Management Review Report 2009-10

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OCCUPATIONAL HEALTH AND SAFETY JOINT ADVISORY COMMITTEE

OCCUPATIONAL HEALTH AND SAFETY MANAGEMENT REVIEW REPORT


2009-10
Summary
This report is submitted in fulfilment of the requirements of the certification of the
Councils Health and Safety Management System (BS OHSAS 18001). It focuses
on the overall performance of the safety management system (SMS).
The Council adopted BS Occupational Health and Safety Series (OHSAS) 18001
in 2005 as a framework for effective implementation of the risk based health and
safety management system. This framework ensures that the Council can
demonstrate that it deals with risks sensibly and proportionately and delivers
continuous improvement in performance. In July 2007 OHSAS 18001 became a
British Standard.
The Chief Executives (DCE), Finance (DF) and Customer Services Directorates
(DCS) achieved Corporate Certification to BS OHSAS 18001 in August 2008
through Lloyds Registers Quality Assurance Division. The Directorate of
Environment and Regeneration Services (DERS) achieved certification to OHAS
18001 as a directorate through BSI in January 2008 as part of their integrated
management system.
The format of the report follows the implementation guidelines and provides a
summary of the review of health and safety performance in all the directorates that
are accredited as above during 2009-10 and provides new objectives and targets
for the coming year 2010/11.
Members are asked to note:
1.

That the safety management system continues to provide consistency and


improvement across the Council in the most cost effective manner.
2. That good progress has been made in preparing for extension of the BS
OHSAS standard to include Social and Community Services and Childrens
and Young Peoples Directorates.
3. That work has been undertaken to prepare for the merger of the 2 separate
systems including certification under the corporate badge, without
compromising the integrated management system operating in DERS. The
integrated system covers Health and Safety, Quality and Environmental
Management.
4. The policy document has been reviewed and there are no recommendations
to amend.
Members are requested:
1.

To approve the objectives and targets for 2010/11 set out in Appendix 3.

1.

Introduction

BS OHSAS 18001 has a requirement for the Councils top management to review the
OHS management system annually in October to ensure its continuing suitability,
adequacy and effectiveness.
The review considered the opportunities for improvements or changes required to the
health and safety policy, objectives and elements of the safety management system
in light of the results of management system audit, the internal audit, changes in
circumstance and the Councils commitment to continual improvement.
Currently within the Council there are two safety management systems, a Corporate
system covering Chief Executive, Finance and Customer Services Directorates and a
directorate safety management system covering Environment and Regeneration
Services. Both are accredited under BS OHSAS 18001:2007 .
Data used in this review included accident statistics, results of internal and external
audits and surveillance visits, risk management and corrective actions carried out,
control processes, emergencies (actual and exercises) reports, and notes from each
directorates safety group meetings.
2.

OHS policy

The policy document is due for its annual review in June this year. The opportunity is
taken to bring this forward to Board now . No changes to the document are
recommended but it needs to be signed and dated by Will Tuckley and Paul Moore to
indicate that it has been reviewed and approved.
3.

Review of performance

BS OHSAS 18001 requires that the Councils safety management system has
procedures for measuring performance and monitoring on a regular basis. Measuring
performance can include qualitative and quantitative measures as well as measuring
the extent to which objectives are met and checking effectiveness of controls.
Quantitative measures include incident, accidents, lost time and ill health reports and
statistics which are reported to directorate safety groups and the Joint Steering
Group and Joint Advisory Committee on a quarterly basis.
In the year 2009/10, the Council reported the following incidents:

Reportable incidents 2009/10


2008/9
Number

2009/10

Days
lost

Number

Days
lost

Assault

96

55

Glass / sharps

28

Handling / lifting / carrying

16

13

Other (explain):

61

21

11

198

94

Struck against fixed object

Struck by moving object

40

Struck by moving vehicle

44

28

422

21

259

Slip / trip / fall on level

Totals

By comparison the year 2009/10 showed a reduction of 25% in the number of


reportable incidents and a reduction in lost time of 38.6%. The most significant
reductions being in the time lost by Assaults (42.7%) and Slips, trips and falls
(52.5%).
The Councils performance on ill health
Based on the London Councils survey, there has been a significant improvement in
the Councils sickness absence rate ranking across London from 9th in 2006-07, 5th
for 2007-2008 to 2nd in 2008-09 (the latest year for which comparative information is
available).
Current performance after 3 quarters is 3.29 so we are projecting for 2009/10 to meet
the target of 6.1 days.
Internal audits
The system of internal control is based on an ongoing process designed to identify
and prioritise the risks to the achievement of the improvements in health and safety
performance and ensure compliance with policies and procedures, orders and
regulations. The process involves the evaluation of how well the safety management
system processes and procedures are meeting those needs, and highlights how well
the Council and its officers are managing risks in specific areas of the directorates.
Such monitoring and measuring performance is carried out on a regular basis. The
programme for internal auditing is over a 3 year period July 08 to June 11. See audit
programme attached at Appendix 1.
The Councils Internal Audit Team is currently carrying out an audit of the OHSAS
system that will provide another level of checking that the system is being
appropriately followed. This will address an issues raised by LRQA as a non
conformity and will be assessed at the next external surveillance visit by LRQA in
August 2010.

External audit and surveillance visits


Excellent progress has been made with the implementation of the agreed corrective
action following external audits. A summary of the corrective actions required
indicating those completed is set out at Appendix 2. This report satisfies two of the
actions required, that is in respect of a Management Review and Review of
Objectives.
The Schedule of Internal Audits has now been updated to include a review of the
Internal Audits, Management Review and Objectives and Programme Clause of the
Standard.
Additional steps are being taken through Directorate Health and Safety Groups to
ensure that DSE Self Assessments are completed by all users of Display Screen
Equipment and service areas have completed risk assessment documentation.
Enforcement notices
Another qualitative/quantitative measure is the number of enforcement notices
served on the Council. No enforcement notices have been served on the Council in
2009/2010.
4.

Risk Assessment and Action Plans

The completion of risk assessments by all managers of service areas within the
Directorates that are accredited is monitored. Increasingly the HR system is being
used to monitor completion of risk assessments and produce reports and distribute
information.
Directorate Health and Safety Groups review outcomes and instigate remedial
actions.
5.

Resources (Financial, Personnel and Material)


a.

Capacity and Capability


Services supporting the implementation of the safety management system
are delivered by trained and experienced Health and Safety Advisors. All
posts have a detailed job description and person specification. Training
needs are identified through the Performance Appraisal and Development
Scheme (PDPs). Individual targets are defined from service and team plans
and monitored through regular 1 to 1s. Additional capacity is delivered
through a service level agreement with the Department of Public Protection
in the Directorate of Environment and Regeneration Services.
During the current year, one member of staff has taken phased retirement
and reduced his hours. Recruitment to the vacant hours is progressing.
The Head of Health and Safety has been absent for a period and support to
the Health and Safety Service is being provided by the Deputy Director

(HR). This absence has had some impact on the work of the team but
resources are sufficient to meet the requirements.
b. Financial and other resources
The Health and Safety Service is being delivered within the agreed budget.
In common with other Council services, the service faces a challenging
budget position in coming years and is seeking efficiencies through better
use of ICT, sharing of administrative support, better procurement processes
and e learning for training.
6.

Effectiveness of Procedures

The internal audits and monitoring programme reveals that managers are aware of
procedures and sources of information including the intranet. There are however
opportunities for improvement particularly in understanding and implementing some
procedures and process and in clarifying exact requirements. This is being achieved
through additional training (e.g. in the management of violence and aggression, and
of management of stress), through e learning packages that enable staff to improve
their knowledge and awareness at times that suit their own circumstances, and
through the Directorate Health and Safety Groups.
Staff and managers are becoming more familiar with what is required and materials
have been developed to assist managers to ensure that the system is applied in a
timely and appropriate manner.
7.

Emergency preparedness - fire safety


a.

Fire Risk Assessments


Estate Services, having initially arranged for fire risk assessments for
Council buildings to be carried out, arrange for annual reviews. There are
some exceptions to this annual review where identified from the fire risk
assessment that fire risk is reduced due to the building being small in area
or light in use. The review in these cases are three yearly.

b. Fire Brigade Visits


An enforcement visit under the Regulatory Reform (Fire Safety) Order 2005
was made to Slade Green Community Centre in February 2010. The
conclusions from the inspecting officers visit were that he was happy with
our procedures, only minor deficiencies were identified and the premises
were generally well managed. This had been a good test for the Councils
fire procedures that had proved to be robust.
c.

Fire Training
E learning modules are currently being developed to replace the fire safety
awareness and fire marshal sessions. Staff will be targeted in the coming

months to complete these using training records data from the TOPS
system.
The table at 9 below includes training carried out and numbers attending
during 2009/10.
8.

Participation and Consultation

The Directorate Health and Safety Groups and Joint Steering Group (JSG) met
regularly throughout the reporting period to monitor health and safety performance
and discuss health and safety issues with Trade Union and Staff Representatives.
9.

Training

A summary of training and attendance figures for the reporting period is given below:
Topic

Numbers

Notes

18001 Managers

29

Focused on managers in DCYPS and DSCS.

18001 Staff briefing

289

Focused on staff in DCYPS and DSCS.

Risk Assessment Workshops

89

Focused on manager or representative from


service areas in DCYPS and DSCS.

Risk Assessment Workshop for


schools

10

Manual Handling awareness

16

Manual Handling awareness (schools)

18

Staff at Risk of Violence and Verbal


Abuse

52

Delivered by Frontline Behavioural Science


Training.

Management of Stress

Pilot session. Sessions due to be rolled out


May 2010. To be delivered by Three60 Stress
Management.

Fire Safety Awareness

108

Due to be replaced by e- learning 2010/11.

Fire Marshal

66

Due to be supplemented with e learning


2010/11.

Fire Risk Assessment Training Schools

22

Fire Risk Assessment - School


Governors

27

New Heads Induction

Heads Briefing - Swimming

41

Governors of VA/Foundation Schools Responsibilities

19

Working At Height - Schools

41

CIEH Level 2

42

CLEAPSS Heads of D&T

18

Training under the above headings will continue to be undertaken during the
year 2010/11. Dates will be announced nearer the times of delivery.

10. Progress against objectives


Objective 1

Maintain BS18001 OH&S Certification in CE and F&BS.

This objective has been achieved. The Certification has been amended to
reflect the new Directorate structure. At the last surveillance meeting in March,
it was noted that a Management Review and Objectives were required to be
agreed in order to comply with the requirements of the standard. This report
summarises the Management Review undertaken. In addition, the proposed
objectives for 2010/2011 need to be agreed and are set out at Appendix 3.

Objective 2 To have the non school departments of Childrens and


Young Peoples Directorate ready for external audit and accreditation and
certification.
Good progress has been made in establishing the Directorate Health and Safety
Group, training relevant managers and carrying out risk assessments and other
activities required. However, there is still further progress required in the areas
of internal audit and risk assessment but it is anticipated that accreditation will
be achieved in the late Summer/Autumn of 2010.
Objective 3 To have the Directorate of Social and Community Services
ready for external audit and accreditation and certification.
Good progress has been made in establishing the Directorate Health and Safety
Group, training relevant managers and carrying out risk assessments and other
activities required. However, there is still further progress required in
completion of additional risk assessments for specific risks e.g. DSE, lone
working and dealing with potentially violent clients but it is anticipated that
accreditation will be achieved in the late Summer/Autumn of 2010.
Objective 4 To maintain certification of the OH&S part of the Integrated
Management System (Safety, Environment and Quality)
This objective has been achieved.
Objective 5 To prepare the DERS Integrated Management Systems
ready for inclusion in the Corporate Safety Management System audit and
certification.
This now forms part of the DERS and the Health and Safety Service work plan
for 2010/2011. Meetings have taken place with external assessors and internal
management to discuss the most effective way of bringing the systems together
under a single schedule of accreditation.
11. Conclusions from the Review
The following conclusions have been made.

That the safety management system continues to provide a framework for


developing consistency and continuous improvement across the Council in
the most cost effective manner

Good progress has been made to include Social and Community Services
and Childrens and Young Peoples Directorates in the corporate safety
management system and certification and this should be achieved by late
Summer/Autumn of 2010. Good progress has been made in winning
managers support for the system through the work of Directorate Groups,
workshops and e learning. The system has assisted in the resolution of
issues, e.g. around new office locations. The safety management system
and its procedures needs more deeply embedding. Further work is required
to nurture ownership of the management system by all staff to take an
active part in delivering the management system.

Further work is required to set out the road map and timing for merging of
the two separate accreditations, without compromising the integrated
management system operating in DERS. The integrated system covers
Health and Safety, Quality and Environmental Management.

Supporting material has been developed to support managers in carrying


out required assessments and reviews in accordance with the systems
procedures and timetable. Documentation and supporting material
continue to be further developed and refined so that they are tailored to the
service areas.

Directorate Health and Safety Groups and DMTs are regularly informed of
key issues and progress in implementing the standard and achieving
continuous improvement.

Training and development is being delivered more flexibly through e


learning, shorter workshops and targeted training.

12. Objectives for 2010/2011


The objectives and action plan for the coming year have been reviewed and
clearly to a large extent involve the continuation of work already undertaken.
The proposed Objectives are set out in Appendix 3.

13

Summary of Legal implications

There are no legal implications .


14.

Summary of Financial Implications

There are no financial implications.

15.

Summary of other implications

There are no other implications

Local Government Act 1972 Section 100d


List of background documents
BS 18001 OHSAS 2007
BS 18001 OHSAS 2007 Implementation Guide
Legal Register
Internal and External Audit
Health and Safety Monitoring Question sets
Internal audits
Legal register
Notes of Directorate Health and Safety Groups meetings

Contact:

Matilda Zindoga, Head of Health and Safety

Report to:

Nick Hollier, Deputy Director Human Resources

Appendix 1
Audit programme and summary of findings 2010 2013
Chief Executives Directorate, Directorate of Customer Services and Directorate of Finance
Service Area Manager
(Area Representative)

Audit
Plan
Date

Audit
Carried Out

Dec-08

09/12/2008

Nonconformities Identified

Action points

Status

9.12.09 Archiving documents stored at an Erith building basement


identified as a potential issue for staff who may need to gain
access. Currently being investigated by Trevor Mogg. 20.4.09 Only
Technical Section currently have storage at this premises which will
be removed in the future. In the interim Trevor Mogg has visited
premises and has assessed current circumstances as satisfactory
for staff to make planned visits.

3.1.2.1 Location not complying with all of the requirements


of the written procedure on risk control measures.

3.1.2.1 Risk assessments had been completed but are in need of


reviewing/updating as appropriate. Updated/reviewed
documentation have now been received.

7.1.1.1 No clear, written description of the workplace(s) for


which you are responsible.

7.1.1.1 This is clear for the Civic Offices location but suitable
arrangements eg lone working, must be in place for the infrequent
visits of staff to premises where documents are archived.

7.3.1.6 No effective arrangements to ensure that all


workstation risk assessments are reviewed at appropriate
intervals.

7.3.1.6 There has been clarification of the need for staff to review
their assessments annually or more frequently where appropriate
and staff will be requested to do this.

7.3.2.4 Users and operators not provided with relevant


information on the risks and control measures associated
with the operation of DSE.

7.3.2.4 A link to Bexley's 'DSE and U' leaflet forwarded for


information to be drawn to staffs attention.

3.1.2.1 Is the location complying with all of the


requirements of the written procedure on risk control
measures?

There has been a clarification of the need for staff to review their
assessments annually or more frequently where appropriate and
staff will be requested to do this as appropriate.

7.1.1.1 Have you a clear, written description of the


workplace(s) for which you are responsible.

Mark has recently taken on responsibility for the 'Farer Charging'


staff based at the Civic Offices. Risk assessment documentation
should be completed for this area also.

7.1.1.2 Do you have effective arrangements for assessing


all of the risks associated with the physical attributes of
the workplace(s) for which you are responsible?

Capita carry out monthly checks of the workplace in addition to


Mark completing the Safety review Checklist that includes a prompt
to consider the physical attributes of the building.

7.3.1.6 Do you have effective arrangements to ensure


that all workstation risk assessments are reviewed at
appropriate intervals?

See 3.1.2.1 action points above

Audit and Technical


Technical Finance - Nigel Bate

Internal Audit - Dave Hogan

Revenues and Benefits - Mark


Underwood

Sep-09

Oct-09

29/09/2009

06.10.09

(7.1.1.1).No clear, written description of the workplace(s)


for which you are responsible.

Chief Executives Directorate, Directorate of Customer Services and Directorate of Finance


Service Area Manager
(Area Representative)

Audit
Plan
Date

Audit
Carried Out

Nonconformities Identified

Action points

Status

7.3.2.4 Are all users and operators provided with relevant


information on the risks and control measures associated
with the operation of DSE?

A link to Bexley's 'DSE and U' leaflet has been forwarded for
information to be drawn to staffs attention.

3.1.2.1Is the location complying with all of the


requirements of the written procedure on risk control
measures?

Use of own safety checklist was identified as a preference. Bexley's


Safety Review Checklist (CL015) will be used from now on. This
will be monitored when documentation next reviewed.

7.3.1.3 Have all users and operators completed a selfassessment questionnaire?

It was identified that some staff needed to complete their self


assessment questionnaire. This would be picked up in the
directorate reminder sent out in June 2009.

2.1 Up to date copy of the written OH&S Policy available


at the location

2.1 John was shown how to access health and safety information
from the BexWeb site as an additional means of knowing where
these documents are located

2.2 Have the contents of the OH&S Policy been


communicated to all employees?

2.2 John is aware that staff should have attended training. Prior to
auditing, HSS should interrogate TOPS system to identify staff who
have not attended the 18001 staff briefings.

3.1.2.1 Is the location complying with all of the


requirements of the written procedure on risk control
measures?

3.1.2.1 Risk assessments have been completed but those for Fire
and DSE are in need of reviewing/updating.

7.3.1.6 No effective arrangements to ensure that all


workstation risk assessments are reviewed at appropriate
intervals.

7.3.1.6 There has been clarification of the need for staff to review
their assessments annually or more frequently where appropriate
and staff will be requested to do this.

7.3.2.4 Users and operators not provided with relevant


information on the risks and control measures associated
with the operation of DSE?

7.3.2.4 A link to Bexley's 'DSE and U' leaflet was forwarded for
information to be drawn to staffs attention.

7.10.1.1 Completion of 'Managers Fire Safety


Assessment' for the area of responsibility.

See 3.1.2.1 action points

5.2.1.1 Is the handling of accidents, incidents and


nonconformities the subject of effective arrangements?

See 2.1 action points above

5.2.1.3 Is the investigation of accidents, incidents and


nonconformities the subject of effective arrangements?

See 2.1 action points above

Finance and Procurement


Risk and Insurance - Stephen
Stuchbury

Apr-09

29/04/2009

Procurement - Charles Hyde (Caroline


Allen)
Budgetary Control - John Wood

BECS Loan Store - Lorraine Bryant

Oct-09

Jul-08

a
g
g

Chief Executives Directorate, Directorate of Customer Services and Directorate of Finance


Service Area Manager
(Area Representative)
Wesley Guy - Finance

Audit
Plan
Date

Audit
Carried Out

Action points

Status

3.1.2.1 Is the location complying with all of the


requirements of the written procedure on risk control
measures?

Unfamiliar with procedures (recent appointment). Risk assessment


documentation had be completed for the area. Training and support
to be provided by HSS..

02/07/2009

None

N/A

11-Jan-10

7.3.1.6 Do you have effective arrangements to ensure that


all workstation risk assessments are reviewed at
appropriate intervals?

DSE assessments were carried in July 2009 new ways of working


equipment has since been issued. I recommend that the
assessments be reviewed by all staff who have been issued with
the new equipment and have not completed a self-assessment for
it. To ensure that the TOPS records are updated as appropriate,
please can copies if the completed DSE assessments be forwarded
to HR Enquiries.

There was an awareness to the documentation being on BexWeb


however, link sent to the Health and Safety BexWeb site where the
policy can be found on the front page. It is suggested that staff
awareness be raised to the H&S BexWeb site/policy/information
etc.

May-09

Policy and Improvement - Fola Ipkehai

Jun-09

Committee Services and Scrutiny Kevin Fox (Louise Peek)

Jul-08

Nonconformities Identified

Legal
Legal Services - Angela Hogan (Brian
West)

Dec-09

Registration of Births, Deaths and


Marriages - Alison Parr

Apr-10

Member Services - Dave Easton

Jul-08

Electoral Services - Sue Loynes

Mar-10

Communications - John Ferry (Pauline


Rootsey)

26-Feb-10

2.1 Is an up to date copy of the written OH&S Policy


available at the location?

2.2 Have the contents of the OH&S Policy been


communicated to all employees?

See 2.1 above

3.1.2.1 Is the location complying with all of the


requirements of the written procedure on risk control
measures?

Risk assessment documentation has been completed but is now in


need of reviewing. Once completed please forward a copy to JM
for 18001 record purposes and uploading onto the H&S website.

7.3.2.4.Are all users and operators provided with relevant


information on the risks and control measures associated
with the operation of DSE?

There was an awareness to some information being available. Link


to DSE & U leaflet to be sent and drawn to staffs attention.

7.10.1.1 Has a Managers Fire Safety Assessment been


undertaken for all of your area of responsibility?

See 3.1.2.1

5.2.1.3 Is the investigation and accidents, incidents and


nonconformities the subject of effective arrangements?

This was discussed and clarified at the time.

a
g

Chief Executives Directorate, Directorate of Customer Services and Directorate of Finance


Service Area Manager
(Area Representative)
Print and Reprographics - Pam Smith

Audit
Plan
Date

Audit
Carried Out

Nonconformities Identified

Action points

Status

There was an awareness to the documentation being on BexWeb


however, link sent to the Health and Safety BexWeb site where the
policy can be found on the front page. It is suggested that staff
awareness be raised to the H&S BexWeb site/policy/information
etc.

Jul-08

ICT Services
ICT Design and Commissioning
Richard Matthews (Maria Goba)

Feb-10

03-Feb-10

2.1 Is an up to date copy of the written OH&S Policy


available at the location?

2.2 Have the contents of the OH&S Policy been


communicated to all employees?

See 2.1 above

3.1.2.1 Is the location complying with all of the


requirements of the written procedure on risk control
measures?

Risk assessment documentation has been completed but is now in


need of reviewing. Once completed please forward a copy to JM
for 18001 record purposes and uploading onto the H&S website.

7.1.1.1. Have you a clear, written description of the


workplace(s) for which you are responsible?

Although the areas of responsibility are known, the Safety Review


Checklist does not identify the server areas or where Alan Butler
works at Wyncham House. It may be that Alan Butlers area is
picked up under arrangements at Wyncham House but this should
be confirmed.

7.3.2.4.Are all users and operators provided with relevant


information on the risks and control measures associated
with the operation of DSE?

There was an awareness to some information being available. Link


to DSE & U leaflet to be sent and drawn to staffs attention.

7.3.2.8 Are there effective arrangements for the cost of


corrective appliances to be born by the user's employer?

Information to be drawn to staffs attention

7.10.1.1 Has a Managers Fire Safety Assessment been


undertaken for all of your area of responsibility?

See 3.1.2.1

7.10.44 Are there effective arrangements for the


evacuation of all contractors and visitors?

Although Steria staff have been made aware of Bexleys fire safety
arrangements via inclusion at corporate training, Maria/Paul would
check if the fire alarm could be heard in the server rooms as these
areas would not be picked up by Fire Marshals.

a) (7.1.1.1) Have you a clear, written description of the


workplace(s) for which you are responsible

a) Not aware of it being written down. Specific areas to be


identified on the risk assessment.

a
a

HR and OD
Payroll and HR Systems - Mandy
Vennard
OD and Internal Communications
Anne-Louise Clark (Terry Wills)

Dec-08

03/12/2008

Chief Executives Directorate, Directorate of Customer Services and Directorate of Finance


Service Area Manager
(Area Representative)

Audit
Plan
Date

Audit
Carried Out

Nonconformities Identified

Action points

Status

b) (7.3.2.4) Are all users and operators provided with


relevant information on the risks and control measures
associated with the operation of DSE?

b) TW identified that some are and some arent therefore


inconsistent. Awareness to be generally raised generally with future
use of the 'Bexley Learning Zone - Health and Safety Module'

c) (7.3.2.8) Are there effective arrangements for the cost


of corrective appliances to be born by the user's
employer?

c) Awareness raised and directed to website

d) (7.10.4.2) Does the fire evacuation procedure ensure


that Fire Marshals check all parts of the building to ensure
that all persons have been evacuated?

d) Issues around late working arrangements and outside tutors to


be further investigated. Corrective arrangements to be monitored
for their effectiveness following TW comments in the notes.

Parking
Parking - Tina Brooks (Sally Standen)
Emergency Planning
Emergency Planning and Business
Continuity - Tony Plowright (Kevin
Toal)
Contact Centre
Customer Services and Contact
Centre - Duncan Bridgewater (Rosa
Ahmet)

Directorate of Childrens and Young Peoples Services


Service Area Manager
(Area Representative)

Audit
Plan
Date

Audit
Carried
Out

Nonconformities Identified

Action points

Status

Planning and Resources


Jennifer Watson - Head of
Development - Development

March
2010

09/03/10

None

Sue Ashton - Schools Finance


Manager - School Finance

March
2010

24/03/10

Staff not aware of location of policy statement

g
Emailed to all staff 24/03/10

Directorate of Childrens and Young Peoples Services


Service Area Manager
(Area Representative)
Julia Webb - Head of Partnerships
& Performance - Performance,
Planning & Resources

Audit
Plan
Date

Audit
Carried
Out

Nonconformities Identified

Action points

Status

March
2010

30/03/10

Staff not aware of location of policy statement. Risk


assessments not completed and returned.

Issues to be raised at next team meeting and risk


assessments to be returned by end of April

March
2010

23/03/10

Staff not aware of location of policy statement. Fire


assessment not completed.

Link to policy emailed to all staff 23/03/10 and fire


assessment to be completed ASAP. (Done 30/03/10)

Anne Mailing - Support Manager

March
2010

09/03/10

None

Lea Dehaney - Principal Officer


Schools HR & Governance

TBA

Janet Ward/Barbara Hill


School Governance

February 17/02/10
2010

None

Meagan Bates - HR Advisor

February 17/02/10
2010

Fire assessment not completed.

Fire assessment to be completed by end of April.

Staff not aware of location of policy statement. Risk


assessments not completed and returned.

Issues to be raised at next team meeting and risk


assessments to be returned by end of April

James Scott - Head of


Information Systems - ICT
School Support
Schools and Educational
Improvement

Brendan Ring - Pri Off Clust Coord Child Ctrs Ext Serv
Jisola Oluwole - Ext Serv in &
Around Sch Supp Officer

TBA
March
2010

Youth and Inclusion


Charlotte Shrimpton - Youth
Offending Team - Service
Manager

TBA

Julie Hayward -Service Manager Youth Service & Awards

TBA

Ellen Mulvihill - Behaviour


Improvement Programme CoOrdinator - Behaviour and
Attendance

TBA

30/03/10

Directorate of Childrens and Young Peoples Services


Service Area Manager
(Area Representative)
Jackie Larkin - Learning Care Homelessness 16+ - Bexley Youth
Advice - Youth Engagement
Service - Connexions Service

Audit
Plan
Date

Audit
Carried
Out

Nonconformities Identified

Action points

Status

TBA

Social Care and Special


Educational Needs
Brenda Tubbs - Education
Psychology Service and Early
Intervention Teams

February 24/02/10
2010

Ruth Murdock - Head of Social


Care - East & West Child Care
Teams

TBA

Ruth Murdock - Childrens


Placement Service CAMHS LSCB

TBA

Staff not aware of location of policy statement. Risk


assessments not completed and returned.

Issues to be raised at next team meeting and risk


assessments to be returned by end of April

Staff not aware of location of policy statement. Risk


assessments not completed and returned.

Link to policy emailed to all staff 23/02/10 and risk


assessment to be completed by 15/03/2010

Mel Newell - Statutory SEN


April
Service - Complex Needs Service - 2010
Safeguarding Children Service Contact Point CAF
Marion Linford - Looked After
Children Virtual School

February 23.02.10
2010

Directorate of Social and Community Services


Service Area Manager
(Area Representative)
Direct Services - Rosemary
England
Social Care Oxleas NHS
Foundation Trust - Margaret
Anderson

Audit
Plan
Date

Audit
Carried
Out

Nonconformities Identified

Action points

Status

Directorate of Social and Community Services


Service Area Manager
(Area Representative)

Audit
Plan
Date

Audit
Carried
Out

Nonconformities Identified

Action points

Status

(2.1) Is an up to date copy of the written OH&S Policy available


at the location?

There was an awareness to the documentation being on


BexWeb however link sent to the Health and Safety BexWeb
site where the policy can be found on the front page. It is
suggested that staff awareness be raised to the H&S BexWeb
site/policy/information etc.

Personalised Care - Judith Bird


Independent Living (ILT) North - Rhys
Davies

Mar-10

North ILT - Carol Miles


Carers Service - Kath Hollands

Jun-10

Independent Living (ILT) South - Neil


Moran

Feb-10

18/02/2010

(2.2) Have the contents of the OH&S Policy been


communicated to all employees?

No. See (2.1)

(3.1.2.1) Is the location complying with all of the requirements


of the written procedure on risk control measures?

No. Neil identified that the risk assessment documentation was


in the process of being completed and would be forwarded to
me at the earliest opportunity. All risk assessment
documentation should be reviewed annually or more frequently
where there are any changes as discussed. It is suggested that
set months be identified to review the different risk assessment
documentation.

Not all staff have completed their DSE Self assessment.


Please remind staff that have not yet completed theirs to do so
and ensure their awareness is raised to the need to review it
annually or more frequently if there has been a change in
circumstances.

(7.3.1.3) Have all users and operators completed a DSE Selfassessment questionnaire?

(7.3.1.6) Do you have effective arrangements to ensure that all


DSE Self-assessments are reviewed at appropriate intervals?

No. See (7.3.1.3)

(7.3.2.4) Are all users and operators provided with relevant


information on the risks and control measures associated with
the operation of DSE?

DSE & U leaflet to be drawn to staffs attention.

(7.3.2.7) Are there effective arrangements for the provision of


free eye and eyesight tests, at appropriate intervals, for all
users?

Bexleys eyesight test/corrective appliance provision to be


drawn to staffs attention.

(7.3.2.8) Are there effective arrangements for the cost of


corrective appliances to be born by the user's employer?

See (7.3.2.8)

Directorate of Social and Community Services


Service Area Manager
(Area Representative)

Audit
Plan
Date

Audit
Carried
Out

Nonconformities Identified
(7.10.1.1) Has a Managers Fire Safety Assessment been
undertaken for all of your area of responsibility?

Reablement Team - Helena Moran

Sep-10

Care Central - Wendy Vincent

Jan-11

Screeners - Teresa Tuttle

May-11

QMH - Anne Checkley

Jun-10

Care Central Allocations - Jaswinder


Kang

Jul-10

BELL - Linda Cross

Feb-10

15/02/2010

Action points

Status

Fire safety management arrangements to cover all services,


including those of partner/non Bexley services, at 8 Brampton
Rd need to be reviewed to ensure appropriate arrangements
are in place, staff are aware of what they are and that full cooperation between all services is occurring. Each service area
should complete a Fire Safety Assessment and a copy be
forward to Jill Moore at the H&S Service for OHSAS 18001
record purposes.

(7.10.1.7) Have all personnel with specific responsibilities for


fire prevention been adequately trained?

Fire safety awareness and marshal training can be arranged by


contacting Nicola Selby via email or on Ext 4083.

(7.10.4.4) Are there effective arrangements for the evacuation


of all contractors and visitors?

See (7.10.1.1)

(2.2) Have the contents of the OH&S Policy been


communicated to all employees?

There was an awareness to the documentation being on


BexWeb however link sent to the Health and Safety BexWeb
site where the policy can be found on the front page. It is
suggested that staff awareness be raised to the H&S BexWeb
site/policy/information etc.

(7.1.1.1) Have you a clear, written description of the


workplace(s) for which you are responsible?

(7.3.2.2) Do all workstations used by operators and users


meet, as a minimum, the requirements of the Schedule to the
DSE Regulations?

Linda identified that there were storage areas at Brampton Rd


and for BELL at the Civic where she has a responsibility for
what is stored and staff who have to go to them. These areas
had not been considered when carrying out the risk
assessment process. Linda confirmed that she would review
these areas and include them on the Safety Review Checklist
and Fire Safety Assessment and forward me updated
documentation when completed .

There are some issues that are outstanding as a result of the


DSE assessments by BELL staff, specifically in relation to R62
at the Civic. These are currently being looked into by Linda.

Directorate of Social and Community Services


Service Area Manager
(Area Representative)

Audit
Plan
Date

Safeguarding Adults - Malcolm


Bainsfair

Dec-10

Quality Assurance Manager - Kim


Ewens

Nov-10

Audit
Carried
Out

Nonconformities Identified

Action points

Status

(7.3.2.4) Are all users and operators provided with relevant


information on the risks and control measures associated with
the operation of DSE?

DSE & U leaflet to be drawn to staffs attention to reinforce


their understanding.

(7.10.1.1) Has a Managers Fire Safety Assessment been


undertaken for all of your area of responsibility?

As for 7.1.1.1

(7.10.1.6) Are all staff instructed in fire safety arrangements?

Linda was unable to establish from the BexWeb site what fire
training was available for staff. Additionally she was unaware of
who had previously been trained and when. JM identified that
this was something that needed to be improved at the centre
Corporately and would let her know when training was next
available. I will also provide a TOPS report to identify staff that
had been on training.

Link sent to the Health and Safety BexWeb site where the
policy can be found on the front page. It is suggested that staff
awareness be raised to the H&S BexWeb
site/policy/information etc.

Commissioning - Kelly Gaddes


Joint Commissioner for Mental
Health - Martin Murphy
Adult Commissioning and
Contracts - Evelyn Wheeler
Commissioning - Phil Bailey

Apr-10

Care Audit Team - Elizabeth Deeves

Jul-10

Voluntary Sector Projects - (Shaheen


Westcombe - left)
Specialist Services - Dave Holman
Sustaining Independence Team (SIT)
- (Kate Matson) Sami Haider

Feb-20

15.02.10

(2.1) Is an up to date copy of the written OH&S Policy available


at the location?
(2.2) Have the contents of the OH&S Policy been
communicated to all employees?

Directorate of Social and Community Services


Service Area Manager
(Area Representative)

Audit
Plan
Date

Audit
Carried
Out

Nonconformities Identified

Action points

Status

A Care Management West Lodge Risk Assessment' and


Safety Review Checklist' had been completed and Fire Safety
Assessment was in the process of being completed for West
Lodge by Helena Moran. Sammi agreed that all the
documentation needed to be completed for the other
areas/staff under his responsibility eg Older Peoples Mental
Health at Upton Rd, Palliative Care at QMH and for the
Dartford area if necessary. Once completed forward a copy to
JM.

(7.1.1.2) Do you have effective arrangements for assessing all


of the risks associated with the physical attributes of the
workplace(s) for which you are responsible?

This has been done using the Safety Review Checklist for
West Lodge but as identified in 3.1.2.1 above needs to be
completed for the other areas/staff under Samis responsibility.

(7.3.1.3) Have all users and operators completed a selfassessment questionnaire?

This is in the process of being completed. Sami will ensure that


staff at the areas identified in 3.1.2.1 and 7.1.1.2 above will be
included in this, not just those based at West Lodge.

(7.3.2.1) Are the risks associated with the use of workstations


reduced to the lowest level reasonably practicable?

As 7.3.1.3

(7.3.2.2) Do all workstations used by operators and users


meet, as a minimum, the requirements of the Schedule to the
DSE Regulations?

As 7.3.1.3

(7.3.2.3) Are the work routines of all users designed such that
appropriate breaks or changes of activity are included?

As 7.3.1.3

(7.3.2.4) Are all users and operators provided with relevant


information on the risks and control measures associated with
the operation of DSE?

DSE & U leaflet to be drawn to staffs attention.

(7.10.1.1) Has a Managers Fire Safety Assessment been


undertaken for all of your area of responsibility?

As 3.1.2.1

(7.10.1.6) Are all staff instructed in fire safety arrangements?

As 3.1.2.1 Currently local fire safety arrangements are being


developed for West Lodge, and staff are attending Fire
Awareness and Marshal training as appropriate. However this
needs to be established for staff at the other locations
identified.

(3.1.2.1) Is the location complying with all of the requirements


of the written procedure on risk control measures?

7.10.1.7 Have all personnel with specific responsibilities for fire


prevention been adequately trained?

As 3.1.2.1 and 7.10.1.6

(7.10.4.1) Does your area of responsibility have an adequate


evacuation procedure for use in the event of fire?

As 7.10.1.6

a
a

Directorate of Social and Community Services


Service Area Manager
(Area Representative)

Audit
Plan
Date

Learning Disability Team - Helen


White

Oct-10

Bexley Twofold - Carol Lynscott

Jun-11

Audit
Carried
Out

Nonconformities Identified

Action points

Status

(7.10.4.2) Does the fire evacuation procedure ensure that Fire


Marshals check all parts of the building to ensure that all
persons have been evacuated?

As 7.10.1.6

(7.10.4.3) Have all staff been made aware of the fire


evacuation procedure?

As 7.10.1.6

(7.10.4.4) Are there effective arrangements for the evacuation


of all contractors and visitors?

As 7.10.1.6

(5.2.1.1) Is the handling of accidents, incidents and


nonconformities the subject of effective arrangements?

Although Sami is aware of Bexleys Incident/Accident reporting


procedures, the staff in Oxleas buildings use Oxleys reporting
procedures therefore, Bexley does not record/investigate these
incidents. Will raise this as an issue to be investigated further
within the Directorate.

There was an awareness to the documentation being on


BexWeb however link sent to the Health and Safety BexWeb
site where the policy can be found on the front page. It is
suggested that staff awareness be raised to the H&S BexWeb
site/policy/information etc.

a
a

Supporting People - Ian Jarman


Neighbourhood and Community
Services - Maureen Holkham
Deputy Director's Office & Support Maureen Thomas
Neighbourhood Services - Kevin
Taylor (Mark Usher)
Community Safety Civic Offices Team
- Mark Usher

May-10

Community Safety - Belvedere Police


Station - Mick Wearing

Dec-10

Drug and Alcohol Team - Shirley


Johnstone

Mar-11

CCTV - Steve Farley

Oct-10

Crisis Intervention - Nola Saunders

Feb-10

04/03/2010

(2.1) Is an up to date copy of the written OH&S Policy available


at the location?
(2.2) Have the contents of the OH&S Policy been
communicated to all employees?

Directorate of Social and Community Services


Service Area Manager
(Area Representative)

Audit
Plan
Date

Audit
Carried
Out

Nonconformities Identified
(3.1.2.1) Is the location complying with all of the requirements
of the written procedure on risk control measures?

Action points
A Lone Working risk assessment had been completed
however this document had not been produced by Nola and
she identified that it needed to be updated to ensure it was
appropriate for her staff.
Nola was aware that the Corporate risk assessment
documentation for her areas, including those at Normandy
Childrens Centre and QMH Outreach Clinic, needed to be
completed and forward to me by 23 April. It is suggested that
set months would be identified to review the different risk
assessment documentation.

(7.1.1.2) Do you have effective arrangements for assessing all


of the risks associated with the physical attributes of the
workplace(s) for which you are responsible?

This will be carried out when the Safety Review Checklist for all
Nolas areas of responsibility are completed.

(7.3.1.3) Have all users and operators completed a selfassessment questionnaire?

Link to DSE self-assessment forwarded to be completed by all


users.

(7.3.1.6) Do you have effective arrangements to ensure that all


workstation risk assessments are reviewed at appropriate
intervals?

See 7.3.1.3

(7.3.2.1) Are the risks associated with the use of workstations


reduced to the lowest level reasonably practicable?

See 7.3.1.3

(7.3.2.2) Do all workstations used by operators and users


meet, as a minimum, the requirements of the Schedule to the
DSE Regulations?

See 7.3.1.3

(7.3.2.4) Are all users and operators provided with relevant


information on the risks and control measures associated with
the operation of DSE?

Please see link below to DSE & U leaflet to be drawn to staffs


attention.

(7.10.1.1) Has a Managers Fire Safety Assessment been


undertaken for all of your area of responsibility?

See 3.1.2.1

(7.10.1.7) Have all personnel with specific responsibilities for


fire prevention been adequately trained?

Fire Marshal arrangements for Nolas office area needs to be


clarified at the Civic. In the event of an evacuation someone
from the team needs to report to the Incident Controller that the
area is clear and all have evacuated from it. Roger Evans,
Facilities, should be asked to run through the Civic
arrangements so Nola can ensure that her staff are fully aware
of what they are and what they need to do with a view in the
future to attend corporate Fire Marshal training.

(7.10.4.1) Does your area of responsibility have an adequate


evacuation procedure for use in the event of fire?

Status

See 7.10.1.7

Directorate of Social and Community Services


Service Area Manager
(Area Representative)

Community - (Robert Dyer) Steven


Burgess

Audit
Plan
Date

Audit
Carried
Out

Nonconformities Identified

Action points

(7.10.4.2) Does the fire evacuation procedure ensure that Fire


Marshals check all parts of the building to ensure that all
persons have been evacuated?

See 7.10.1.7

(5.2.1.1) Is the handling of accidents, incidents and


nonconformities the subject of effective arrangements?

Bexleys Incident/Accident reporting procedure was explained


at the time of the audit. Link sent to the documentation on the
website.

(5.2.1.3) Is the investigation of accidents, incidents and


nonconformities the subject of effective arrangements?

See (5.2.1.1)

(2.1)Is an up to date copy of the written OH&S Policy available


at the location?

There was an awareness to the documentation being on


BexWeb however link sent to the Health and Safety BexWeb
site where the policy can be found on the front page. It is
suggested that staff awareness be raised to the H&S BexWeb
site/policy/information etc.

Status

Sep-10

Housing Options - Adrian Emmitt


Allocations Team - Wendy Bishop

Aug-10

Placement and Support Team - Jo


Songer

Feb-10

04/02/2010

(2.2) Have the contents of the OH&S Policy been


communicated to all employees?

See (2.1)

(3.1.2.1) Is the location complying with all of the requirements


of the written procedure on risk control measures?

Jo agreed to complete the Safety Review Checklist and use


the corporate Risk Assessment Form when next reviewing the
Visiting Officers risk assessment and forward a copy to JM
by19 February 2010.

(7.1.1.2) Do you have effective arrangements for assessing all


of the risks associated with the physical attributes of the
workplace(s) for which you are responsible?

This will be achieved by completing the Safety Review


Checklist. See 3.1.2.1.

(7.3.1.3) Have all users and operators completed a selfassessment questionnaire?

TOPS report sent identifying staff who have completed their


assessment. Where date is 12 months or more or there has
been a change in circumstances then they need to be
reviewed. It is suggested that staff awareness be raised to this.
Please remind staff that have not yet completed their DSE self
assessment to do so.

(7.3.1.6) Do you have effective arrangements to ensure that all


workstation risk assessments are reviewed at appropriate
intervals?

See 7.3.1.3
a

Directorate of Social and Community Services


Service Area Manager
(Area Representative)

Prevention and Assessment Team Val Green

Audit
Plan
Date

Audit
Carried
Out

Nonconformities Identified

Action points

Status

(7.3.2.4) Are all users and operators provided with relevant


information on the risks and control measures associated with
the operation of DSE?

Link to DSE & U leaflet to be drawn to staffs attention.

(7.10.1.1) Has a Managers Fire Safety Assessment been


undertaken for all of your area of responsibility?

Copy requested to be sent to me for record purposes.

(5.2.1.3) Is the investigation of accidents, incidents and


nonconformities the subject of effective arrangements?

Discussed and clarified.

(7.3.1.3) Have all users and operators completed a selfassessment questionnaire?

There was an awareness to all but one member of staff having


completed the DSE self assessment. However, Sonia was not
aware of completion by those staff not based at Hill View.
TOPS report forwarded identifying those staff who have not yet
completed their DSE self assessment to follow up on.

Link sent to the Health and Safety BexWeb site where the
policy can be found on the front page.

r
g

Jun-10

Business Management - Alison


McLaughlin
Business Centre - Sonia Miles

Feb-10

25/02/2010

Director's Office incl Deputy


Directors & Support - Sarah Fletcher
Administration - Karen Noulton
8 Brampton Rd - Linda Cross

Feb-10

Post Room - Christine Heddle


CF21 Project Team - Judith Childs

Apr-11

Business Planning & Performance Suzie Wenham/Nicola Couchman


Steven Burgess (Civic)
Jamie Dickie (Hill View)
Communications and Customer
Engagement - Elaine Green
Communications and consultation Mollie Pepper
Customer Relations Manager - Edna
Menta

Feb-10

11/02/2010

2.1 Is an up to date copy of the written OH&S Policy available


at the location?

Directorate of Social and Community Services


Service Area Manager
(Area Representative)

Audit
Plan
Date

Audit
Carried
Out

Nonconformities Identified
2.2 Have the contents of the OH&S Policy been communicated
to all employees?

See (2.1)

7.3.1.3 Have all users and operators completed a selfassessment questionnaire?

Although this had not been completed at the time of the audit
this has now been done and forwarded to HR Enquiries. I
advise that Edna flags this to be reviewed annually or more
frequently where there is a change in circumstances.

7.3.1.6 Do you have effective arrangements to ensure that all


workstation risk assessments are reviewed at appropriate
intervals?

See 7.3.1.3

7.3.2.1 Are the risks associated with the use of workstations


reduced to the lowest level reasonably practicable?

See 7.3.1.3

7.3.2.2 Do all workstations used by operators and users meet,


as a minimum, the requirements of the Schedule to the DSE
Regulations?

See 7.3.1.3

7.3.2.4 Are all users and operators provided with relevant


information on the risks and control measures associated with
the operation of DSE?

DSE & U leaflet & eyesight tests/corrective appliances


information discussed and links sent for information.

7.3.2.7 Are there effective arrangements for the provision of


free eye and eyesight tests, at appropriate intervals, for all
users?

See 7.3.2.4

7.3.2.8 Are there effective arrangements for the cost of


corrective appliances to be born by the user's employer?

See 7.3.2.4

7.10.1.1 Has a Managers Fire Safety Assessment been


undertaken for all of your area of responsibility?

This has now been completed and forwarded to HR Enquiries.

5.2.1.1 Is the handling of accidents, incidents and


nonconformities the subject of effective arrangements?

From personal experience of needing to follow Bexleys


Incident/Accident procedures, Edna does not feel that either
the handling or investigation of accidents has effective
arrangements being computer based. Edna was aware that a
form was available for completion on line and had been given
the link to complete the documentation. At the time of the audit
the Bexley Incident/Accident procedures and the need to
complete the documentation were reinforced.

5.2.1.3 Is the investigation of accidents, incidents and


nonconformities the subject of effective arrangements?
Culture - Toni Ainge
Leisure Development - Janet Stone

Action points

Status

See 5.2.1.1

g
a

Directorate of Social and Community Services


Service Area Manager
(Area Representative)
Arts Manager - Saskia Delman
Contracts - Ruth Baty
Outdoor Recreation - Claire Wells
Library Services - Judith Mitlin

Audit
Plan
Date

Audit
Carried
Out

Nonconformities Identified

Action points

Status

Appendix 2
LRQA Audit and Internal Audit Action Plans 2009-10
Key to table
XLRQA - External Auditor recommendation for improvement

Minor NC - Minor Nonconformity

Major NC - Major Nonconformity

XHSS - Significant findings from internal audits and


recommendations for improvements

Grade

Status

Finding

Corrective Action Review

Process

Date

BSI Ref

XLRQA

Open

There needs to be clarity on


where and when each relevant
regulation is evaluated.

CP20 Evaluation of compliance


was issued in January 09.
However, the mechanism for
how this will be undertaken
needs to be clarified.

Evaluation of
compliance

May 09

4.5.2

Minor NC

Open

The Schedule does not include


a review of the Internal Audits,
Management Review or
Objectives and Programme(s)
clauses of the standard.

Schedule to be updated to
include a review of the Internal
Audits, Management Review
and Objectives and
Programme(s).
NOTE: If this review has not
been undertaken by the next
Surveillance Visit this finding
will be raised to a Major NonConformity.

Internal audit

Aug 09

4.5.5

Major NC

New

Procedure for OH&S


Management Review calls for
an Annual Review in October of
each year. There was no
evidence that this had been
undertaken.

Report to be submitted to
Management Board April 2010

Management
review

Mar 10

4.6

Procedure for maintaining


OH&S Objectives and
Programmes requires a review
of Corporate OH&S Objectives
in January of each year. There
was no evidence that this had
been undertaken.

Objectives and
programme(s)

4.3.3

Minor NC

New

DSCS and DCYPS Insufficient


DSE Self Assessments have
been completed and returned.
These need to be completed
and returned for all users of
Display Screen Equipment prior
to the next Surveillance Visit.

Reported to and being


monitored through Health and
Safety Service and OHS
Groups

Risk assessment

Mar 10

4.3.1

XHSS

New

Staff working and being


managed by Partners and/or
others premises are not being
suitably protected against risks

Partners and commissioning


Departments to ensure
completion of necessary
procedures to safeguard Bexley
employees.

Risk assessment

Feb 10

4.3

Partners are not correctly


reporting incidents for Bexley
employees they manage

Meetings with Oxleas Trust and


commissioning departments to
take place to resolve will take
place during May 2010

Incident
investigation,
nonconformity,
corrective action
and preventive
action

4.5.3

Appendix 3
BS18001 OH&S Objectives and implementation programme 2010 - 11
Objective 1
Maintain BS18001 OH&S Certification in CE and F&BS
Ref
HSMZO1

Action Required

Action By

Performance Indicator

Date/status

Action findings from 6 monthly


surveillance visit Aug 2009 and March
2010

HSS, DH (Internal
Audit)

Minutes of meetings,
reports

Aug 10

Action findings and ensure closure of


actions resulting from internal audits

JM, AB

Minutes, Notes, Records

July 10

HSMZO3

Compile additional audit questions

JM, AB

Question sets

HSMZO4

Evaluation of Compliance

MZ

Notes, Minutes

HSMZO5

Improve internal monitoring

HSS

70% Returns of question


sets by managers

HSMZO2

A
Ongoing
A
July 10
R
Ongoing
A

Objective 2
To have the non school departments of Children and Young Peoples Directorate ready for
external audit and certification by August 2010
Ref

Action Required

Action By

Performance Indicator

status

HSMZO6

Prepare description of non school


departments OH&S SMS and obtain
authorization to start project

MZ

Completed

HSMZO7

Prepare and agree implementation


plan

MZ

Completed

HSMZO8

Complete H&S assessments

AB

Completed assessments on
website

Ongoing

Completed Risk assessments on


website

Ongoing

Delegate
numbers/documentation

Ongoing

Docs on website

Ongoing

HSMZO9

HSMZ10

HSMZ11

Complete Risk assessments

Deliver OH&S Training

Prepare OHS procedures

AB

AB

AB

Objective 3
To have Directorate of Social and Community Services ready for external audit and
certification by August 2010
Action Required

Action By

Performance Indicator

Status

HSMZ12

Prepare description of departments


OH&S SMS and obtain authorisation to
start project

MZ

completed

HSMZ13

Prepare and agree implementation


plan

MZ

completed

HSMZ14

Carry out Senior Management


briefings

JM/AB/MZ/NH

Delegate
numbers/documentation

Ongoing

Deliver Risk Assessment Training to


Service Area Managers or nominated
representatives

JM

Delegate
numbers/documentation

Ongoing

Action Required
HSMZ15

HSMZ16

HSMZ17

Action By

Performance Indicator

Status

Completed Risk Assessment


Documentation received from Service
Areas

Service
Areas/JM/AB

Completed Risk assessments on


website

Ongoing

Carry out Staff Briefings

JM

Delegate
numbers/documentation

Ongoing

Docs on website

Ongoing

Prepare OHS procedures

JM/MZ/AB

Directorate of Environment and Regeneration Services OH&S Objectives, Targets and


Performance indicators
Objective 4
To maintain certification of the OH&S as part of the Integrated Management system (Safety,
Environment and Quality)
Ref

Programme

Objective

Comment

HS01

Premises

improve levels of compliance at internal


audit

No significant issues were identified

HS02

Fire Drills

To improve efficiency and effectiveness of


evaluation procedures

No significant issues were identified.

HS03

Training/information

Raise Staff Awareness of their respective


roles and responsibilities

An induction programme was piloted with a


focus group. This identified a number of
issues requiring resolution prior to roll out.
Improvements planned including use of
intranet to support the training.
Accident & incident reporting awareness
raised via Bexweb

HS04

DSE Assessments

DSE risk assessments reviewed (incl.


remote/mobile workers)

Initial assessments completed but subject to


periodic review. At a recent internal audit
electronic copies were available for the
majority of service areas. Action is being
taken to make the remainder available.

HS05

Minimising third party insurance


claims for injury/damage

Minimise damage /injury to 3rd parties as a


result of tree root damage and new traffic
management schemes

Progress with this objective can only be


assessed over a prolonged cycle. The
objective has therefore been revised to
reflect the situation.

HS06

Hazardous substances control

Improve the control of hazardous


substances

Completed 20/7/09

HS07

Electronic storage of

Copies of risk assessments to be stored


electronically for each team

System established including COSHH

HS08

First Aid Risk Assessment

Risk Assessment in place for each


occupied premises

Completed

HS09

Modify the OHSAS system to


conform to OHSAS 18001:2007

Achieve accreditation to BS OHSAS


18001:2007 by July 2009

This was added part way into the year.


Completed 21/7/09

Objective 5
To prepare for DERS Integrated Management Systems ready for inclusion in the Corporate
Safety Management System audit and certification process

Ref

Programme

Objective

HS01

Premises

Improve levels of compliance at internal audit. To this end introduce a scoring


system to measure current performance against which future changes can be
measured.

HS02

Fire Drills

Receive and monitor feedback from fire/evacuation drills and identify common
issues where further guidance may be useful.

HS03

Training / Information

Raise staff awareness of their respective roles and responsibilities for OHS

HS04

DSE assessments

DSE risk assessments (incl. home/mobile) monitored for timely


completion/review, implementation of corrective actions and identify common
issues where further guidance may be useful.

HS05

Minimising 3rd party insurance claims for


injury/damage

Monitor insurance claims for trends over rolling 10 year period. Identify key
issues and preventative measures for reducing the number and/or impact of
individual claims.

HS07

Electronic storage of records

Internal health and safety advisors to monitor and review electronic risk
assessments for each team to ensure up to date and identify common issues
where further guidance may be useful.

HS10

Combine Councils OHSAS with DERS


system

HS11

Management of Contractors

1.

Use single set of documentation for both systems.

2.

Seek single accreditation body for the combined systems.

Ensure that all contractors are effectively managed:


1.

Devise training programme for all contract managers

2.

Deliver training to contract managers to ensure effective monitoring


of contractors health an safety performance

Contact:

Nick Hollier, Deputy Director Human Resources

Reporting to:

Paul Moore, Director of Customer Services

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