Auditing

Although safety management systems are set up within individual organisational units it is not sufficient to assume that these will always operate as planned and that everyone involved will adopt best working practices.  As with any management system, regular monitoring is required to ensure that the system is initially suitable and workable and thereafter continues to function at a satisfactory standard.

As part of the University's governance function, SEPS operate a rolling programme of safety management auditing across the University.  This is monitored and overseen by the Health, Safety and Wellbeing Committee.  It is expected by HSE and by our insurers that such a process should be in place.

Auditing is a complementary process to inspection and looks at the function of the management system that has been set up. The aim is to gain a comprehensive view of how well the system is operating. It will usually examine the systems for management of one or more elements of health and safety from beginning to end rather than relying only on what can be seen from the inspection process alone. 

For example, a basic audit of an accident investigation system will look, not only, at whether accidents are recorded but will also consider whether reports are of an adequate standard, whether they are submitted to the right people and whether action is taken on findings.  Documentation associated with this system will also be examined and selected staff may be interviewed to test their awareness of the system within the unit. i.e. whether policies and arrangements have been effectively communicated.

Safety Management Audit Programme Objectives

• To examine the University’s compliance with statutory and other appropriate health and safety requirements and with its own procedures as set out in the University Health and Safety Policy, and to make recommendations for areas of improvement or for further work as necessary.
• To assist the University and individual management units in prioritising the appropriate resources and organisational arrangements for effective risk management in relation to health and safety.
• To monitor the University and management units’ progress against health and safety performance objectives and targets.
• To report findings to Court and to senior university management to allow the institution to effectively oversee and manage its safety performance.

Audit Process

SEPS use the guidance provided for head or management unit as a benchmark for our internal audit process.

Safety Management for Heads of Management Units

Our areas of enquiry map, broadly, to ISO 45001 safety management standards but are specific to the University, reflecting the organisation management and structure and approach within the University.  Our audit takes the form of a structured discussion around the 8 elements of safety manageemnt highlighed in the head  of unit guidance, followed by a programme of sample inspections to verify matters discussed.  A formal audit report is then prepared, firstly in draft for a period of consultation and then as a final report with agreed actions.

Here is a brief summary of the audit process. Our audits and normally conducted by a team of two comprising a Lead and Support Auditor.  Whilst this is our formal process there is room for some flexibility and adjustment of the process through discussion with the audit team.
 

Step1: Pre-audit planning
The Lead Auditor will notify the head of unit and local Safety Co-ordinator that an audit is scheduled and will agree a proposed audit date. The unit will decide which of their staff their wish to be in attendance based on the structure and roles within the unit. A list of documentation which teh audit  team would hope to review in advance of the audit will be provided with a request that this be supplied in electronic form in advance of the audit date. It is helpful for the Head of School to participate in some part of the audit but they need not attend for the entire duration.

Step2: Audit - desktop review
The audit will be conducted over 1 or 2 days depending on the size and risk profile of the School or Service being audited. The main part of the audit is a review of the arrangements in place within the unit and considers each of the 8 key safety management areas.  It is a discussion-based process that is conversational in style and explores the various areas of interest rather than being a checklist based process. The auditor may request to interview anyone in the workplace who may be able to provide on-the-spot confirmation or other information relating to the audit. The auditor may also request documents required as evidence of work health and safety legislative compliance. 

Step3: Audit - verification and sampling inspections
After the desktop review has been completed the audit team will carry out a series of inspections around the units premises and operations.  The aim of these is to obtain verification of the measures stated to be in place during discussions and to assess the practical risk control standards across the department.  This is a sampling process only and is not a full inspection of the unit. In smaller units it may be completed within a half day, following the desktop element of the audit.  In larger units inspections will normally be done on a subsequent day.

Step4: Draft audit report preparation and issue
On completion of the on-site elements of the audit the Lead Auditor will prepare a draft report.  This will be reviewed by the Support Auditor and when complete will be forwarded to the Head of School and Safety Co-ordinator (and others where required) as a formal consultation draft.  SEPS aim to issue the draft report within 4 weeks of the on-site audit work being completed. The draft report is provided to allow the School or Service an opportunity to review the content and any proposed Actions, to comment or these and to indicate any factual errors or misrepresentations.  After issue, a maximum of 4 weeks will be allowed for consultation on the draft report.

Step5: Final audit report issue 
When consultation on the draft report has been completed and any amendments agreed, the report will be reissued as a Final Report.

Step 6: Action tracking and HSWC monitoring
Agreed actions will at that point be entered in SEPS Action Tracker and will thereafter be tracked to completion.  Formal monitoring of progress will be conducted on a quarterly basis with progress on Actions completed/remaining open reported to the University Health, Safety and Wellbeing Committee until full completion of all Actions.