HSP8 Issue 1 Insp & Audit

7/30/2019 HSP8 Issue 1 Insp & Audit

1/20

University Health & SafetyPolicy Manual

Health and Safety Procedure 8

Guidelines Workplace Inspections andSafety Auditing

Rev.No.

Date AmendmentDetails

Author IssueStatus

01/01/2008 Health and SafetyOffice

This document forms part of the University of Southamptons OHSAS18001:2007 OccupationalHealth and Safety Management System.

HSP8/1 Page 1 of 20 Review by 10/10


2/20

CONTENTS

Section Page

Executive Summary 3Flow Chart 4

1 Introduction and Scope 5

Definitions 5

2 Related Documents 6

3 Responsibilities 6

4 Conducting Inspections and Audits 7

4.1 Frequency and planning 7

4.2 Inspection and audit teams 8

4.3 Checklists 8

4.4 Records, remedial actions and reports 9

Appendix 1 Workplace Inspection Checklist 11

Appendix 2 a) General Audit Checklist 12

b) Alternate Audit Checklist 14

Appendix 3 Safety System Auditing Schedule 16

Appendix 4 - Further Guidance on Internal Auditing 17



3/20

Executive Summary

The University has had a system for conducting workplace inspections formany years. This procedure (HSP8) builds on this system and describeshow both workplace inspections and audits should be carried out.

Inspections and audits are different processes, although currently mostSchools/Professional Services combine them to some degree.

Heads (of Schools and Directors of Professional Services) should take partin at least one inspection/audit per year and ensure that:

Inspection/audit teams are appointed and that their membersare suitably trained

A programme of inspections/audits is established

Inspections/audits are conducted with the required frequency Where the need for corrective actions are identified, that the

actions are tracked through to completion.

The audit/inspection programme does not absolve line management ofthe responsibility to supervise and monitor operations on a day to daybasis.



4/20

Flowchart for Inspections and Internal Audits

Teams selected for inspections/ audits

Checklists developed

Inspection/audit carriedout, with findings noted

Remedial actionsidentified

Reports issued

SSO follows up toprogress chase/ actions

SSO plans schedule for the yearComment: All

members t o be

suitably trained

Comment: Immediateaction to be taken at

time ofinspection/ audit

wherever possible

Comment:1. To linemanagers/ supervisors

for remedial actions;2. To H&S Committee

for monitoring

Comment: Follow up

reports issued asrequired

Comment:SSO leads

but involves thosewhose work areas willbe covered, with

advice from the ASA



5/20

1. Introduction and Scope

This document outlines procedures for the systematic monitoring ofhealth and safety performance within a School/Professional Service byway of workplace inspections, and for more in depth auditing of

School/Professional Service health and safety management systems. Oneof the aims of the guidance is to encourage Schools and ProfessionalServices to adopt a proactive approach to health and safety and todemonstrate commitment by involving as many people as possible in theprocess.

1.1Definitions

Workplace inspection

Routine monitoring of basic health and safety provisions bySchool/Professional Service staff, usually using a checklist to ensureconsistency of approach.

Internal (Safety) Audit

An internal safety audit is a systematic evaluation of a School orProfessional Services organisation and systems for implementing theUniversity Health and Safety Policy. The internal audit focuses mainly onsystems, but also on the performance of individuals. Its aim is to identifystrengths and areas of weakness in management systems to assist Heads

in improving the health and safety performance of theirSchool/Professional Service. Internal audits are carried out bySchool/Professional Service staff, with assistance from ASAs whererequired, using checklists based on University and local procedures.

Workplace inspections and internal audits can be carried out as acombined exercise.

(External) Safety Audit

Periodically the Health and Safety Office will conduct an independent

audit of a School/Professional Services organisation and systems forimplementing the University Health and Safety Policy. These audits willtake place as part of a rolling 3 year programme, sanctioned by the Safetyand Occupational Health Committee. Audits will be carried out using anexternally derived protocol, such as the Universities Safety and HealthAssociation (USHA) Health and Safety Management PerformanceStandards (HASMAP) audit or the Occupational Heath and Safety StandardBS OHSAS18001 (as amended). The audit programme will allow forassessment of how effectively the University Health and Safety Policy isbeing implemented within the whole organisation, and for internal and

external benchmarking.



6/20

This procedure does not describe the (external) safety audit process.Please consult the Health and Safety Office for more information.1.2 Glossary

ASA Area Safety Advisor. Health and Safety Office employee providing

specialist health and safety advice to the University andSchools/Professional Services

Heads of School or Directors of Professional Services. Note that Schoolincludes Research Institutes

HSP Health and Safety Procedure. Documents providing guidance andadvice on achieving compliance with specific requirement of theUniversity Health and Safety Policy Manual

SSO School Safety Officers. These include full time School orProfessional Service Health and Safety personnel, however named, e.g.Health and Safety Advisor, Manager etc.

The above terms are shown in bold in the main body of the text.

2. Related Documents

University of Southampton Health & Safety Policy Manual.

HSP Series of documents and related Guidance/Codes of Practice

Universities Health and Safety Association(USHA) Health and SafetyManagement Performance Standards

3. Responsibilities

3.1 The Head is responsible for ensuring that:

Inspection/audit teams are appointed and that their membersare suitably trained

A programme of inspections/audits is established

Inspections/audits are conducted with the required frequency

Where the need for corrective actions are identified, that the

actions are tracked through to completion.

The Head should participate in at least one health and safety inspectionand/or internal audit per year.

3.2 Line managers and supervisors are responsible for:

day-to-day monitoring of health and safety

participating in inspections and audits as defined by local

procedures

ensuring that identified problems are dealt with in a timely

manner.

http://www.resource1.soton.ac.uk/hr/healthandsafety/policy/index.htmlhttp://www.resource1.soton.ac.uk/hr/healthandsafety/HSPs/index.htmlhttp://www.resource1.soton.ac.uk/hr/healthandsafety/policy/index.htmlhttp://www.resource1.soton.ac.uk/hr/healthandsafety/HSPs/index.html


7/20

3.3 The SSO is responsible for:

co-ordinating inspection and audit programme(s), and in particular for:

Establishing the inspection and audit timetable(s)

Producing checklists

Participating in inspections and audits

Producing inspection and audit reports

Following up the results of inspections and audits to track thatrequired remedial actions have been taken

Reporting the outcome of inspections and audits to the Headand/or School/Professional Service Health and SafetyCommittee.

3.4 Members of inspection and audit teams are responsible for:

attending training to enable them to conduct effective inspections andaudits.

3.5 The Health and Safety Office is responsible for:

providing advice and assistance on all aspects of the inspection and auditprocess, in particular:

Assisting with the development of checklists,

Advising on the membership of teams,

Participating in inspections and audits as requested,

Training members of inspection and audit teams,

Providing clarification and interpretation on specific issues, e.g.where the inspection team are unsure of health and safetyissues, where advice is required about appropriate correctiveaction.

The Health and Safety Office is also responsible for carrying out (external)safety audits (see 1.1).

4. CONDUCTING INSPECTIONS and AUDITS

4.1 Frequency and Planning

Monitoring in Schools and Professional Services must be carried out bothon a day to day basis by line managers and supervisors and also bymeans of planned internal inspections and audits. Planned inspectionsshould take place at least annually for office based activities and at least6 monthly for all other activities. However, it is recommended that basicinspections should be carried out on a monthly basis as this allows forearly detection of missing or damaged equipment and for deficiencies indaily monitoring and maintenance procedures to be identified.



8/20

To adequately cover all the areas indicated on a checklist could take moretime than a team can afford in one session. It is therefore recommendedthat inspection or auditing teams cover the School or Professional Servicein planned segments over the period of a year. The time allotted for eachmonitoring session should be agreed beforehand and, for inspections, a

limit of 2 hours is suggested to prevent errors due to time pressure on allparties.

Internal audits can be combined with inspections, e.g. where the systemsfor conducting risk assessments are examined as part of the inspection.However, it is often convenient to plan internal audits as an annual cycleso that all critical management systems are examined over a year. Anexample of an annual plan is given in Appendix 3.

Pre-notification of inspections/audits allows for collation of relevantdocumentation and ensures relevant staff and students can be present. Itis therefore recommended that all inspections and audits take place withadvanced notice, except in exceptional circumstances, i.e. accidentinvestigation.

4.2 Inspection and audit teams

Inspections and audits must be carried out by teams rather than by anindividual. Members of teams will vary according to the organisation in aSchool/Professional Service and with the aims of the particular inspectionor internal audit, but may include:

The SSO or deputy

A person from outside the School/Professional Service such asthe ASA

The Head, or senior manager acting as nominated deputy

Trade Union representative(s)

Another staff member from the School/Professional Service.

It is not generally considered that a group of more than three can carryout an effective inspection. The team should be selected to best cover

the area/work activity to be inspected. Although the number of persons islimited there is no reason why the same people should be in the team onevery occasion. Rotation of membership so that all members of aSchool/Professional Service are involved over a period of time is extremelyuseful in promoting involvement in health and safety and in generatingawareness of other activities and issues in a School/Professional Service.

To ensure that inspections and audits are effective, training of teammembers in appropriate techniques is essential.

4.3 Checklists

4.3.1 Workplace inspections



9/20

To ensure consistency of approach, checklists should be used during aninspection to record the findings. Checklists must be designed to fit theneeds of the area/work activity being inspected, and an example is givenin Appendix 1. Advice on the composition of checklists can be obtained

from the appropriate ASA, and it is important to also consult those whosework areas will be inspected to ensure that all relevant activities areincluded on the checklist. It is particularly important that inspectionsinclude a check that risk assessments are in place and that they are ofsufficient quality.

4.3.2 Internal Auditing Checklists

When drawing up internal auditing checklists reference should be made tothe School/Professional Service Health and Safety Policy and relatedprocedures and to relevant HSPs. Examples of internal auditingchecklists are given in Appendices 2a/b. The checklist should becirculated prior to the audit as this will avoid confusion as to what areasare to be covered and allow participants to collate records, e.g. training,risk assessments, procedures etc, for examination. This will reducewasted time searching for evidence and allow more time to observeactivities and to ask questions. Random sampling may be acceptable,especially for large scale operations or those carried out over severallocations, although care should be taken to ensure the sample isrepresentative of the whole.

Further advice on conducting internal audits is given in Appendix 4.

4.4 Records, Remedial Action and Reports

4.4.1 Records

A suitably designed checklist can be used to record an inspection, seeAppendix 1. In addition, a Hazard Report form for use during safetyinspections has been devised and copies are available from the Healthand Safety Office. Whatever format is used, a record needs to be madeduring the inspection to note any deficiencies observed, and this will form

the basis of subsequent reports.

Copies of inspection records should be kept for three years.

4.4.2 Remedial Action

Where deficiencies are noted, it is essential that effective and timelycorrective action is taken. Simple problems should be correctedimmediately or within a short time. More complex problems should beresolved before the next inspection/audit.

A formal follow-up should be undertaken by the SSO (or other nominatedteam member) as required, but at least one month after the


Please refer to Health & Safety Office webpage for current issue

EBSITEFORLAT

ESTEDITIONBEOREUSE


10/20

inspection/audit to identify progress with remedial actions. Actions notcompleted within the agreed time scale or to the agreed standard must beraised with the relevant line manager/supervisor and if necessaryrecorded on a Corrective Action Request form and processed inaccordance with the procedures documented in HSP11 Corrective and

Preventative Action Procedures.

4.4.3 Reports

In addition to the records made at the time of an inspection, there is aneed to ensure that reports are made to those who need to take remedialaction, e.g. line managers and supervisors, and also to those who have amonitoring remit, e.g. the School/Professional Service Health and SafetyCommittee. In the case of the former, the record made at the time of theinspection may, if designed appropriately, be all that is required. If so, acopy of the record should be forwarded to relevant line managers andsupervisors for their attention. If this is not the case, reports to linemanagers/supervisors need to identify the following:

date of inspection

to whom the report is addressed (senior manager)

list of those involved

name of the person to carry out follow up any action

location of hazard or fault

description of hazard or fault

recommended remedial action

person recommended to carry out remedial action

target date for action completed

date action completed

comments - reason for delays, difficulties in completion,temporary controls, etc.

Raw data obtained from the hazard report (or other record) form shouldbe converted into a summary of actions required and prioritised.

For monitoring purposes, a summary report of findings should besubmitted to the Head and/or School/Professional Service Health andSafety Committee. Reports should highlight where improvements havebeen made as well as where new deficiencies have been found, andidentify underlying trends where they have become apparent. Thesereports should be able to answer the questions; what are safetystandards currently like? and what more needs to be done? The reportsshould also assist with compiling Annual Health and Safety Reports andAction Plans.


PLEASECHECKHEALTH&SAFETYOFFIC


11/20

Appendix 1

SAFETY CHECKLIST FOR WORKPLACE INSPECTIONS(EXAMPLE)Note: The following is not a definitive checklist. Schools or Professional Services should

prepare their own checklist based on their own health and safety arrangements asdescribed in their health and safety policies and procedures, with advice from the AreaSafety Adviser.

Location: Area Date:

Yes/No/NA

Action/Comments

FOLLOW UPHave all actions from previous inspection

reports been completed?

EXTERNALPathways/approaches in good repair?

Is lighting adequate?

Are fire exit doors and stairs free fromobstruction and in good repair

Is there adequate signage on fire exit doors?

Are main entrances/exits secure and freefrom obstruction?

ENTRANCE/CORRIDORSIs lighting adequate?

Are fire extinguishers in place and in test?

Are fire safety advice notices in place?Are emergency exit signs in place?

Are stairs and corridors free fromobstruction?

Are floors in good condition?

RISK ASSESSMENTAre all necessary risk assessments

completed?

Are risk assessments of sufficient quality?

ELECTRICAL EQUIPMENTAre RCD devices operational?

Does all observed equipment and extensioncables have current PAT test label?Are all telephone and data cables safelyrouted?Broken or damaged equipment withdrawnfrom service?

SAFETY EQUIPMENTDoes PPE store contain adequate supplies?Do First Aid Boxes contain listed supplies,within date?Are lifting aids in good repair?

WELFAREAre toilets/shower/washbasin areas clean?

Are amenity provisions clean and providedwith essential equipment?



12/20

Inspected by: Print Name/Title

Please return completed copy to:



13/20

Appendix 2 (a)

Internal Audit Checklist/Aide-Memoir (General Example)

Note: The following is not a definitive checklist. Schools or Professional Services shouldprepare their own checklist based on their own health and safety arrangements as

described in their health and safety policies and procedures, with advice from the AreaSafety Adviser. The list can be used as an aide-memoir in conjunction with the HazardReport Form, available from the Health and Safety Office, and can prompt suitablytrained inspection/auditing teams when conducting a combined inspection and audit.

AREAS TO BE COVERED

PREMISES1 Lighting2 Heating3 General Ventilation

4 Housekeepinga)

Cleanliness

b)

Storage of materials

c)

Waste disposal arrangements/frequency

5 Means of Accessa)

Floors

b)

Passages

c

)

Stairs

d)

Ladders

6 MaintenanceMACHINERY PLANT AND EQUIPMENT

1 General condition2 Maintenance3 Guarding of dangerous parts4 Testing and inspection

a) Pressure and vacuum vessels and associated pipe workb)

Lifting machines and tackle marking of SWELL, etc.

5 Electrical equipment, test and inspection6 Fume Cupboards

a) Effectivenessb)

Construction

c) Inspection and testing records

7 Office machines, copiers, printers, VDUsHEALTH, ENVIRONMENTAL HAZARD, HAZARDOUS MATERIALS

1 Noise2 Toxic substances

a) Use

b)

Storage



14/20

3 Dust4 Fumes and Gases5 Ionising micro-wave and other radiation6 Lasers7 Control of dangerous chemicals

a) Storage and use of highly flammable or explosive materialsb)

Gas cylinders use and storage

8 Cutting Oils9 Control and disposal of waste and effluent10 Hygiene

a) Washing facilitiesb)

Toilet facilities

c) Cleansing materials

GENERAL1 School or Professional Service Health and Safety Policy and relevant

proceduresa) Availabilityb)

Updating

2 Recording of accidentsa) Follow-up system

3 Protective clothing and personal equipmenta) Typeb)

Suitability

c) Acceptabilityd

)

Standard of use

4 First Aida) Qualified First Aidersb)

Adequate equipment

c) Information

5 Firea) Alarm systemb)

Means of escape

c) Detectors (if provided)d

)

Provision and maintenance record of extinguishers

e) Trainingf) Special hazards (flammable liquids stored, heat sources (soldering, welding,

long running electrical equipment)g)

Date of fire drills

6 School or Professional Service activities organisation andarrangementsa) List of identified hazardous activities (activities with a potential to harm or

injure)1 Routine activities associated with course content2 Off-site activities (UK) Staff and/or Student.

Includes: FieldworkVisitsSurveys



15/20

Data collectionExternal lecturesAttending seminars or courses

3 Student placements4 Working overseas

b

)

Location and availability of risk assessment documents or records

c) Means of identifying assessment review dates

7 Training activities (Records)a) Identified training needsb)

Training conducted since last inspection

8 Progresses on Annual Report Action Plan items



16/20

Appendix 2 (b)

Internal Audit Checklist (Alternate Example)

Note:The following is not a definitive checklist. Schools or Professional Services shouldprepare their own checklist based on their own health and safety arrangements as

described in their health and safety policies and procedures, with advice from the AreaSafety Adviser. This checklist is a basic audit checklist to which Schools/ProfessionalServices would add, making reference to appropriate specialised subjects such as COSHHetc, depending on their own activities.

Checklist

Last Inspection

Have remedial actions agreed after the last inspection beensatisfactorily implemented?

Training

Has new staff received induction training? (Check records)

Have training needs for staff been identified? Is there a plan for providing necessary training as identified above?

Have student inductions been carried out, are there attendancerecords to verify?

Accidents

Have all accidents been investigated, recorded and reported?

Are there sufficient accidents to monitor a trend over a period of time?

Health and Safety Policy

Has the policy been communicated to all staff?

Is everyone working from the same version of the policy and have

earlier versions been destroyed? Is there a summary for students? How is this presented (in what form)

Is there a source of information for visitors allocated school officespace?

Is there a Health and Safety Law information poster displayed withinthe school or building area?

Condition of premises

Have building defects with health and safety implications beenreported to Estates & Facilities?

If repairs were not carried out in a timely manner, was the matter

followed up? Is lighting and heating/cooling adequate in the working and access

areas?Fire Precautions

Are there any unacceptable accumulations of combustible materials(boxes, packaging, used envelopes particularly in area ofphotocopiers)?

Are there procedures for what to do in the event of a fire are theyposted?

Are evacuation routes kept clear and adequately signed andilluminated?

Are fire doors in good condition and kept closed? Can they be easilyopened to effect escape?



17/20

Have fire extinguishers been serviced within the last 12 months?

Has a fire drill been held during the past 12 months?

First Aid

Are there adequate arrangements for first aid?

Can staff/students find out easily what those arrangements are?

Electrical Safety

Is PAT testing being carried out?

Are tests/inspection records in date?

Housekeeping

Are walkways clear of obstructions (furniture, rubbish, trailing cables)?

Are floors in good condition and free from trip hazards?

Are there sufficient waste bins, etc.?

Is waste removed sufficiently regularly?

Manual Handling

Have situations where staff might be injured lifting or carrying beenidentified?

Have these situations been brought to the staff attention?

Has action been taken to remove or reduce the risk of injury? (Thisincludes training)

Computer Workstations

Have users been identified?

Have workstation assessments been carried out, either by individualusers or other trained staff?

Are users using the workstation in accordance to training?

Have there been any ill health or injuries reported with reference tocomputer workstation use?Access to Heights

Is there safe access to any storage above head height?

Are ladders, stepladders and kick stools regularly inspected?

Machinery/Equipment(Photocopiers, communal printers, trucks and trolleys, roller stack shelves,TVs, Video/DVD players, etc.)

Are there safe systems of work for the operation ofmachinery/equipment in the school/department

Are safe systems of work being followed?

Are safe devices on machinery maintained? (Service records)

Off Site Activities(Seminar or conference attendance/Placement Officers Visits/OutreachTeaching/Home Visits)

Are risk assessments done (to a suitable and sufficient standard)

Are contact (booking out/in) arrangements in place

Are the Safety Guidance documents available for staff to consult

Are local procedures covered in School Policy

Is feedback obtained and evaluated for improvement of safety systems



18/20

Appendix 3

Safety System Annual Audit Schedule for 2008 (Example)

School/ProfessionalService

Division/Section

Month/Activity

JanFeb

Mar

AprMay

Jun JulAug

Sep

OctNov

Dec

Training S

Fire Safety C/O

Safety Policy C

Inspection(s) C

Electricity AtWork

R S

Waste C

Ladders C

COSHH C/O

PPE S

Lone

WorkingS

First Aid S

ManualHandling

S

Noise S

Code:

S Scheduled O Outstanding ActionC Completed R Rescheduled

Note: This is an example only and the structure and composition of theschedule should be based on the nature of the activities carried out, thefindings of relevant risk assessments and review past safety performance.Advice on how to structure the schedule can be obtained from the AreaSafety Adviser.



19/20

Appendix 4

Further Guidance on Internal Auditing

1. Internal auditingThis is more than an examination of the physical workplace, althoughexamination of workplace inspection records should form part of theprocess. Individual behaviour should be monitored and monitoringsessions should be primarily directed at the management systems set outin the School/Professional Service Health and Safety Policy, localarrangements and records.

This should be carried out for each activity scheduled for examination.

2. Individual Behaviour

Internal audits involving observation of individual behaviour must becarried out during the normal working day, to ensure access to personnelinvolved in the scheduled activity. Individuals should be observedcarrying out relevant tasks and questioned about health and safety issuesthat might not yet have been identified. Questionnaires or verbalquestions, agreed in advance with the ASA, can establish the success orfailings in induction or other training provision for individuals and groupsof staff.

3. Documentation

Records generated by the School or Professional Service that should beexamined to ensure contents are still valid, relevant and relatedprocedures are being followed. These should include:

a) School or Professional Service Health and Safety Policy and localarrangements content, issue status and accessibility

b) risk assessments

c) workshop rules or protocols

d) previous inspection report forms

e) training records

f) action plansg) maintenance work requisitions/permits (where they involve work

related to safety)

h) information in relevant handbooks

i) what follow up corrective action is taken if faults are not rectified insuitable time or manner?

j) who takes on the follow up actions?

k) what records are kept?

4. Premises



20/20

When making observations of the premises an aim could be to ensure thatnormal daily maintenance faults are corrected. The main concern here isthe system and its effectiveness how faults and deficiencies areidentified, corrected and controlled. The questions to ask here might be:

a) how are faults reported and to whom?

b) to whom and how are they reported outside agencies?

c) how long do they take to be remedied?

5. Activities

Similarly, an audit targeted on computer workstations might include thefollowing:

a) inspecting records showing details of workstation assessmentscarried out

b) carrying out a physical inspection of a sample of workstations to

confirm that assessments are still validc) inspecting training records to confirm workstation users have

received appropriate training

d) holding discussions with a sample of users to seek their views onthe effectiveness of the assessment and the training.

6. Communication

The team should communicate with those in the area being audited, bytalking to the people and involving them in the process.

Positive feedback on good performance can encourage commitment tofurther improvement and can be used to mitigate reporting of morenegative observations. Attempts should be made to avoid out and outcriticism by being tactful.

Where possible, ways should be identified in which problems can becorrected, rather than merely noting they exist.

If possible, those being audited should be encouraged to come up with thesolutions themselves (but avoiding getting bogged down in detail at thetime of inspection).


HSP8 Issue 1 Insp & Audit

Documents

Transcript of HSP8 Issue 1 Insp & Audit