QSA AUDIT REPORT - Cumbria · 9 OHSAS 18001:2007 Chart 35 ... from maintaining these documents. ... based on HSG65 and OSHAS 18001.

QSA/CCC Mar 2015

QSA AUDIT REPORT

Cumbria County Council March 2015

AUDITOR: Bernie Cerrino, MSc, CMIOSH, Senior Health and Safety Consultant

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Contents Section Subject Page 1 Summary 4 2 Introduction 5 3 Policy 6 4 Organising 7 5 Planning and Implementation 17 6 Measuring Performance 29 7 Audit and Review 31 8 Score Summary 33 9 OHSAS 18001:2007 Chart 35 10 Acknowledgements 36 Appendices

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1. Summary This report details the findings of a QSA audit of Cumbria County Council during March 2015. The audit found that there had been further development of procedures e.g. with regard to CDM, Work at Height, Stress. There is still a need to develop other procedures such as New Road and Street Works that should outline the purpose, responsibilities and inform the reader with guidance how the objectives are to be met and activities controlled. It would now appear that due to budgetary constraints that here are now 5 vacancies within the Corporate Health and Safety Team. Whilst there are a number of areas where enhancement of procedures has been identified the lack of resources are likely to impact on what is achievable within the Corporate Health and Safety Team. The Organisation maintained an overall Health and Safety Performance Rating of 93, though there were some slightly reduced scores within the planning and implementation sections. When considering the performance in the audit sub-sections, it can be seen that eligibility to claim a QSA Award level 5, Diamond has been maintained which is commendable. Cumbria County Council should aim to maintain this high level score and re-audit in 2017. OHSAS 18001:2007 There were no major non-conformances identified. It is recommended that a certificate of OSHAS 18001compliance is re issued.

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Key Recommendations are as follows:

Cumbria County Council is awarded a QSA Level 5 Award; Cumbria County Council is awarded the OHSAS 18001:2007

Certificate of Compliance; Continue the development of procedures in Highways and Transport

Operations with regards to New Road and Street Works; Provide sufficient numbers of people within the Corporate Health and

Safety Team to continue to maintain the current high standard.

Encourage Directors involvement with senior management tours in all Directorates;

Review key performance Indicators, KPI and consider new areas to measure.

2. Introduction

The Royal Society for the Prevention of Accidents, RoSPA was commissioned by Cumbria County Council to carry out a QSA audit of the Council occupational health and safety activities. The audit was carried out using issue 4 of the QSA system, developed by RoSPA. This system is primarily based on the HSE publication HSG 65 ‘Successful Health and Safety Management’. It also incorporates all the elements of OHSAS 18001. The system is also based on BS 8800 ‘Guidance on Occupational Health and Safety Systems’, and the methodology of the audit is that described in ISO 19011 (formerly BS 7229) for quality system auditing. Traditional monitoring systems have focused on the reporting and investigation of accidents, together with detailed compliance inspections of workplaces. Research has shown, however, that in 70% of accidents the underlying causes have been failures in the health and safety management system (HSMS). The QSA audit therefore concentrates on the HSMS, but also includes an examination of compliance with a number of key areas of legislation. More details of the QSA system can be found in Appendix 1. There is no intention to criticise individuals, but to examine and comment on the HSMS of the Organisation. Although every effort was made to identify relevant documentation, it was the responsibility of the client to bring this to the attention of the auditor. Audits are by nature sampling exercises; therefore the auditor cannot guarantee to identify all possible breaches of legislation or good practice. Absence of comment on any issue should not be taken to imply full compliance with legislation. The structure and aims of the audit were discussed at an opening meeting at the start of the audit with the Health and Safety Manager. Some initial

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feedback, principally the main audit results, was given at a closing meeting on the 19th March 2015 to Julian Stainton, Health and Safety Manager. Observations on the HSMS, together with detailed recommendations for improvement, follow in the body of the report. A summary of section and sub-section scores is given towards the end, with the QSA ‘radar chart’ giving an overall view of results.

3. Policy

Overall 100%

General 100% Commitments 100%

The health and safety policy should consist of two levels of document; a short policy statement describing overall responsibility and commitments, followed by a larger document outlining specific responsibilities and general arrangements. In the context of the latter, it may also either contain or refer to detailed health and safety arrangements (i.e. procedures), in a similar fashion to a quality manual. 3.1 Policy (General) The Policy Statement of Intent had been jointly signed and dated 23rd October 2014 by both the Leader of the Council and Cabinet Member for Fire Safety and General Support and the Chief Executive. 3.2 Policy Commitments The writing of a health and safety policy is a legal obligation for any organisation employing five or more people, but its purpose should be much greater than simply satisfying a statutory duty. It should communicate the beliefs and commitment of the organisation to the principles of protecting and promoting the health and safety of its workforce. In a similar way to a quality policy, the health and safety policy statement that forms part of it should serve as a mission statement in this regard. It should be produced, approved and authorised by the highest level of management in the organisation; to demonstrate that such commitment to health and safety starts at the very top of the organisation, where the legal responsibility ultimately lies. Once having produced the policy, the organisation should then ensure that it effectively brings it to the attention of its workforce. In view of the high score in this section no further recommendations are made except to maintain vigilance.

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4. Organising

Section Overall 92%

Organising for Health and Safety i.e. allocation of responsibilities

100%

Organisational Procedures 90%

The objectives of this section of the QSA Audit are to establish the extent to which the organisation has assigned clear responsibilities for health and safety arrangements, and whether formal organisational procedures have been developed. 4.1 Roles and Responsibilities

Sub Section Overall 100%

Policy Makers 100% Planners 100% Implementers 100% Health and Safety Assistance 100% Employees Duties 100% Health and Safety Organisational Chart

100%

As with any area of management, allocation of specific responsibilities is crucial to ensure that the necessary action is taken and that the necessary controls are in place. The management of health and safety is no exception. The HSE describe three levels of health and safety management, as follows:

a) Policy Makers b) Planners c) Implementers

Typically, the policy makers would comprise of the chief executive and executive management team, the planners would comprise of senior managers, whereas the implementers would be first line managers and supervisors. The HSE also describe the role of safety advisors, who assist the three levels of health and safety management described above. Such division of duties is intended to ensure that responsibility starts at the very top of the organisation, and is then cascaded down through the various levels of management. Implicit in this is the understanding that the implementation of health and safety arrangements is a line management responsibility, and not something that is ‘looked after’ by a health and safety department, whose role should be advisory.

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The allocation of employees’ legal responsibilities is also examined in this section. The Corporate Health and Safety Policy and Arrangements document has recently been updated in 2014. Further supporting documentary evidence was found in the Duties document CCC SP4 dated 2011 this contained clear responsibilities. Scoring 100% there are no recommendations made aside from maintaining these documents. 4.2 Organisational Procedures

Organisational Procedures - Overall 92%

Control 94% Co-operation 97% Communication 76% Competence 91%

There is a legal requirement to have a written health and safety management system, where five or more are employed. In the same manner as for a policy, however, such a system should go beyond legal obligations to communicate the importance of health and safety to employees, and guide compliance with both legislation and best practice. The HSE describe four ‘building blocks’ of a health and safety culture, as follows: a) Control of the elements of the health and safety management system b) Co-operation between the parts of the organisation and with external

bodies c) Communication channels into, around and out of the organisation d) Ensuring and maintaining the Competence of employees Organisations are often putting more into action than would be suggested from the extent of their written health and safety management system (i.e. ‘doing more than they say they are doing’). Whilst actual implementation is clearly vital to safeguarding health and safety, it would also clearly be improved by comprehensive and relevant guidance provided in the form of procedures. Such written guidance also helps to ensure that controls are consistently applied. From the foregoing, it can be appreciated that procedures should be based on the results of risk assessment to ensure relevance. These documents should be developed in accordance with HSG 65 Inset 5 in a suitable directive style that clearly outlines who, why, what, where, when and how activities should be carried out. This could be narrative or process mapping.

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Control of the HSMS

Control Overall 94%

Development and Control of the HSMS

98%

Supervision 89% Measuring Performance - Active Monitoring

91%

Measuring Performance - Reactive monitoring

95%

Auditing of the SMS 97% Reviewing Health & Safety Performance

92%

Control procedures should address issues such as the development and control of the health and safety management system, and the elements of supervision within the organisation to ensure that these are adequate for the risks and competencies involved. Procedures are also required to address the other elements of the health and safety management system included in the structure described by the HSE (i.e. planning, active and reactive monitoring, auditing and review of performance). Planning procedures will be discussed in the planning section of this report. Development and Control of the HSMS Within a HSMS, there should be a mechanism or procedure for the formulation and development of that system to ensure that it meets the requirements of the organisation and continues to do so. The controlled production and distribution of procedures and guidance documents is essential to ensure that all employees of the organisation operate to the same system and standards. It is a concept recognised in the field of quality systems, and the requirement for such a discipline is equally pertinent when dealing with health and safety systems. SMS & Communications Document 2 provides an overview of the HSMS based on HSG65 and OSHAS 18001. In Section 11 of the document the system for document control is described requiring all documents to be in a standard format but lacks the detail of the format to be used. It is recommended that:

SMS & Communications Document 2 is enhanced to include the template to be used for corporate documents.

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Supervision The provision and extent of supervision is a fundamental part of the control mechanism of any organisation, and should seek to ensure that employees are provided with a level of supervision that is appropriate to their activities, level of expertise and any special needs they have. Within the Duties document 04 it would appear that there has been some enhancement with regard to the levels of supervision required and team building. The health and safety competencies for managers and supervisors however are not made clear. It is recommended that:

The health and safety competencies for managers and supervisors are clearly stated.

Active Monitoring Active monitoring comprises one aspect of measuring the health and safety performance of an organisation (reactive monitoring being the other). Active monitoring seeks to identify the degree of compliance with health and safety requirements and arrangements before an accident or incident occurs. It includes: Systematic inspections of workplaces Examination of health and safety documentation Procedures to monitor specific objectives Observation of activities and behaviour by first line supervisors Consideration of reports on performance by senior management Health and safety tours by senior managers Health and safety attitude and behaviour questionnaires Document 05 Health and Safety Auditing and Active Monitoring 2011, sets out clear responsibilities for these activities, the training and qualifications for auditors are clearly stated. The measurement of performance standards by setting goals and monitoring their progress towards these goals is clearly stated. Further detail was found in Document 31 with regard to the training requirements for those carrying out performance checks e.g. IOSH Managing Safely. The requirement for senior managers to conduct health and safety tours is stated and outlines how this should be done. Document 11 Workplace Inspections identifies the need for the use of the checklist provided in Appendix 1 of that document. However the document doesn’t identify any specific training requirement for those carrying out the inspections. Whilst the inspection of lifts was captured within the workplace

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inspection checklist the auditor was unable to find reference to schedules for statutory inspection and who should carry out such inspections. The Periodic Inspection and Test Manual, Part 13, Fire and Rescue Service, deals with calibration of equipment. No reference was found with regard to health and safety reward schemes as a result of active monitoring. It is recommended that:

Document 5 is enhanced to include the need for the inspection of specific equipment and includes the need to draw up schedules for statutory inspection;

Document 5 is enhanced to include a statement that active monitoring will be linked to health and safety reward schemes for teams and individuals;

Document 11 should identify the training requirements for those carrying out inspections;

Document 11 should identify the need for drawing up of statutory inspections and who is responsible for this task.

Reactive Monitoring Reactive monitoring systems are designed to identify report and investigate events after they have happened. As such, they play a complimentary role to active monitoring systems, but are often the focus of attention in assessing health and safety performance. Such systems should include: Injuries and cases of ill-health Other losses, including property damage Incidents with the potential to cause injury/damage (‘near-misses’) Hazard reporting Weaknesses or omissions in standards The lead document CCC06 was identified as Recording, Reporting & Investigating of Adverse Events dated 2014. This updated version includes the adverse event reporting procedures and identifies changes introduced due ICASS database that facilitates analysis of adverse events reported, the removal of the previous accident report form P25, and the new online form to be used. Clear responsibilities for investigation and the level of event investigation, and the training required are described within the document. The document has been developed to closely follow the requirements set out in HSG 245 Investigating Accidents and Incidents. Little was found in terms of procedural enhancement following the work put in by the Corporate Health and Safety Team.

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For consideration the procedures for adverse event investigation could be further enhanced to include: The reporting and investigation of other incidents causing loss e.g.

property, equipment and loss of business continuity are considered; The reporting and investigation of non-conformances with established

procedures and protocols;

The Health and Safety Practitioners review should consider the: o The total number of people who could have been directly affected

by the event;

The Corporate Health and Safety Officers report should consider: o An evaluation of the quality and accuracy of information contained

in completed accident/incident reports; o An evaluation of the time taken/costs involved in the accident and

subsequent investigation. Auditing the HSMS An audit is: ‘The structured process of collecting independent information on the efficiency, effectiveness and reliability of the total health and safety management system and drawing up plans for corrective action’ (HSG 65) In order to fulfil the criteria detailed above, HSG 65 specifies that the audit should examine all the elements of the health and safety management system, as examined in this report. The ultimate aim of any such audit should be to promote continuous improvement of the health and safety management system. Audits should be carried out by competent auditors, ideally independent of the activities or areas being audited, and the methodology of the audit should be as per ISO 19011 (formerly BS 7229). It is the umbrella activity that may include workplace inspections, but operates at a higher and more systemic level. It is thus important to make the distinction between audits and inspections when considering this issue. As with quality systems, the operation of an internal audit programme is required, irrespective of any external audits carried out. Competency of auditors is that of International Register of Certified Auditors Lead Auditor or RoSPA QSA auditor. It is recommended that minor enhancement can be made to Document 5 by including: The duties of the auditor to include:

o "Closing" the audit at a final meeting;

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Reviewing Performance In the context of the health and safety management system, review is defined as: ‘The process of making judgements about the adequacy of performance and taking decisions about the nature and timing of the actions necessary to remedy deficiencies’ and, ‘The aims of the review process reflect the objectives of the planning process’ (HSG 65). In the context of this audit, review covers: a) Assessment of the degree of compliance with organisational procedures; b) Identification of activities where procedures either do not exist or provide

inadequate guidance; c) Assessment of the achievement of specific objectives; d) Examination of accident, ill health and incident data, accompanied by the

analysis of both immediate and underlying causes, trends and common features.

This can then be fed back into policies, procedures and plans to ensure not only compliance with legislation and standards, but to promote the continuous improvement recommended in HSG 65. Document No 13, Managing Health and Safety Performance in CCC, dated 2010 considers this activity and is at the same issue status as last audit. This suggests that the objectives of this procedure are to set out the Corporate and Directorate requirements The Corporate Management Team, CMT; Directorate Management Team, DMT with the appropriate Health and Safety Practitioner. All targets will be reviewed using the Councils Performance Plus computer system. It is recommended that document 13 is enhanced to include: Information from first line supervisors (including successes and failures

and any deficiencies in plans, standards, procedures and systems) as an input to the process;

Identification of areas or activities where procedures are absent or inadequate;

Co-operation

Health and Safety Committees 97%

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Co-operation procedures should principally address how the organisation consults with its workforce (which is a legal requirement for all organisations, whether unionised or not), but would also cover co-operation with other organisations that may share the workplace. The commonest form of consultation is through a formal health and safety committee. Document No 03, Health and Safety Consultation and Safety Representation in CCC dated 2009 sets out the arrangements for consultation and includes clear responsibilities for those involved in the consultation process. Clear objectives are outlined with terms of reference that are required to be posted on the intranet as are the meeting minutes; these are also circulated to the members. This document scored highly only one recommendation is made.

That the Terms of Reference include the provision of any facilities and assistance that the committee may reasonable require to carry out its function.

Communication

Dissemination of Information 76%

Communication procedures should describe how the organisation obtains health and safety information (and what this consists of), how such information is distributed around the organisation, and the dissemination of health and safety information to external bodies such as enforcement authorities and even the general public. The lead document identified was Information and Communication dated 2011. The document describes the duties of a number of persons involved in this process, and defines the procedure for identifying, accessing, dissemination and communicating legal and other occupational health and safety information that are relevant to CCC. However it would appear that information to disseminate outside of CCC is not identified within the document. It is recommended that further enhancement to the document include: A record is kept of every employee to whose attention the documents

have been drawn; All employees are made aware of any risks notified by contractors

working on a temporary or permanent basis; Information required to leave the organisation includes:

o Product safety; o Safety of services; o Supply of hazardous materials; o Risks to the local community; o Health and safety educational material.

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Competence

Competence Overall 91%

Recruitment and Placement Procedures

75%

Identification of Training Needs 89% Provision of Training 97% Provision of Health and Safety Assistance

100%

This section of the audit is not an examination of the actual level of competence of individuals, but rather the ability of the HSMS to develop and maintain the high level of personal competence required to meet organisation and personal responsibilities. It looks at the procedures for recruitment and placement, identifying training needs, providing training, and the role and competence criteria for health and safety assistance (i.e. advisors) Recruitment and Placement The methods by which people are recruited into, or otherwise placed in, the organisation are important in ensuring that suitable competencies exist. Document No 31 Awareness and Competency identifies in Section 6 that job descriptions and person spec will outline where relevant the level of health and safety knowledge, qualifications and experience required for the post. It is not clear that job descriptions are given to the employee. It is recommended that recruitment and placement procedures include: That employees are given job descriptions or other documentation which

include their health and safety duties; That health and safety competence is part of the employer's

performance appraisal system; That the assessment of the employee's potential health and safety

competence is one part of the criteria for promotion or re-deployment. Identification of Training Needs Organisations need to systematically assess the training needs of their employees to maintain and develop personal competencies, and allow for specific needs to be addressed. Health and Safety Procedure 31 dated 2010 deals with Awareness and Competency in Health and Safety. This is applicable not only to employees but others including agency workers and contractors. There is a Corporate Learning and Development Policy within the HR toolkit. Section 7 of the document asks the question ‘Do your risk assessments identify a training need’.

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It is recommended that Document 31 is enhanced to include the identification of training needs for: Employees with special needs; That a skills or competence matrix is used.

Provision of Training Training should be provided in a structured manner, based on the needs of the organisation and any specific needs of individuals within it, to assist the effective implementation of policy and procedures. The document Awareness and Competency in Health and Safety was also used to score this section. Scoring highly only minor enhancement is required. It is recommended that Document 31 is enhanced to include:

That training should take place during working hours without loss of pay;

That the procedure requires the use of pre-training briefings for delegates.

Health and Safety Assistance The appointment of competent persons to assist the organisation in meeting its health and safety responsibilities is a legal requirement. This is described as health and safety assistance, and can be provided by external or internal people. Their profile and remits are detailed in inset 9 of HSG 65, and include the provision of advice and co-ordination on health and safety matters. Document 31 also describes the required competencies of H&S Practitioners and others. Specified qualifications for those in health and safety roles are clearly identified e.g. Grad IOSH, NEBOSH Diploma, for practitioners and lower qualifications are also specified e.g. NEBOSH Certificate etc. Other specific training qualifications are also specified for Legionella and Asbestos etc. The authority for stopping work that is in contravention of agreed standards was found in the Duties Document 4 Section 9. In view of the excellent score no recommendations are made.

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5. Planning and Implementation

Section Overall 93%

The Planning Process 89% Implementation of Organisational Procedures

96%

Risk Control Performance Indicators 94%

5.1 The Planning Process

The Planning Process - Overall 89%

Corporate Planning 100% Operational Planning - Risk Assessment Procedures

86%

Implementation of Corporate Planning Procedures

88%

Implementation of Risk Assessment Procedures

93%

As with other aspects of management, planning is crucial to ensure that the relevant issues are adequately addressed, that sufficient resources are allocated, and that meaningful objectives and performance standards are set to achieve the aims and obligations of the organisation. It is important that any objectives are SMART (Specific, Measurable, Agreed with those involved, Realistic, and Time based with appropriate deadlines). The audit distinguishes between two categories of planning, i.e. corporate and operational. Corporate Planning Procedures Corporate planning is concerned with setting overall health and safety objectives and targets. It also includes actions to get the long-term objectives integrated at functional and individual level. These objectives should encompass the following:

a) Defining, developing and maintaining the health and safety policy; b) Developing and maintaining organisational arrangements; and c) Developing and maintaining systems of risk control to meet defined

performance criteria. Document No 13, revision 1 Dated 29/3/2010 Section 6 requires that a corporate health and safety action plan is developed by each Directorate. The H&S Team is also required to produce plans to implement corporate issues and any that are specific to that Directorate. The plans are to be recorded on the performance management system ‘Performance Plus’ and requires that deadlines are recorded, and those responsible for action are identified. There

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is also the requirement for actions to be tracked monthly; targets for each performance indicator are to be included in the quarterly and annual reports. In view of the high score no recommendations are made. Operational Planning Procedures Operational planning is concerned with the implementation of corporate plans through the assessment of the risks arising from work activities, plus the establishment and maintenance of suitable control measures. The current document for risk assessment CCC SP15 dated 2006 was identified as the lead document for this topic. As there has been no change then the comments and scores from the 2013 audit remain as is. A separate document the Management of Risk Procedure HTO-H&S-003 was also presented with regard to Highways and Planning. This document relates to the management of risk within Highways and Transport Operations providing guidance on the completion of the Location and Multiple location Specific safety and Health Risk assessment form attached to the document. The document includes the need for the review of completed risk assessments to be carried out by the Corporate Health and Safety Team. It is recommended that:

The risk assessment procedure(s) give guidance to assessors where these are applied to meet legal requirements which are less than absolute to include:

The application of best practice; An assessment of the options available; The relative costs and effectiveness of the options; Justification of the costs of control measures.

N.B. The auditor would concur with the previous auditor’s comment that there is no clear procedural requirement for the need for a process change risk assessment, which is an OHSAS 18001 requirement. Though reference to the risk assessment document 15, Section 15.2.8 identifies that managers are responsible for the review of risk assessments and the degree of change within an activity, this is tenuous. It is more usual to see a formal process change risk assessment. Implementation of Corporate Planning Evidence of corporate planning was provided with clear objective set with the objectives being cascaded via Directorate plans from the Corporate H&S Action plan, there is clear allocation of targets and persons identified for action. Quarterly reports indicate how the plan is progressing by indicating leading and lagging performance indicators.

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It would now appear that due to budgetary constraints that here are now 5 vacancies within the Corporate Health and Safety Team. Whilst there are a number of areas where enhancement of procedures has been identified as objectives within the plan the lack of resources are now starting to impact on what is achievable within the Team. It is recommended that:

Prioritisation of objectives and the provision of sufficient (people) resources will be required to continue to maintain the current high standard.

Implementation of Operational Planning The ‘SHE Assure’ web based risk assessment software system is being used to record risk assessments from within the Directorates. There is a tranche of corporate generic assessments available on line that cover activities such as lone working, stress road risk, asbestos, DSE, Legionella etc. That said it was evident that the risk assessments viewed that had been produced with regard to Manual Handling of service users using the DIAG format were of a good standard. Premises risk assessments have also been completed to a good standard as evidenced at Elizabeth Welsh Care Home. Evidence was also sighted of completed fire risk assessments and service user PEEP’S in the above premises. The generic risk assessments produced within Highways and Transport identify where risks are fully controlled. Where this is not the case then further controls and site specific controls are recorded and applied. Tool box talks covering the hazards identified in these risk assessments are available on the ‘In touch’ intranet system. These are briefed out to operatives on site. Evidence of completed risk assessments and tool box talks was found on the sites visited. It is recommended that:

Vigilance is maintained to ensure that suitable and sufficient risk assessments continue to be developed, implemented and reviewed.

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5.2 Implementation of Organisational Procedures

Overall 96%

Control 100% Co-operation 100% Communication 100% Competence 93%

Control

Control Overall 100%

Development and Control of the HSMS

100%

Supervision 100%

Implementation of Development and Control It was evident there is a full suite of HSMS documents that are controlled by the Corporate Health and Safety Team for the separate Directorates. These documents are available in electronic write protected PDF format. The documents viewed during the audit had suitable referencing, issue status and dates of issue. It was reported that the approval of documents by the Lead Officer Group (Directors) and Safety Practitioner Group may be reviewed to reduce the number of meetings held as part of the approval process. It was reported that the approval of documents by the Lead Officer Group (Directors) and Safety Practitioner Group may be reviewed to reduce the number of meetings held as part of the approval process. Ownership of Health and Safety and ‘leading from the top’ are core values promoted by the HSE and Institute of Directors. Notwithstanding this activity scored highly and will require vigilance to maintain the high standard achieved. Implementation of Supervision Good levels of supervision were in evidence at Elisabeth Welsh Care Home and on the two sites visited in the Highways and Transport Operations. CQC are responsible for setting the levels of supervision in care homes, Engineers with the HTO decide on supervision levels dependent on risk and activity. A high scoring activity that will require vigilance to maintain the high standard achieved. Co-operation Evidence of quarterly consultation meetings from the three separate groups H&S Lead Officer, Corporate Union safety meetings and H&S Practitioner meetings was sighted. The Meetings are chaired by the Corporate Health and

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Safety Officer. Meeting minutes are published on the intranet, and included responsibilities for action. Formal training has been completed for all Union Appointed Safety Representatives, and it was also good to see that a high proportion of the Lead Officers Group have also recently received training. It was reported that the Assistant Director for Highways and Transport Operations is proactive and regularly carries out site visits this would seem to be the exception. It is recommended that:

Lead Officers from all Directorates should regularly visit areas under their control this visible presence will show personal commitment and provide an opportunity for further two way communication.

No recommendations are made in view of the high score. Communication There are H&S advisors for each Directorate within the Corporate Health and Safety Team. The in touch intranet also provides much in the way of health and safety information. Evidence of rolling news feed was seen and included information such as updated procedures. Information comes from a number of sources such as IOSH, National Association of Care Homes, and hazard alerts. In the induction process the HR Checklist brings to the attention of news employees information such as the H&S Policy, fire and evacuation procedures. Managers cascade via team meetings risk assessments which are acknowledged by signature within the Schools and Care home Directorates. Annual and quarterly reports are available on the intranet. A number of toolbox talks were sighted within the Highways and Transport operations during the audit these are included in the training received by such individuals. Well being road shows have been delivered with regard to stress and health eating and lifestyle choices. This section scored highly no recommendations are made aside from maintain the high standard. Competence

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Competence Overall 93%

Recruitment and Placement Procedures

75%

Identification of Training Needs 92% Provision of Training 97% Provision of Health and Safety Assistance

100%

Implementation of Recruitment and Placement As per the previous audit report findings there are robust recruitment processes and job descriptions contain some health and safety duties. The recommendations made at the last audit remain extant. It is recommended that:

Health and safety competence forms part of the appraisal process; Health and safety competence forms part of the employee’s

assessment for promotion or redeployment. Implementation of Identification of Training Needs It was evident that there has been training of staff within the care home and Highways and Transport Operations visited. Training plans were evident in the Elisabeth Welsh Care Home for support workers, this clearly identified who had received training and had accrued sufficient CPD points e.g. 15 hours of training per year. The operatives in HTO were able to provide relevant evidence of training e.g. abrasive wheels, CITB Construction, CPCS tipper lorry, dump truck etc. Training certificates were also to hand in all areas audited. In the HTO offices in Penrith some operatives were seen to have recently expired LANTRA training, a refresher course has been booked for the individuals in early April. In view of the high score no recommendations are made. Implementation of Provision of Training It was evident that health and safety training has been provided for all employees including senior management. Identification of training needs can be via the learning and development manager, and departmental managers as part of the appraisal process. Evidence of competency matrices were sighted on the In Touch System and locally within the care home visited. Special needs of employees are identified as evidenced on the L&D training booking form. Training plans are evident as sighted in the Trent HR system.

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There was also evidence of training of non employees such as asbestos surveyors and also with regard to Legionella. Those employed within HTO had also received appropriate New Road and Street Works training as evidenced by operator competency cards. It was reported that there has been a reduction in the training courses available this may well be due to the reduced funding available. It is recommended that: The necessary resources are made available to support the training

plan. Implementation of Health and Safety Assistance All health and Safety Practitioners are highly trained to Diploma standard. They are supported by trained risk assessors from within the Council. Scoring maximum points there are no recommendations other than vigilance is required.

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5.3 Risk Control Performance Indicators

Overall 94%

Lone working 96 % Work at Height. 100 % Control of Contractors 100 % Asbestos 98 % Excavations 94 % Safety at Road Works 80 % Patient handling 95 % Legionnaires’ disease 100 % Management of occupational road risk

92 %

Stress 86 %

As part of the QSA audit, ten areas of legislative issues are considered in relation to the client. These are selected from a collection of indicators on the basis that they are relevant to the organisation, and therefore provide a measure of how well the organisation is managing specific legal requirements. They can be equated to the Risk Control Systems referred to in HSG 65, which are systems designed to address particular areas of risk that may not be adequately covered by the general health and safety management system. Each of the ten issues is examined in terms of both procedural control and actual implementation. An audit score is assigned to each of these areas, and they are referred to as Risk Control Performance Indicators. The ten areas are commented on below. Lone working The lead document identified for this topic was Lone Working CCC Procedure 24 dated 2006. The document contains policy, and guidance with regard to assessing and controlling the risk from lone working. Clear responsibilities are set out for line managers including the taking into account employees’ capability and training and putting in place suitable arrangements for monitoring of lone workers. It was reported that there is a trial being carried out with regard to Orbis a downloadable phone application. At present there would seem to be some technical difficulties with regard to local government security issues. Once addressed this will permit monitoring and alerting via a receiving centre. Evidence of lone worker risk assessment was sighted within the corporate risk assessment 03. Buddy arrangements, and white boards, and electronic calendars were seen to be in use for monitoring purposes. The Child protection team use Guardian Angel a card communication system. For high risk activities no lone working is permitted and pairs are used e.g. Out of Hours Team and Mental health Team when visiting clients or where there has

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previously been previously reported issues. Whilst lone worker training has been provided, no refresher training has been provided. It is recommended that:

Refresher training for lone workers is provided that includes the use of the Orbis Application once approved for use.

Work at Height A recent work at height policy statement has been produced with regard to ladder and stepladder use. This is supported by a number of detailed tool box talks on ladders and stepladders TBT 38, work at height TBT 05, scaffolding TBT 62, the use of lightweight scaffolding is also captured within TBT 40. During the audit a visit to Beacon Edge junction it was evident that tree works were being carried out by Clark Davidson Contractors to clear trees and branches in accordance with BS3998 from the corner of the road junction using a tracked telescopic boom, the work area onto the road had been coned off in accordance with NRSW. Risk assessments and method statements were in evidence and tool box talks had been briefed out were of a good standard had been acknowledged by the operators for this work at height. Induction onto the site was carried out by the supervisor. No recommendations are made in view of the high score. Control of Contractors The main document identified of relevance to this topic was H&S in Contracts and Procurement this is supported by A Contractors Code of Practice containing rules for contractors on site. There has also been development of a new procedure with regard to CDM 2015. For contractors involved in higher risk work e.g. construction and highways there is a PQQ process, and PAS 91 applied. Approved contractors may also be CHAS registered and SSIP approved. It was reported that some contractors also have OSHAS 18001 management standards. Evidence of inspections on site was evidenced to monitor contractor performance. There is also evidence of regular site meetings on construction projects. No recommendations are made in view of the high score. Asbestos The current document identified was Document 29 dated 2012. This contains guidance with regard to the management of Asbestos. Assessment surveys continue to be carried out by two different UKAS accredited contractors for schools and corporate buildings respectively. Currently there are 250 or so corporate assets and over 450 schools that have been surveyed. Evidence of completed surveys was sighted on the Atrium database, (Petteril House Care Home) together with an asbestos management plan from within the asbestos register. Actions are tracked and managed by the Property team. Separate

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analysts are used to negate conflict of interest from the asbestos removal contractors currently being used. Clearance certificates for the Victoria School in Ulveston were sighted, these indicated 0.01 f/ml. No Recommendations are made in view of the high score. Excavations A new PTW procedure has been drafted that captures the need for excavations to be controlled via a permit to dig. This document also identifies that only persons with the required competencies and knowledge should issue permits and describes the process for permit issue and collation. A number of documents were also made available including HTO-OP-004 March 2013, Damage to Services Report Form; HTO-OP-016, Permit to Dig; HTO-OP-017revision 2, and the Risk Avoidance process. Risk assessments on site at Low Hurst for the replacement and addition of a carrier drain were in place. Relevant TBT’S had been briefed out to the team, evidence of the use of a CAT survey, safe digging methods, service plans and drawings were also present on site. There is a requirement within the risk assessment for weekly inspection of the excavation. Training certificated and a variety of CITB cards were provided whilst on site and appeared to be current. The road in either direction had been closed, relevant permissions obtained and suitable barriers had been erected to prevent access during the works. It is recommended that the permit procedure is formally approved as a controlled document. Safety at Roadwork’s As yet there would appear to be no formal standalone document with regard to controlling this activity. Formal documentation in the form of a process map or narrative document is required to bring it all together. These should stipulate who, why, what where when how etc, as per the previous audit report recommendations. All works are conducted in accordance with the current NRSW Act and the Red Book guidance document with suitably qualified and competed personnel. The 3 sites visited were well laid out with good safety zones and signage. A three-way traffic lights system was in use to control traffic at the Beacon Edge junction. However it was disappointing to note that the Cumbria Traffic Management operative controlling the traffic at this location had not signed the risk

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assessment for this activity. Both operatives had received training with regard to the Traffic Management Registration Scheme. CCC permits were in evidence for the works visited. It was noted that the partial road closure at the Beacon Edge site had been subject to a traffic survey however when questioned with regard to pedestrians walking along the coned area the operatives from CTM were unsure as to what actions they should take and had to be prompted with regard to the escorting of pedestrians along the length of the works. It is recommended that:

A formal procedure is developed that describes and pulls together all the responsibilities and requirements for any street works activity;

That all NRSW operatives should sign relevant risk assessments; Where pedestrians may need to transit along street works that

operatives are briefed with regard to escorting of pedestrians along the route.

Patient handling The lead document identified for this activity was M9 the Moving and Handling Policy this document provides a good level of guidance for the handling of object and service users. The procedure identifies that CCC has adopted the Derbyshire Inter agency Group (DIAG) Code of Practice for the moving and handling of service users. The document however doesn’t identify the economic benefits of applying efficient movement principles. Within the Elisabeth Welsh care home visited it was clear to see that care plans for each service user have been completed and that these include the DIAG risk assessment form for the service user, particular needs of the service user including frailty and mobility, and the specific equipment to be used. Each care home has a manual handling key worker, and care plans are monitored monthly by the care home manager. Risk assessments for care staff also identified any particular needs, e.g. pregnant care workers, and physiological issues that might increase the risk when handling of service users. Evidence of the statutory inspection by Zurich engineers of hoists and slings etc was made available during the audit. Evidence of the training of care staff was also to hand with regard to use of lifting aids. Information from the Rehab Team, and Occupational Therapists regarding the service user and existing care plans is also provided to the care home prior to service users being transferred into the care home. It was good to report that a review of the current arrangements with regard to manual handling of service users has recently been carried out by Cumbria Care in Residential and Day Care Settings.

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It is recommended that procedure is enhanced to include: The economic benefits of minimising all potential hazardous patient

lifting operations. Legionnaires’ disease Health and Safety Procedure No 30, revision 3 has recently been updated in 2015. The document fully captures what is required with the procedural score for this topic. Clear responsibilities are set out within the document including those for the responsible person identified as the Contracting Technical Manger. Evidence of comprehensive Legionella risk assessments were sighted during the audit, these have been compiled by Waterman an external contractor. A data base of completed assessments is held within the Atrium system, these are readily accessible to CCC. There is a programme of remedial actions that are reviewed during contractor review meetings. It was reported that there is currently a new tender underway for the provision of Legionella risk assessment and management. Further training in Legionella awareness, sampling and testing has been arranged. No recommendations are made in view of the high score. Management of Occupational Road Risk The management of road risk procedure 25 was reviewed in 2013 and includes new procedures for driving licence checks, Cardinus driver profiling and driver training. This has been supported by a Drivers Handbook that was also reviewed in 2013. The majority of vehicles driven for the Cumbria County Council are grey fleet owner drivers. Valid MOT and insurance details are required to be submitted by drivers to the Road Risk Team. Pool cars are increasingly being used and can be booked on line. Hire cars are also another option dependant on mileages driven. Area based teams are also being put together in an effort to reduce miles driven. It was reported that whilst road traffic accidents are reported to insurers there is recognition that general bumps scuff and scrapes e.g. whilst parking are not necessarily reported. The auditor would agree that there is a need to report these minor incidents and a KPI is suggested. Costs of crashes are calculated only when insurance claims are made. It is recommended that:

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The reporting of general bumps and scratches etc of all vehicles used on County Council business is recorded and logged as a KPI.

Stress The lead document identified was Managing the Causes of Work Related Stress Document 20 dated 2014. This revised document now included hyper links to the organisations stress management tool, and risk assessment process for identifying stress and advocates early intervention to reduce absence from work. The document also provides guidance on the use of the HSE’s stress management standards and use of the return to work questionnaire again using the HSE’s stress management standard. Whilst the document identifies that mandatory stress and wellbeing training for managers will be provided this is likely to be rolled out shortly via an e-learning portal. The intranet contains a generic stress risk assessment for the activities carried out within the Council. The stress management approach has been used and actions from the manager and Individual are applied where stress has been reported. Evidence of use of a return to work questionnaire was provided during the audit (with personal details removed). It was identified within the last quarterly report that the prevalence of stress in not currently improving, this may well be due to a number of organisational changes and restructuring within the organisation that will include further staff reductions. It is recommended that:

Stress and wellbeing training is delivered at the earliest opportunity to managers and employees.

6. Measuring Performance

Overall 89%

Active Monitoring 89%

Reactive Monitoring 89%

In order to monitor health and safety performance to identify strengths and weaknesses, and areas for improvement, an organisation needs to operate systems to collect relevant data and statistics. This will also provide crucial information for planning and review activities. Such systems are in addition a legal requirement. 6.1 Active Monitoring

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It was evident that monthly inspections of care homes is carried out monthly using a checklist as evidence at Elisabeth Welsh care home, training has been received by the care home manager. Other workplace inspections are generally carried out on an annual basis. Problems are reported to the Properties department help desk, priority for actions are assigned and tracked. The adequacy of inspections regimes has been assessed within the Corporate Health and Safety Team. Within HTO regular checks of relevant H&S documents are carried out by the H&S advisor when visiting site, such document scan include permits, risk assessments, and tool box talks delivered relevant to the activities on site. HAVS monitoring sheets for individual using vibrating equipment are completed and analysis of the data clearly identifies if HTO workers have exceed the action level, appropriate actions are taken to reduce HAVS exposure. Evidence of statutory inspection of lifting slings within the care home and for construction plant was available and found to be current. It was evident that the Director for HTO regularly carried out safety tours, this is to be commended. It is recommended that: All Senior Management carry out tours of areas under their control Areas for improvement are tracked as a KPI.

6.2 Reactive Monitoring It was evident that the ICASS reporting system is being used to report events and this system can also capture near miss reporting. No fault Incidents are also recorded with regard to service users’ frailty. The quarterly reports clearly identify accident trends and lessons learned. With regard to the online ICASS report form, the completeness of report forms would appear not to be an issue as all fields have to be completed before filling in other parts of the form. Performance between the Directorates is analysed by use if the ICASS system. It was reported that there is some cross referencing of the data with regard to back issues from the use of non-profiling beds used in smaller rooms with only one carer being able to manually handle service users. It is recommended that: The reporting of accidents causing property damage should be

encouraged and investigated; The reporting of non-conformances should be encouraged and

investigated; o The report to Lead Practitioners Group should include an

evaluation of the time taken/costs involved in the accident and investigation.

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7. Audit and Performance Review

Overall 93%

Auditing 96% Performance Review 91%

The last two elements of the health and safety management system structure examined in the audit relate to the activities of the organisation in auditing its HSMS and reviewing its overall performance. 7.1 Audit It was evident that the HSMS is subject to regular internal auditing by the safety practitioners. A new system is being trialled using a Hastam web based electronic software system called Pro-evaluate. This closely follows elements of QSA and OSHAS 18001. It was reported that a more user friendly version may soon be made available in an n offline version. Whilst 170 of these internal audits were completed last year there well may be a fewer number of audits completed as there are now fewer competent persons to carry out this function. It is still apparent that some documentation is in need of updating e.g. the procedure for risk assessment. It is recommended that:

A sufficient number of auditors are maintained within the Corporate Health and Safety Team to maintain the current auditing of the Council’s HSMS.

7.2 Review Quarterly reports continue to be produced for review by senior management. The reports clearly identify what has been reviewed in the past quarter. It was evident though that due to the reduced number of safety practitioners (5 vacancies) that there are a number of KPI’s that have yet to be met. On a positive note the last report identified a number of issues that have been subject to review these included re- inspection of Asbestos in schools and the Legionella control contract. Senior Executive training has been delivered with the 90% target nearly met. A number of H&S procedures have been updated e.g. CDM. There has been some good co-operative work with the HSE with regard to controls for health measures for construction and highway activities. Reports would suggest that a wide variation of information is also used within the review process with commentary on incidents within other local authority networks. It is recommended that the formal review report includes:

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The costs of accidents; The costs of preventative action; The cost of monitoring health and safety performance e.g. inspections; The adequacy of resources applied to health and safety compliance;

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8. Score Summary

The overall results are summarised in the following table and

reproduced graphically using the QSA radar chart. Policy

Section Overall 100%

Policy General 100%

Policy Commitments 100%

Organising

Section Overall 90%

Organising for health and safety 100%

Organisational procedures 92%

Planning and Implementation

Section Overall 93%

Planning Process 88%

Implementation of Organisational Procedures 96%

Risk Control Performance Indicators 94%

Measuring Performance

Section Overall 89%

Active monitoring 89%

Reactive Monitoring 89%

Audit and Performance Review

Section Overall 93%

Audit 96%

Performance Review 91%

Health and Safety Performance Rating 93 QSA Award Level 5 Diamond Award

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POLICY

Policy

General

100%

Policy

Commitments

100%

80%

70%

60%

45%

30%

Performance

Review

91%

Organising

for Health

& Safety

100%

Organisational

Procedures

92%

Planning process

88%

Organisational

Procedures

Implementation

96%Risk

Control

Performance

Indicators

94%

Active

Monitoring

89%

Reactive

Monitoring

89%

HEALTH & SAFETY

PERFORMANCE RATING

RoSPA AWARD LEVEL

93

5= l

= 2

Award Scheme Levels

= 3= 4= 5

Auditing

96%

2015

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9. OHSAS 18001 Score Summary

OHSAS Para Aspect Percentage Score

4.2 Policy 100%

4.3 Planning

4.3.1 Hazard Identification, Risk Assessment & Determining Controls

89%

4.3.2 Legal & Other Requirements 100%

4.3.3 Objective Setting & Programme 92%

Planning Overall 94%

4.4 Implementation & Operation

4.4.1 Resources, Roles, Responsibility, Accountability & Authority

100%

4.4.2 Competence, Training & Awareness 92%

4.4.3 Communication, Participation & Consultation 93%

4.4.4/5 Documentation and Document & Data Control 100%

Overall 96%

4.4.6 Operational Control

4.4.6 Purchase of Services & Goods 100%

Hazardous Tasks 90%

Hazardous Materials 98%

4.4.7 Emergency Preparedness & Response 2013 98%

Overall 97%

Implementation and Operational Control Overall

97%

4.5 Checking & Corrective Actions

4.5.1/2 Performance Measuring & Monitoring 76%

4.5.3 Incident investigation, non-conformity, corrective action and preventative action

82%

4.5.4 Control of Records 100%

4.5.5 Internal Audit 96%

Overall 89%

4.6 Management Review 88%

Policy 100%

Planning 94%

Implementation & Operation 97%

Checking & Corrective Actions 89%

Management Review 88%

Overall 93%

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10. Acknowledgements

The Royal Society for the Prevention of Accidents, RoSPA and its Auditor Bernie Cerrino would like to thank Cumbria County Council for their hospitality and assistance during the conduct of this audit; in particular; Julian Stainton Corporate Health and Safety Officer and the Safety Practitioner Team; and all others who assisted in the audit.

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APPENDIX 1

THE QSA AUDIT The HSE has recognised that the consequences of the traditional approach to health and safety of compliance with numerous discrete items of prescriptive legislation leave many management activities not addressed. In order to provide guidance to organisations and their managers, HSE published the document "Successful Health and Safety Management" HSG 65 in 1991 (updated in 1997). This provides valuable guidance to support the requirements of the UK Management of Health and Safety at Work Regulations 1999. HSG 65 identifies the framework of management.

The Management of Health and Safety at Work Regulations 1999, Regulation 5 states: “Every employer shall make and give effect to such arrangements as are appropriate, having regard to the nature of his activities and the size of his undertaking, for the effective planning, organisation, control, monitoring and review of the preventative and protective measures.”

In practical terms, organisations should develop a Safety Management System which contains appropriate policies and procedures. Another HSE Publication HS (G) 96 “Cost of accidents” identifies other implications of poor health and safety performance, examples include: A construction site recorded a loss of over 8% of the original tender price of £8 million. An NHS Hospital had losses amounting to 5% of annual running costs.

A transport Organisation was experiencing losses that amounted to 37% of their annual profits. The QSA Audit system is based on the recommendations of ‘Successful Health and Safety Management’ [HSG 65], BS 8800 ‘ A Guide to Occupational Health and Safety Management Systems’, recent European derived legislation and all parts of OHSAS 18001. The auditing technique used to gather information for this report is based on the methods outlined in ISO 19011: 2002 ‘Guide to Quality and/or Environmental Systems Auditing’. Further development of the audit system to its current version (issue 4) has incorporated all the elements of OHSAS 18001.

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QSA consists of a standard set of over 1,200 questions structured to test the HSMS in five key areas identified in “Successful Health and Safety Management” HSG 65. These are:

Policy Organisation Planning and Implementation Measuring Performance Audit and Performance Review

Each of the questions must be answered ‘yes’ or ‘no’ and marks have been allocated to reflect the importance of the matter under scrutiny. Further weighting factors are applied to each section according to its importance in the whole system to give a final overall Health and Safety Performance Rating. This enables single number comparisons to be made between sites, or from year to year. QSA is a means by which the capability and performance of the management system for health and safety can be gauged and is not intended to give a comprehensive review of the adequacy of risk control measures. However, the effectiveness of implementation of selected control measures is examined as part of the exercise. It should be noted that this audit could act as the initial and / or periodic safety management system status review suggested in BS 8800 ‘ A Guide to Occupational Health and Safety Management Systems’.