 Overview Page 2 of 4 The auditor has many points to cover during the inspection, a list of activities and environmental considerations has been produced to guide and prompt their attention. The auditor may wish to look at each section as it appears on the list or deal with them as and when they appear during the audit. For each area covered on the list the auditor will determine whether the section applies to that particular area. If it does not apply then a tick will be placed in the box (not applicable) If the section does apply and all areas are satisfactory the appropriate box is ticked. Risk rating If an issue is highlighted where improvements can be made then a risk rating will need to be attached to the appropriate section and the box ticked, the issue should then be written down on the next page 3 of 4. Coding The code should be written in the section marked code i.e. (1, Housekeeping) Summary A short description of the issue raised should be written i.e. it was noted that rubbish is allowed to accumulate in the corridor near fire exits which may impede evacuation during an emergency. Risk Area 4
The risk area which has been identified with the corresponding issue on page 2 of 4 should then be transferred to the appropriate column. Low, Medium, High. On page 3 of 4. Pages 4 of 4 should be used as continuation sheets and added to if necessary. The Auditor continues to work through the list of audit points completing each section as described. When the audit is complete both the auditor and the manager agree the points raised and sign the document as a true and accurate account of the audit. Remedial Actions For each issue raised the manager/representative would be expected to provide a timescale of when any remedial actions would be completed, as many issues may be resolved immediately and few issues will take time to complete. Report Writing Some auditors may wish to add a brief report on their findings which can accompany the audit paper work; again the unique reference number should be used to identify the report; this should not be seen as a time consuming or onerous task. Completed Audits Should be copied by the auditor and sent to the Patient Safety Officer responsible for the Directorate who will ensure the administration of the paper work. When the manager of the area receives the results of the audit they simply return the tear off slip to the patient safety officer who has issued the improvement notices. Improvement Notices (Appendix 4 Health and Safety Improvement Notice) The improvement notices detail the issues to be addressed. Notices include the description of the issue raised, who is responsible for taking action or providing advice on actions, a risk rating will be attached to grade the importance of the action. When the issue has been resolved the improvement notice should be completed by the managers and sent back to the appropriate Patient Safety Officer for their records. Remedial Action Will be monitored by inviting the managers involved in the audit to a Directorate group meeting to discuss what actions they have taken to resolve the issues raised and give the reasons why some issues may still be awaiting action. 5
6