Health and Safety Termly Systems Audit

• Health and Safety Termly Systems Audit

• Westminster Kingsway College

• Client / Site

• Conducted on

  Date

• Derek Wilkinson

• Location
  Address

• Personnel

1. PREVIOUS AUDIT - ISSUES ARISING

• 1.1 Issues arising from last audit have been resolved? If not give details

  Yes

  No

  N/A

2. POLICY

• 2.1 Is there a health and safety policy authorised by the Principal and Chair of Governors, clearly stating the overall health and safety objectives and demonstrating a commitment to improving performance?

  Yes

  No

  N/A

• 2.2 Is this policy:

• a) appropriate to the nature and scale of the organisation's health and safety risks?

  Yes

  No

  N/A

• b) including the commitment to ensure continued improvement aimed at elimination of work-related injury and illness?

  Yes

  No

  N/A

• c) Includes

  Yes

  No

  N/A

• c) including a commitment to comply with relevant health and safety legislation and best practice.

  Yes

  No

  N/A

• d) documented, implemented, maintained and communicated to all employees?

  Yes

  No

  N/A

• e) available to interested parties?

  Yes

  No

  N/A

• f) reviewed periodically to ensure it remains relevant and appropriate to the organisation?

  Yes

  No

  N/A

• g.) including supporting policies and procedures which are also regularly reviewed and kept up to date?

  Yes

  No

  N/A

• Evidence for the above is :

• Health and Safety Policy, associated policies and procedures, filed on the cross-college drive and available to view on the college intranet

3. PLANNING

3.1 Planning identification of Hazards, Hazard/Risk Assessment and Control of Hazards/Risks

• 3.1.1. Have procedures been established, implemented and maintained for hazard identification and risk control ?

  Yes

  No

  N/A

• 3.1.2. Has the methodology for risk management and control been developed and evolved taking account of operational factors, near miss incidents etc.

  Yes

  No

  N/A

• 3.1.3. Is this methodology regularly reviewed and updated?

  Yes

  No

  N/A

• Evidence for the above is :

• System of risk assessment in place and used, reviewed with departments periodically, near misses recorded and taken account of in risk management planning

3.2 Legal and other requirements

• 3.2.1. Are legal requirements taken account of in the the planning and implementation of its activities and operations?

  Yes

  No

  N/A

• 3.2.2. Is this information kept up-to-date and are updates communicated to employees as needed?

  Yes

  No

  N/A

• Evidence for the above is :

• Central information database with up to date legal information, active updates from Barbour and the British Safety Council, updates to health and safety committee.

3.3 Objectives and Targets

• 3.3.1. Have general objectives been set and are these being achieved or worked towards ?

  Yes

  No

  N/A

• 3.3.2 Are the objectives as set consistent with legal requirements and do they anticipate impending legal and regulatory changes where needed?

  Yes

  No

  N/A

• 3.3.3. Are the objectives and targets consistent with the Health and Safety Policy?

  Yes

  No

  N/A

• 3.3.4 Are the objectives consistent with a policy of continuous improvement?

  Yes

  No

  N/A

• Evidence for the above is :

• Health and safety committee minutes, centre health and safety operational group meetings, annual reviews and audits

3.4 Management Plans

• 3.4.1. Has the organization established and maintained management plans for achieving its objectives and targets?

  Yes

  No

  N/A

• 3.4.2. Has a designation of responsibility for achievement of objectives and targets been set at different levels in the organisation?

  Yes

  No

  N/A

• 3.4.3 Have means and outline timeframes been set by which objectives and targets are to be achieved?

  Yes

  No

  N/A

• 3.4.4 Are arrangements in place for plans to be reviewed and revised as necessary as circumstances change?

  Yes

  No

  N/A

• Evidence for the above is :

• Action planning from health and safety committee, centre health and safety operational group meetings, annual reports and reviews including annual report to the Corporation.

4. IMPLEMENTATION

4.1 Structure and Responsibility

• 4.1.1. Is structure and responsibility for implementation clearly established?

  Yes

  No

  N/A

• Evidence for the above is :

• Health and safety policy and supporting policies and procedures, management organisational charts, annual reports, reviews and action plans.

4.2. Resources

• 4.2.2. Has management identified and provided the resources required to implement, maintain, and improve health and safety management systems ? (Resources such as human resources, and specialized skills, technology and financial resources)

  Yes

  No

  N/A

• Evidence for the above is :

• Staff with assigned health and safety responsibilities, organisational, training matrix and lists of H&S trained staff, health and safety budget.

4.3. Responsibility and Accountability

• 4.3.1. Is accountability and responsibility clearly defined, documented and communicated?

  Yes

  No

  N/A

• 4.3.2. Is accountability and responsibility clarified with respect to contractors?

  Yes

  No

  N/A

• 4.3.3. Is a director appointed to be responsible for ensuring legal and regulatory compliance for all health and safety operations?

  Yes

  No

  N/A

• Evidence for the above is :

• Health and safety policy, organisational charts, training records, appointed director, TFM (KFM) contractor health and safety policy agreed with WKC, TFM (KFM) contract.

4.4.Training and Competency

• 4.4.1. Have training needs been identified, in consultation with employees, in support of healthy and safe operations, and implemented ?

  Yes

  No

  N/A

• 4.4.2. Are procedures in place to ensure that health and safety competencies are developed and maintained?

  Yes

  No

  N/A

• 4.4.3. Are personnel assessed as competent on the basis of education, training or experience, to perform assigned tasks safely?

  Yes

  No

  N/A

• 4.4.4. Do training arrangements take account of the skills and competencies of staff weighed against the hazards and risks they may encounter?

  Yes

  No

  N/A

• 4.4.5 Is it ensured that all personnel (including contractors and visitors) have undertaken training appropriate to the needs identified?

  Yes

  No

  N/A

• 4.4.6. Is this training carried out by persons with appropriate knowledge, skills, experience and training?

  Yes

  No

  N/A

• Evidence for the above is :

• Training matrix, rolling training plan regularly reviewed by health and safety committee and training needs discussed by centre ops groups. All staff carry out compulsory online health and safety training at induction and this is regularly refreshed. Contractor induction and training arrangements regularly reviewed.

4.5. Consultation, Communication and Reporting

4.5.1.Consultation

• 4.5.1.1.Have the employees:

• a) been involved in the development, implementation and review of policies and procedures to identify hazards and assess and control hazards/risks?

  Yes

  No

  N/A

• b) been consulted where there are any changes that affect workplace health and safety

  Yes

  No

  N/A

• c) selected those who will represent them on health and safety matters

  Yes

  No

  N/A

• d) are aware of the employee health and safety representative(s) and specified management representatives?

  Yes

  No

  N/A

• 4.5.1.2. Are there documented procedures for employee involvement and consultation in health and safety issues?

  Yes

  No

  N/A

• 4.5.1.3. Are those representing the employees and employer receiving appropriate training to undertake effectively, their involvement in the development, implementation and review of health and safety arrangements?

  Yes

  No

  N/A

• Evidence for the above is :

• Input at health and safety committee meetings and centre health and safety operational groups. Trades union representation at these groups and in attendance during site safety inspections. It is a matter of policy that consultation with employees takes and there is a separate policy statement. Assistance given by college with training.

4.5.2 Communication

• 4.5.2.1 Pertinent information is communicated to and from employees and other interested parties?

  Yes

  No

  N/A

• Evidence for the above is :

• Reports to health and safety committee and centre health and safety operational groups. Updates from external information sources selectively distributed to staff and stakeholders. Articles published on staff intranet.

4.5.3 Reporting

• 4.5.3.1. Are appropriate reporting procedures in place?

  Yes

  No

  N/A

• Are reporting procedures established to cover the following:

• a) Health and safety performance including audits, inspections, reviews?

  Yes

  No

  N/A

• b) Near miss incidents and system failures

  Yes

  No

  N/A

• c) Hazard identification

  Yes

  No

  N/A

• d) Risk assessment

  Yes

  No

  N/A

• e) Preventative and corrective actions

  Yes

  No

  N/A

• f) Statutory reporting requirements

  Yes

  No

  N/A

• Evidence for the above is :

• Regular reports to the health and safety committee and centre health and safety operational groups. Annual and termly reports to governors. Ad hoc reports to individuals, stakeholders, staff and student groups, and regulatory authorities as required.

4.6. Documentation

• Is information provided in a suitable medium such as print or electronic form to:

• a) describe the core elements of the management system and its interaction?

  Yes

  No

  N/A

• b) provide direction to related documentation?

  Yes

  No

  N/A

• Evidence for the above is :

• Information available via a range of media with the aim of reaching as wide an audience as possible. The use of links in electronic documentation assists the communication process.

4.7 Document and Data Control

• 4.7.1. Are all relevant documents and data established and presented to ensure that:

• a) they can be readily located?

  Yes

  No

  N/A

• b) they are periodically reviewed, revised as necessary by competent and responsible personnel?

  Yes

  No

  N/A

• c) current versions of relevant documents and data are available at all locations as needed?

  Yes

  No

  N/A

• d) obsolete documents and data are promptly removed from all points of issue and use or otherwise assured against unintended use?

  Yes

  No

  N/A

• e) archival documents and data retained for legal or knowledge preservation purposes or both, are suitably identified?

  Yes

  No

  N/A

• 4.7.2. Is this documentation and data legible, dated (with dates of revision) and readily identifiable and maintained in an orderly manner for a specified period?

  Yes

  No

  N/A

• 4.7.3. Are procedures and responsibilities established and maintained concerning the creation and modification of the various types of documents and data?

  Yes

  No

  N/A

• Evidence for the above is :

• Held on central drive and published on the intranet. Old information sent to archive.

4.8. Hazard Identification, Hazard/Risk Assessment and Control of Hazards/Risks

4.8.1. General

• 4.8.1.1 Are documented procedures established and implemented to ensure that:

• a) hazards are identified?

  Yes

  No

  N/A

• b) hazards/risks are assessed?

  Yes

  No

  N/A

• c) hazards/risks are controlled; and then

  Yes

  No

  N/A

• d) steps (a) to (c) are evaluated?

  Yes

  No

  N/A

• Evidence for the above is :

• Accident reporting system with facilities for investigation and RIDDOR referral as necessary. Risk assessment carried out across the college. Risk scores assigned and residual controlled as required

4.8.2 Hazard Identification

• 4.8.2.1. Does the identification of hazards in the workplace take into account:

• a) the situation or events or combination of circumstances that has the potential to give rise to injury or illness;

  Yes

  No

  N/A

• b) the nature of potential injury or illness relevant to the activity, product or service; and

  Yes

  No

  N/A

• c) past injuries, incidents and illnesses?

  Yes

  No

  N/A

• 4.8.2.2. Does the identification process also include consideration of:

• a) the way work is organised, managed, carried out and any changes that occur in this;

  Yes

  No

  N/A

• b) the design of workplaces, work processes, materials, plant and equipment;

  Yes

  No

  N/A

• c) the fabrication, installation and commissioning and handling and disposal (of materials, workplaces and plant and equipment);

  Yes

  No

  N/A

• d) the purchasing of goods and services;

  Yes

  No

  N/A

• e) the contracting and subcontracting of plant, equipment, services and labour, including contract specification and responsibilities to and by contractors; and

  Yes

  No

  N/A

• f) the inspection, maintenance, testing, repair and replacement (of plant and equipment).

  Yes

  No

  N/A

• Evidence for the above is :

• Regular accident reports to health and safety committee. Near miss reporting follow up. Hazard elimination action following up from safety inspections. Discussion with main TFM contractor ref to safe working systems and procedures.

4.8.3. Hazard/Risk Assessment

• 4.8.3.1. Are all risks arising from hazards given a risk rating?

  Yes

  No

  N/A

• Evidence for the above is :

• Severity x likelihood risk rating system consistently used.

4.8.4. Hazard/Risk Control

• 4.8.4.1. Are all risks controlled according to the hierarchy of control with elimination as the preferred control measure?

  Yes

  No

  N/A

• Evidence for the above is :

• Hierarchy of control observed wherever reasonably practicable. Attention given to promoting elimination wherever possible.

4.8.5 Evaluation

• 4.8.5.1. Are hazard identification and risk control measures evaluated for effectiveness and modified as necessary?

  Yes

  No

  N/A

• Evidence for the above is :

• Reviews with staff - individuals and groups - central database of risk assessments maintained and monitored. Templates, where used, are updated as necessary according to legislative, procedural or resource changes.

4.9 Emergency Preparedness and Response

• 4.9.1. Are all reasonably predictable potential emergency situations identified and procedures documented for preventing and mitigating associated illness and injury?

  Yes

  No

  N/A

• 4.9.2. Have emergency preparedness and response procedures been reviewed and revised after the occurrence of incidents or emergency situations?

  Yes

  No

  N/A

• 4.9.3. Are emergency procedures periodically tested? (NOTE: it may not be practicable to test some procedures, in which case training and efficacy should be tested by other means)

  Yes

  No

  N/A

• Evidence for the above is :

• Reports in fire safety log, monitoring records of evacuation drills, fire risk assessment including action planning, disaster recovery plan.

5 MEASUREMENT AND EVALUATION

5.1 Monitoring and Measurement

5.1.1 General

• 5.1.1.1. Are there documented procedures to regularly monitor and measure the key causes of work related illness or injury?

  Yes

  No

  N/A

• 5.1.1.2. Is the effectiveness and efficacy of these measures evaluated?

  Yes

  No

  N/A

• 5.1.1.3. Is appropriate equipment for monitoring and measurement related to health and safety risks deployed as necessary, and maintained in good order?

  Yes

  No

  N/A

• 5.1.1.4. Are procedures in place to monitor the performance, effectiveness and compliance of the health and safety management system?

  Yes

  No

  N/A

• Evidence for the above is :

• Accident statistics. Breakdowns and trend reports for health and safety committee, near miss and incident reports. Record of non work-related illnesses. Measuring and monitoring equipment held maintained in central location.

5.1.2 Health Surveillance

• 5.1.2.1. Have situations where health surveillance may be required been identified and implemented as necessary?

  Yes

  No

  N/A

• Evidence for the above is :

• Procedures in place for dealing with contagious disease outbreaks.

5.2 Incident Investigation, Corrective and Preventative Action

• 5.2.1.Has the organisation established, implemented and maintained procedures for:

• a) investigating, responding to , and taking action to minimise any harm caused from incidents;

  Yes

  No

  N/A

• b) investigating and responding to system failures; and

  Yes

  No

  N/A

• c) initiating and completing appropriate corrective and preventative action.

  Yes

  No

  N/A

• 5.2.2. Are procedural changes resulting from incident investigations and corrective and preventive action recorded?

  Yes

  No

  N/A

• Evidence for the above is :

• Investigations recorded on centralised accident reporting system. Safety Inspections have monitoring and follow up built in where hazards are located.

5.3 Records and Record Management

• 5.3.1. Are procedures in place and maintained for health and safety, including the results of audits and reviews?

  Yes

  No

  N/A

• 5.3.2. Are records legible, identifiable and traceable to the activity, product or service involved?

  Yes

  No

  N/A

• 5.3.3. Are records stored and maintained ensuring that they are readily retrievable and protected against damage, deterioration and loss?

  Yes

  No

  N/A

• 5.3.4. Are records maintained, as required by the college and relevant legislation?

  Yes

  No

  N/A

• 5.3.5. Are their retention times established and recorded?

  Yes

  No

  N/A

• Evidence for the above is :

• All records stored electronically on safe and secure database platforms. Hard copy records kept as appropriate. Categorised according to main regulatory and legislative categories.

5.4 External and Internal Audit

• 5.4.1. Is a programme of regular internal and external audits in place and maintained in order to:

• a) determine whether the health and safety management system:

  Yes

  No

  N/A

• i) conforms to planned arrangements?

  Yes

  No

  N/A

• ii) has been properly implemented and maintained?

  Yes

  No

  N/A

• iii) is effective in achieving continual improvement according to policy objectives?

  Yes

  No

  N/A

• b) provide information on the results of audits to management and employees.

  Yes

  No

  N/A

• 5.4.2. Does the audit program focus on health and safety priorities, taking account of the results of previous audits?

  Yes

  No

  N/A

• Evidence for the above is :

• Internal inspections and audits recorded. External audits recorded.

6. MANAGEMENT REVIEW

• 6.1. Is the health and safety management system subject to review at directorate and governor level?

  Yes

  No

  N/A

• 6.2. Have processes for enabling directors and governors to effectively review this information been established.

  Yes

  No

  N/A

• 6.3. Does the management review reflect changing priorities due to changing business profile, legislation and regulation?

  Yes

  No

  N/A

• 6.4. Does the management review consider ongoing resourcing implications using a prioritised risk-based approach?

  Yes

  No

  N/A

• 6.5. Does the management review, in considering all determining factors, continue to promote and support a process of continuous improvement.

  Yes

  No

  N/A

• Evidence for the above is :

• Reports to health and safety committee and Corporation - Termly and annual

• Yes

  No

  N/A