University Health & Safety Policy Manual Health and Safety Procedure 8

Guidelines Workplace Inspections and Safety Auditing

Rev. No. Date 01/01/2008 Amendment Details Author Health and Safety Office Issue Status

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

HSP8/1

Page 1 of 20

Review by 10/10

Please refer to Health & Safety Office webpage for current issue

CONTENTS

Section Executive Summary Flow Chart 1 Introduction and Scope Definitions 2 Related Documents 3 Responsibilities 4 Conducting Inspections and Audits 4.1 Frequency and planning 4.2 Inspection and audit teams 4.3 Checklists 4.4 Records, remedial actions and reports Appendix 1 Workplace Inspection Checklist Appendix 2 a) General Audit Checklist b) Alternate Audit Checklist Appendix 3 Safety System Auditing Schedule Appendix 4 - Further Guidance on Internal Auditing

Page 3 4 5 5 6 6 7 7 8 8 9 11 12 14 16 17

HSP8/1

Page 2 of 20

Review by 10/10

Please refer to Health & Safety Office webpage for current issue

Executive Summary
The University has had a system for conducting workplace inspections for many years. This procedure (HSP8) builds on this system and describes how both workplace inspections and audits should be carried out. Inspections and audits are different processes, although currently most Schools/Professional Services combine them to some degree. Heads (of Schools and Directors of Professional Services) should take part in at least one inspection/audit per year and ensure that: Inspection/audit teams are appointed and that their members are 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 of the responsibility to supervise and monitor operations on a day to day basis.

HSP8/1

Page 3 of 20

Review by 10/10

Please refer to Health & Safety Office webpage for current issue

Flowchart for Inspections and Internal Audits

SSO plans schedule for the year

Comment: All members t o be suitably trained

Teams selected for inspections/ audits

Comment: SSO leads

Checklists developed

but involves those whose work areas will be covered, with advice from the ASA

Inspection/ audit carried out, with findings noted

Comment: Immediate

Remedial actions identified

action to be taken at time of inspection/ audit wherever possible

Reports issued

Comment: 1. To line managers/ supervisors for remedial actions; 2. To H&S Committee for monitoring

SSO follows up to progress chase/ actions

Comment: Follow up

reports issued as required

HSP8/1

Page 4 of 20

Review by 10/10

Please refer to Health & Safety Office webpage for current issue

1.

Introduction and Scope

This document outlines procedures for the systematic monitoring of health and safety performance within a School/Professional Service by way of workplace inspections, and for more in depth auditing of School/Professional Service health and safety management systems. One of the aims of the guidance is to encourage Schools and Professional Services to adopt a proactive approach to health and safety and to demonstrate commitment by involving as many people as possible in the process. 1.1Definitions Workplace inspection Routine monitoring of basic health and safety provisions by School/Professional Service staff, usually using a checklist to ensure consistency of approach. Internal (Safety) Audit An internal safety audit is a systematic evaluation of a School or Professional Services organisation and systems for implementing the University Health and Safety Policy. The internal audit focuses mainly on systems, but also on the performance of individuals. Its aim is to identify strengths and areas of weakness in management systems to assist Heads in improving the health and safety performance of their School/Professional Service. Internal audits are carried out by School/Professional Service staff, with assistance from ASAs where required, using checklists based on University and local procedures. Workplace inspections and internal audits can be carried out as a combined exercise. (External) Safety Audit Periodically the Health and Safety Office will conduct an independent audit of a School/Professional Services organisation and systems for implementing the University Health and Safety Policy. These audits will take place as part of a rolling 3 year programme, sanctioned by the Safety and Occupational Health Committee. Audits will be carried out using an externally derived protocol, such as the Universities Safety and Health Association (USHA) Health and Safety Management Performance Standards (HASMAP) audit or the Occupational Heath and Safety Standard BS OHSAS18001 (as amended). The audit programme will allow for assessment of how effectively the University Health and Safety Policy is being implemented within the whole organisation, and for internal and external benchmarking.

HSP8/1

Page 5 of 20

Review by 10/10

Please refer to Health & Safety Office webpage for current issue

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 and Schools/Professional Services Heads of School or Directors of Professional Services. Note that School includes Research Institutes HSP Health and Safety Procedure. Documents providing guidance and advice on achieving compliance with specific requirement of the University Health and Safety Policy Manual SSO School Safety Officers. These include full time School or Professional 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 Safety Management Performance Standards Responsibilities The Head is responsible for ensuring that: Inspection/audit teams are appointed and that their members are 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 inspection and/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.

3.
3.1

HSP8/1

Page 6 of 20

Review by 10/10

Please refer to Health & Safety Office webpage for current issue

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 that required remedial actions have been taken Reporting the outcome of inspections and audits to the Head and/or School/Professional Service Health and Safety Committee. 3.4 Members of inspection and audit teams are responsible for:

attending training to enable them to conduct effective inspections and audits. 3.5 The Health and Safety Office is responsible for: providing advice and assistance on all aspects of the inspection and audit process, 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 safety issues, where advice is required about appropriate corrective action. The Health and Safety Office is also responsible for carrying out (external) safety audits (see 1.1). 4. 4.1 CONDUCTING INSPECTIONS and AUDITS Frequency and Planning

Monitoring in Schools and Professional Services must be carried out both on a day to day basis by line managers and supervisors and also by means of planned internal inspections and audits. Planned inspections should take place at least annually for office based activities and at least 6 monthly for all other activities. However, it is recommended that basic inspections should be carried out on a monthly basis as this allows for early detection of missing or damaged equipment and for deficiencies in daily monitoring and maintenance procedures to be identified.

HSP8/1

Page 7 of 20

Review by 10/10

Please refer to Health & Safety Office webpage for current issue

To adequately cover all the areas indicated on a checklist could take more time than a team can afford in one session. It is therefore recommended that inspection or auditing teams cover the School or Professional Service in planned segments over the period of a year. The time allotted for each monitoring session should be agreed beforehand and, for inspections, a limit of 2 hours is suggested to prevent errors due to time pressure on all parties. Internal audits can be combined with inspections, e.g. where the systems for conducting risk assessments are examined as part of the inspection. However, it is often convenient to plan internal audits as an annual cycle so that all critical management systems are examined over a year. An example of an annual plan is given in Appendix 3. Pre-notification of inspections/audits allows for collation of relevant documentation and ensures relevant staff and students can be present. It is therefore recommended that all inspections and audits take place with advanced notice, except in exceptional circumstances, i.e. accident investigation. 4.2 Inspection and audit teams

Inspections and audits must be carried out by teams rather than by an individual. Members of teams will vary according to the organisation in a School/Professional Service and with the aims of the particular inspection or internal audit, but may include: The SSO or deputy A person from outside the School/Professional Service such as the 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 carry out an effective inspection. The team should be selected to best cover the area/work activity to be inspected. Although the number of persons is limited there is no reason why the same people should be in the team on every occasion. Rotation of membership so that all members of a School/Professional Service are involved over a period of time is extremely useful in promoting involvement in health and safety and in generating awareness of other activities and issues in a School/Professional Service. To ensure that inspections and audits are effective, training of team members in appropriate techniques is essential. 4.3 Checklists

4.3.1 Workplace inspections

HSP8/1 Page 8 of 20 Review by 10/10

Please refer to Health & Safety Office webpage for current issue

To ensure consistency of approach, checklists should be used during an inspection to record the findings. Checklists must be designed to fit the needs of the area/work activity being inspected, and an example is given in Appendix 1. Advice on the composition of checklists can be obtained from the appropriate ASA, and it is important to also consult those whose work areas will be inspected to ensure that all relevant activities are included on the checklist. It is particularly important that inspections include a check that risk assessments are in place and that they are of sufficient quality. 4.3.2 Internal Auditing Checklists When drawing up internal auditing checklists reference should be made to the School/Professional Service Health and Safety Policy and related procedures and to relevant HSPs. Examples of internal auditing checklists are given in Appendices 2a/b. The checklist should be circulated prior to the audit as this will avoid confusion as to what areas are to be covered and allow participants to collate records, e.g. training, risk assessments, procedures etc, for examination. This will reduce wasted time searching for evidence and allow more time to observe activities and to ask questions. Random sampling may be acceptable, especially for large scale operations or those carried out over several locations, although care should be taken to ensure the sample is representative 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, see Appendix 1. In addition, a Hazard Report form for use during safety inspections has been devised and copies are available from the Health and Safety Office. Whatever format is used, a record needs to be made during 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 timely corrective action is taken. Simple problems should be corrected immediately or within a short time. More complex problems should be resolved before the next inspection/audit. A formal follow-up should be undertaken by the SSO (or other nominated team member) as required, but at least one month after the
HSP8/1 Page 9 of 20 Review by 10/10

EBSITE FOR LATEST EDITION BEORE USE

Please refer to Health & Safety Office webpage for current issue

PLEASE CHECK HEALTH & SAFETY OFFIC

inspection/audit to identify progress with remedial actions. Actions not completed within the agreed time scale or to the agreed standard must be raised with the relevant line manager/supervisor and if necessary recorded on a Corrective Action Request form and processed in accordance 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 a need to ensure that reports are made to those who need to take remedial action, e.g. line managers and supervisors, and also to those who have a monitoring remit, e.g. the School/Professional Service Health and Safety Committee. In the case of the former, the record made at the time of the inspection may, if designed appropriately, be all that is required. If so, a copy of the record should be forwarded to relevant line managers and supervisors for their attention. If this is not the case, reports to line managers/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 should be converted into a summary of actions required and prioritised. For monitoring purposes, a summary report of findings should be submitted to the Head and/or School/Professional Service Health and Safety Committee. Reports should highlight where improvements have been made as well as where new deficiencies have been found, and identify underlying trends where they have become apparent. These reports should be able to answer the questions; what are safety standards currently like? and what more needs to be done? The reports should also assist with compiling Annual Health and Safety Reports and Action Plans.

HSP8/1

Page 10 of 20

Review by 10/10

Please refer to Health & Safety Office webpage for current issue

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 as described in their health and safety policies and procedures, with advice from the Area Safety Adviser.

Location:

Area Yes/No/N A

Date: Action/Comments

FOLLOW UP
Have all actions from previous inspection reports been completed?

EXTERNAL
Pathways/approaches in good repair? Is lighting adequate? Are fire exit doors and stairs free from obstruction and in good repair Is there adequate signage on fire exit doors? Are main entrances/exits secure and free from obstruction?

ENTRANCE/CORRIDORS
Is 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 from obstruction? Are floors in good condition?

RISK ASSESSMENT
Are all necessary risk assessments completed? Are risk assessments of sufficient quality?

ELECTRICAL EQUIPMENT
Are RCD devices operational? Does all observed equipment and extension cables have current PAT test label? Are all telephone and data cables safely routed? Broken or damaged equipment withdrawn from service?

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

WELFARE
Are toilets/shower/washbasin areas clean? Are amenity provisions clean and provided with essential equipment?
HSP8/1 Page 11 of 20 Review by 10/10

Please refer to Health & Safety Office webpage for current issue

Inspected by: Please return completed copy to:

Print Name/Title

HSP8/1

Page 12 of 20

Review by 10/10

Please refer to Health & Safety Office webpage for current issue

Appendix 2 (a) Internal Audit Checklist/Aide-Memoir (General 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 as described in their health and safety policies and procedures, with advice from the Area Safety Adviser. The list can be used as an aide-memoir in conjunction with the Hazard Report Form, available from the Health and Safety Office, and can prompt suitably trained inspection/auditing teams when conducting a combined inspection and audit.

AREAS TO BE COVERED PREMISES 1 Lighting 2 Heating 3 General Ventilation 4 Housekeeping

a ) b ) c ) a ) b ) c ) d ) Cleanliness Storage of materials Waste disposal arrangements/frequency

5 Means of Access
Floors Passages Stairs Ladders

6 Maintenance MACHINERY PLANT AND EQUIPMENT 1 General condition 2 Maintenance 3 Guarding of dangerous parts 4 Testing and inspection
a) b ) Pressure and vacuum vessels and associated pipe work Lifting machines and tackle marking of SWELL, etc.

5 Electrical equipment, test and inspection 6 Fume Cupboards

a) b ) c) Effectiveness Construction Inspection and testing records

7 Office machines, copiers, printers, VDUs HEALTH, ENVIRONMENTAL HAZARD, HAZARDOUS MATERIALS 1 Noise 2 Toxic substances
a) b )
HSP8/1

Use Storage

Page 13 of 20

Review by 10/10

Please refer to Health & Safety Office webpage for current issue

3 4 5 6 7

Dust Fumes and Gases Ionising micro-wave and other radiation Lasers Control of dangerous chemicals
a) b )

Storage and use of highly flammable or explosive materials Gas cylinders use and storage

8 Cutting Oils 9 Control and disposal of waste and effluent 10 Hygiene

a) b ) c) Washing facilities Toilet facilities Cleansing materials

GENERAL 1 School or Professional Service Health and Safety Policy and relevant procedures
a) b ) Availability Updating

2 3

Recording of accidents
a) a) b ) c) d ) Follow-up system Type Suitability Acceptability Standard of use

Protective clothing and personal equipment

First Aid
a) b ) c) Qualified First Aiders Adequate equipment Information Alarm system Means of escape Detectors (if provided) Provision and maintenance record of extinguishers Training Special hazards (flammable liquids stored, heat sources (soldering, welding, long running electrical equipment) Date of fire drills

Fire
a) b ) c) d ) e) f) g )

School or Professional Service activities organisation and arrangements

a) List of identified hazardous activities (activities with a potential to harm or injure) 1 Routine activities associated with course content 2 Off-site activities (UK) Staff and/or Student. Includes: Fieldwork Visits Surveys
Page 14 of 20 Review by 10/10

HSP8/1

Please refer to Health & Safety Office webpage for current issue

b ) c)

Data collection External lectures Attending seminars or courses 3 Student placements 4 Working overseas Location and availability of risk assessment documents or records Means of identifying assessment review dates Identified training needs Training conducted since last inspection

Training activities (Records)

a) b )

Progresses on Annual Report Action Plan items

HSP8/1

Page 15 of 20

Review by 10/10

Please refer to Health & Safety Office webpage for current issue

Appendix 2 (b) Internal Audit Checklist (Alternate 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 as described in their health and safety policies and procedures, with advice from the Area Safety Adviser. This checklist is a basic audit checklist to which Schools/Professional Services would add, making reference to appropriate specialised subjects such as COSHH etc, depending on their own activities.

Checklist Last Inspection Have remedial actions agreed after the last inspection been satisfactorily 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 attendance records 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 office space? Is there a Health and Safety Law information poster displayed within the school or building area? Condition of premises Have building defects with health and safety implications been reported 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 of photocopiers)? Are there procedures for what to do in the event of a fire are they posted? Are evacuation routes kept clear and adequately signed and illuminated? Are fire doors in good condition and kept closed? Can they be easily opened to effect escape?
HSP8/1 Page 16 of 20 Review by 10/10

Please refer to Health & Safety Office webpage for current issue

 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 been identified? Have these situations been brought to the staff attention? Has action been taken to remove or reduce the risk of injury? (This includes training) Computer Workstations Have users been identified? Have workstation assessments been carried out, either by individual users or other trained staff? Are users using the workstation in accordance to training? Have there been any ill health or injuries reported with reference to computer 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 of machinery/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/Outreach Teaching/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

HSP8/1

Page 17 of 20

Review by 10/10

Please refer to Health & Safety Office webpage for current issue

Appendix 3 Safety System Annual Audit Schedule for 2008 (Example)

School/Professional Service Division/Section
Month/Activit y Training Fire Safety Safety Policy Inspection(s) Electricity At Work Waste Ladders COSHH PPE Lone Working First Aid Manual Handling Noise S C C R C C C/O S S S S S C/O Jan Fe b Ma r Apr Ma y Jun Jul Au g Se p S Oct No v De c

Code: S C Scheduled Completed O Outstanding Action R Rescheduled

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

HSP8/1

Page 18 of 20

Review by 10/10

Please refer to Health & Safety Office webpage for current issue

Appendix 4 Further Guidance on Internal Auditing

1. Internal auditing This is more than an examination of the physical workplace, although examination of workplace inspection records should form part of the process. Individual behaviour should be monitored and monitoring sessions should be primarily directed at the management systems set out in the School/Professional Service Health and Safety Policy, local arrangements and records. This should be carried out for each activity scheduled for examination. 2. Individual Behaviour Internal audits involving observation of individual behaviour must be carried out during the normal working day, to ensure access to personnel involved in the scheduled activity. Individuals should be observed carrying out relevant tasks and questioned about health and safety issues that might not yet have been identified. Questionnaires or verbal questions, agreed in advance with the ASA, can establish the success or failings in induction or other training provision for individuals and groups of staff. 3. Documentation Records generated by the School or Professional Service that should be examined to ensure contents are still valid, relevant and related procedures are being followed. These should include: a) School or Professional Service Health and Safety Policy and local arrangements content, issue status and accessibility b) risk assessments c) workshop rules or protocols d) previous inspection report forms e) training records f) action plans g) 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 in suitable time or manner? j) who takes on the follow up actions? k) what records are kept? 4. Premises

HSP8/1

Page 19 of 20

Review by 10/10

Please refer to Health & Safety Office webpage for current issue

When making observations of the premises an aim could be to ensure that normal daily maintenance faults are corrected. The main concern here is the system and its effectiveness how faults and deficiencies are identified, 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 the following: a) inspecting records showing details of workstation assessments carried out b) carrying out a physical inspection of a sample of workstations to confirm that assessments are still valid c) inspecting training records to confirm workstation users have received appropriate training d) holding discussions with a sample of users to seek their views on the effectiveness of the assessment and the training. 6. Communication The team should communicate with those in the area being audited, by talking to the people and involving them in the process. Positive feedback on good performance can encourage commitment to further improvement and can be used to mitigate reporting of more negative observations. Attempts should be made to avoid out and out criticism by being tactful. Where possible, ways should be identified in which problems can be corrected, rather than merely noting they exist. If possible, those being audited should be encouraged to come up with the solutions themselves (but avoiding getting bogged down in detail at the time of inspection).

HSP8/1

Page 20 of 20

Review by 10/10

Please refer to Health & Safety Office webpage for current issue