HSMS08 Health and Safety Management System Audits · Audits will be carried out in accordance with ISO standardscurrent and will examine all key elements of the health and safety

Anglia Ruskin University Higher Education Corporation Risk Management

AR-RMD-HSMS08/Issue 12.0 Page 0 of 21 March 2017

Title Health and Safety Management System Audits Reference Number

AR-RMD-HSMS08

DOCUMENT HISTORY Issue Date Issue Date Amendments

1.0 May-02 9.0

Sept-12

2.0 Mar-04 10.0 Nov-13

Section 4.1 added “as per app 1” Removed Understanding/Allocating Responsibility, Securing commitment and training, Hazard identification and record keeping Added new Audit form App 1

3.0 May-05 11.0

Sep-15

4.0 Jan-06 12.0

March-17

Changed support services to professional services. Change of VC name. Question added (appendix 1, Q13) with regards to retention of health and safety records. All recommendations from the audit programme are tracked as KPI’s. (sect 4.1, BP7)

5.0 Jan-07

6.0 Jan-08

7.0 Oct-09

8.0 May-11

Author

Name: P Varley

Reviewer

Name: HSPG

Authorised by

Name: I. Martin Vice Chancellor

Issued by

Name: Risk Management



Health and Safety Management System Audits

AR-RMD-HSMS08 Table of Contents 1. Executive Summary ....................................................................................... 2 2. Health and Safety Management System Audits ............................................ 3

2.1 Policy ...................................................................................................... 3 2.2 Application .............................................................................................. 3

3. Responsibilities and Requirements ............................................................... 4 3.1 Vice Chancellor ...................................................................................... 4 3.2 Health and Safety Policy Group ............................................................. 4 3.3 Faculty Deans and Directors of Professional services ........................... 5 3.4 Lead Auditors ......................................................................................... 6 3.5 Risk Management ................................................................................... 6

4. Internal Audit of Faculties and Professional services .................................... 7 5. HSMS Compliance Checks ........................................................................... 8 6. References .................................................................................................... 8 7. Definitions ...................................................................................................... 8

Appendix 1 - Internal Audit pro-forma .................................................................



1. Executive Summary

The health and safety policy group (HSPG) have responsibility for evaluating the reliability, efficiency and effectiveness of Anglia Ruskin University’s health and safety management arrangements. This is achieved through an audit process, as detailed within this policy.

Audits will be carried out in accordance with current ISO standards and will examine all key elements of the health and safety management system (HSMS) and the implementation of it, and any local policies and procedures, within the area being audited. Auditors will be suitable trained and independent of the area being audited. Faculty deans and directors of professional services must give their full co-operation to the auditing team and ensure that their staff does the same.

The policy provides further information on the aspects of the HSMS that are to be audited, the responsibilities of the auditor(s) and the responsibilities of the management within the area being audited. Information is also provided on how Risk Management will undertake internal audits of faculties/ professional services.

Originating Legislation: Health and Safety at Work Act 1974 Management of Health and Safety Regulations 1999 Other relevant documents: Health and Safety Management System Review, Formulation and Development of the University’s Health and Safety Management Systems

AR-RMD-HSMS03

Review, Formulation and Development of the School and Departmental Health and Safety Management Systems

AR-RMD-HSMS23



2. Health and Safety Management System Audits

2.1 Policy

Anglia Ruskin University is committed to ensuring that all its employees are consistently provided with a level of competent health and safety management appropriate to the degree of risk associated with their activities.

Anglia Ruskin University will ensure, so far as is reasonably practicable, that the risks to the health and safety of staff, students and visitors will be managed in compliance with the Health and Safety at Work etc. Act 1974, the Management of Health and Safety at Work Regulations 1999 and other appropriate regulations and guidance.

To comply with the relevant legislation and guidance, Anglia Ruskin University will:

• Appoint competent persons, within Risk Management (RM), to assist

Anglia Ruskin University in understanding, coming to terms with and complying with the regulations

• Clearly define the role of all personnel in order to help them to effectively meet their responsibilities within the university health and safety management system (HSMS)

• Ensure that all staff are suitably trained to deal with the health and safety issues relevant to their position

• Provide suitable and sufficient information, instruction, training and supervision to all relevant staff, students and visitors

• Ensure effective liaison with local authorities and other external bodies where appropriate

• Regularly audit all the components of the HSMS 2.2 Application

It is the policy of the Anglia Ruskin University to regularly audit all the components of the HSMS to aid Anglia Ruskin University’s health and safety review, planning and risk control activities. This activity will provide the health and safety policy group (HSPG) with information that will enable them to evaluate the reliability, efficiency and effectiveness of the university’s arrangements for policy making, organising, planning, implementing, measuring and reviewing performance.

Auditors will comply with the methodology of ISO ‘Guide to Quality Systems Auditing’ and will ensure coverage of:



• The Health and Safety Policy Statement (AR-RMD-HSMS01), including its intent, scope and adequacy

• Organisational responsibilities and procedures for the HSMS including: The control of the HSMS The co-operation and involvement of employees The communication of health and safety information The competence of employees The planning and implementation of the HSMS The measurement of health and safety performance The reviewing the health and safety performance of the

organisation The extent of compliance with:

~ Organisational procedures ~ The control measures identified in the risk

assessment procedures ~ The long-term improvement in the accident and

incident performance ~ The allocation of resources to implement the policy

3. Responsibilities and Requirements

3.1 Vice Chancellor

The vice chancellor has overall responsibility for the establishment, ongoing development, implementation, monitoring and review of the HSMS.

3.2 Health and Safety Policy Group The health and safety policy group (HSPG) have been delegated

operational responsibility for planning and guiding the ongoing development, implementation, monitoring and review of the HSMS, including this procedure.

The HSPG are responsible for:

• Arranging for total system audits in specific areas to be held at 2-3

yearly intervals • Ensuring that a competent person, qualified to ISO/CMIOSH standard

is appointed as lead auditor • Ensuring that all auditors have been trained to an appropriate level and

have a suitable level of operational experience to enable them to gather and interpret information and make appropriate conclusions

• Ensuring that all auditors on the team are independent of the area being audited



• Ensuring that the auditors have the full support of faculty deans/directors of professional services and their managers and supervisors, and access to specialist advice, if required

• Maintaining copies of total system audit reports, together with any accompanying documentation, for audit and review purposes, for a minimum of three years

Note: The HSPG may delegate the above tasks to specific personnel (e.g. Risk Management (RM), faculty deans and directors of professional services etc), as appropriate.

3.3 Faculty Deans and Directors of Professional services

Faculty deans and directors of professional services are responsible for:

• The implementation of this procedure within their area of responsibility • Identifying the required level of general health and safety competency

required by their managers • Ensuring that there are arrangements in place to provide appropriate

information to members of staff, students, visitors etc • Co-operating fully with the auditors, including the provision of access to

relevant facilities, resources and any evidence or material as requested by the auditors

• Appointing responsible persons to accompany the auditors in order to assist in the discovery and interpretation of required information

• Ensuring that relevant employees are informed about the audit objectives and scope

• Reviewing the total system audit report and findings, and producing a suitably resourced and documented implementation plan for any required corrective measures

• Ensuring the planned actions are reviewed at set intervals in order to check progress and verify that objectives have been achieved

• Providing a report each semester to the HSPG, in order to aid their review of the HSMS

Note: The faculty deans/directors of professional services may delegate the above tasks to specific managers, within their area of authority, as appropriate.



3.4 Lead Auditors

Lead Auditors are responsible for:

• Assisting with the selection and training of other auditors, if appropriate • Defining the audit scope and the management of the area being

audited • Preparation of an audit plan to meet the agreed scope • Communicating and clarifying the audit requirements as appropriate

with the management and staff of the area to be audited • “Opening” the audit at an initial meeting, during which the audit

requirements and methodology are confirmed with local management and employee representatives

• Planning and carrying out assigned responsibilities effectively and efficiently in order to comply with the audit requirements, collecting evidence by the review of documentation, interview and activity observation

• Documenting observations accurately within an audit workbook • “Closing” the audit at a final meeting at which the auditors’ findings and

initial conclusions/recommendations are presented to the local management team

• Submitting an audit report, within an agreed time-scale • Treating all information with discretion and ensuring that all documents

remain confidential • If requested to do so, verifying the effectiveness of corrective actions

taken as a result of the audit

3.5 Risk Management

RM is responsible for:

• Arranging, in consultation with HSPG, suitable audit training for members of the audit team

• Providing support, as requested, to the auditors and attending audits, if requested and appropriate

• Reviewing the total system audit reports, and any accompanying documents, for adequacy of cover and corrective action. Reports and requests for remedial action will be submitted to the faculty dean or director of professional services for action

• Carrying out HSMS compliance checks to ensure that all identified managers and staff carry out their delegated responsibilities

• Prepare an annual report for the HSPG on the adequacy of the audit system. This shall form part of the university’s annual review of its HSMS performance and will include key performance Indicators, covering such areas as percentage of outstanding recommendations



4. Internal Audit of Faculties and Professional services

In addition to the total system audits, a programme of internal audits will be established, to ensure that faculties and professional services comply with the requirements of the HSMS. This programme will be developed and implemented by RM, on behalf of the HSPG, and run on a biannual basis.

4.1 RM will:

• Carry out Internal audits, as per Appendix 1 • “Open” the internal audit at an initial meeting with the faculty

dean/head of professional services • Arrange subsequent meetings with those who have been delegated

responsibility for health and safety within the area being audited • Examine relevant faculty/ professional services documents in order

to establish the current level of compliance with the requirements of the HSMS

• Complete the internal audit pro-forma (Appendix 1), and send a signed copy, together with a list of action points required, to the dean or director. The report will include recommended implementation time-scales for each action point listed. Implementation plan objectives shall be specific, measurable, agreed with those responsible for their implementation and time targeted. No audit finding or recommendation shall be rejected without a good reason

• Prepare an annual report for the HSPG on the adequacy of the internal audit system. This shall form part of the university’s annual review of its HSMS performance

• Track recommendations from the audit programme as key performance indicators (KPI’s)

4.2 In order to assist RM, faculty deans and directors of professional

services will:

• Consider the findings of internal audit report and the associated action points and producing a suitably resourced and documented implementation plan

• Sign the internal audit report and return it to RM for future reference.



5. HSMS Compliance Checks

In addition to the total system audits and internal audits, a programme of HSMS compliance checks will be established, to ensure that all managers and staff carry out their delegated responsibilities, as identified in the HSMS. This programme will be developed and implemented by RM, on behalf of the HSPG.

6. References

6.1 HSG 65 ‘Successful Health and Safety Management’.

BS 8800: 1996 ‘Guide to Occupational Health and Safety Management

Systems’.

BS EN 30011-1:1993 (ISO 10011) ‘Guide to Quality Systems Auditing’.

7. Definitions

7.1.1 Audit:

A systematic and, whenever possible, independent examination to determine whether activities and related results conform to planned arrangements. The aim of audit is to determine whether these arrangements are implemented effectively and whether they achieve the organisation’s policy and objectives.

7.1.2 Total Systems Audit:

An audit that examines the quality of both the formal and implementation aspects of the University’s health and safety management system against: • Current Health and Safety Executive guidance. • Current legislation • The British Standard BS 8800 ‘Guide to Occupational Health and

Safety Management Systems'. • The guidance of OHSAS 18001 Occupational Health and Safety

Management Systems - Specification’.



7.1.3 Internal audit:

An audit that examines the standard of implementation of the university’s existing health and safety management system procedures.

7.1.4 External Auditors

ROSPA – Royal Society for the Prevention of Accidents. 7.1.5 Internal Auditors

Members of Anglia Ruskin University Risk Management. 7.1.6 Health and Safety Management System

A composite, at any level of complexity, of personnel, resources, policies and procedure, the components of which interact in an organised way to ensure that a given task is performed, or to achieve or maintain a specified objective in a manner which gives rise to minimum risk to those who could be affected.



Appendix 1 AUDIT FORM

Faculty / support service: Date:

Name of auditor: Signed for RM:

Name of staff representative for faculty / support service: Newest Staff Member: Started:

Signed for faculty / support service:

Overview

Policy Yes No In Progress N/A Comments

1) Has the Faculty / support service produced a signed and dated health and safety management structure appropriate to the scale and nature of the Faculty / professional services activities?

2) Are the management and / or other individual’s with special responsibility for co-ordinating health & safety identified and responsibilities clearly identified?

3) * Is there evidence to show that the policy has been communicated to employees and students, e.g. though induction, student guides.



Organising and Planning Yes No In

Progress N/A Comments

4) Have all managers been briefed and accepted their H&S responsibilities?

5) Are the levels of supervision influenced by the severity of the risks in the workplace and the competence of the employees involved?

6) Are regular H&S meetings being held by the faculty / support service?

7) Are meeting minutes effectively communicated to all employees, and stipulated actions and those responsible for implementing such actions carried out?

8) Has a member of senior management been present at all Health and Safety meetings?

9) * Have emergency procedures been communicated to all employees and students?

10) Is relevant H&S documentation available in student module guides or on the VLE, is this communicated to all students at the start of the new academic year by all academic staff?

11) * Is H&S covered as part of new employee inductions, and new employees made aware of ARU’s RM website?

12) Is all H&S documentation available on the ‘J’ drive for circulation within the Faculty / support service?

13) Are the legal requirements, confidentiality, write protection and disposal of health and safety records for retention



considered? Who is responsible?



14) Is there a Faculty/Support Service process for risk assessment?

15) Does the process cover?

a) Activities of all persons having access to the workplace

(including contractors and visitors)?

b) Activities outside the workplace such as fieldwork/ lone working / student placements / employee business travel both nationally and internationally?

c) Activities within the faculty / support service that may affect others within the vicinity and not directly involved in the activity?

d) Occupational exposure and health assessments?

e) Records of incidents and accidents

f) Noise / vibration

g) PEEP

h) Pregnant or nursing mothers





i) Children and young person’s / work experience / summer school

j) Disabled employees or students

k) CoSHH - Is there evidence to show that measures have been taken for the control of substances hazardous to health?

l) Has a list or inventory of hazardous substances been compiled showing stock levels, storage locations, and storage conditions?

m) Is there consistent assessment of chemical substances, micro-organisms / biological agents, radiation and DSEAR?

16) Are there safe systems of work, procedures, or protocols, available and accessible for employees and students?

17) Are the manufacturers or suppliers instructions for operation and maintenance of equipment and MSDS information for chemical or hazardous substances available?



Organising and Planning

Yes No In Progress

N/A Comments

18) Have control measures e.g. for ventilation, guarding, PPE, etc been implemented and reviewed?

19) Is the maintenance of equipment up to date? Have measures been taken to address the risks from the use and maintenance of work equipment?

20) Is there evidence to show that the faculty / support service has identified all DSE users?

21) * Has a DSE assessment been completed by all staff within the faculty / support service?

22) Have the risks of lone working been assessed and procedures put in place?

23) With regards to staff and students, has the potential psychological effects of events which may occur been risk assessed and a procedure to deal with this been put in place.



24) Is there a fire risk assessment in place, and are escape routes clear and procedures in place in case of emergency?



25) Have senior management completed safety training?

26) * Are arrangements in place for training / are employees trained in the following as applicable:

a) Risk Assessment

b) Fire / Fire Marshalls

c) First aid

d) DSE

e) CoSHH assessment

f) DSEAR assessment

g) PEEP

h) Manual handling

i) Any other training requirements?



27) Are training records available and up to date?

28) Are there arrangements in place for H&S tours to be conducted?



29) Is suitable PPE provided along with information on its intended use?

30) Is there evidence to show that PPE in use is in a reasonable condition, with regular inspection or test of PPE as recommended by the manufacturer?

31) Are procedures and RA’s in place for the disposal of waste?

32) Are procedures and RA’s in place for the safe transport of items around buildings or across campus in place? E.g. moving chemicals and gas cylinders, waste products, movement of books within the library, movement of equipment.

33) Are the correct trolleys / equipment available for the movement of items mentioned above and are staff trained in the use of them.

34) Is there evidence to show that the faculty / support service has addressed the risk of injury as a result of manual handling operations?



35) Have all of the employees covered by a manual handling assessment been provided with information and training on the use of correct lifting techniques and assessment of manual handling tasks?



36) Are permit to work forms being implemented and issued by the authorised person(s) and records kept?

37) Are contractors H&S policy, risk assessments, accident records and method statements assessed before the award of contracts?

38) Is there evidence to confirm that risk assessments have addressed the risks of injury or death from electrical causes?

39) Are arrangements in place to address the risks associated with working at heights?

40) Are scaffolds erected by competent scaffolders (CITB approved)?

41) Are arrangements in place to address the risks associated with using powered access equipment for working?

42) Are ladders in good condition (e.g. not split, damaged, been painted, altered, rungs missing, rotten or corroded)?

43) When not in use are ladders stored securely to prevent unauthorised use?



44) Are risk assessments in place and procedures set for entry into confined spaces?



45) Are risk assessments and procedures in place to address the risks associated with excavations?

46) Is there evidence to show that arrangements for controlling the health risks associated with the possible exposure to asbestos fibres are in place?

47) Is there evidence to show that arrangements for controlling the health risks associated with the control of Legionnaire's disease?

48) Is there an appointed responsible person for the management of Legionella?

49) Is there evidence to show that risk assessments and procedures are in place to address the risks associated with Placements?

50) Is there evidence to show that risk assessments and procedures are in place to address the risks associated with Field Work (staff & students)?

51) Is there evidence to show that risk assessments and procedures are in place to address the risks associated with Research Projects (staff & students)?



52) Is there evidence to show that risk assessments and procedures are in place to address the risks associated with Overseas Travel (staff & students)?

Measuring Performance Yes No In


53) Have Deans / Managers taken part in regular workplace health and safety tours (Deans annually, HOD’s quarterly)?

54) Is there evidence to show that individuals or groups of individuals have been appointed to carry out workplace inspections?

55) Is there evidence to show that completed inspection checklists and report forms are signed and dated following each inspection?

Measuring Performance Yes No In


56) * Are all staff aware of the procedure for reporting injury, ill health or damage?

57) Have individuals been nominated to carry out accident and incident investigations?

58) Are the following records retained?

a) risk assessment and risk control



b) Workplace inspections

c) training records

d) incident and accident follow up actions

e) health surveillance activities, and the issue and maintenance of PPE

f) emergency response drills

Audit Review Yes No In Progress

N/A Comments

59) Does the faculty / support service audit and review their health and safety procedures on an annual basis?

Summary

Please note: * questions are to be asked to a newer member of staff within the department as well as the staff member assisting the auditor. Where there is no recent new starter in the department available then the question should also be asked to a staff member not directly involved with the audit.



Action

number

Timescale for completion

1

2

3

4

5

6

7

8

9

10

(Signed) ……………………………………… Date………………. RM Auditor Dean/Head ………………………………………………………………… Date……………….

Documents

HSMS08 Health and Safety Management System Audits · Audits will be carried out in accordance with ISO standardscurrent and will examine all key elements of the health and safety