Management Review Report 2009-10
Management Review Report 2009-10
Management Review Report 2009-10
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:
2009/10
Days
lost
Number
Days
lost
Assault
96
55
Glass / sharps
28
16
13
Other (explain):
61
21
11
198
94
40
44
28
422
21
259
Totals
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.
(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.
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.
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
289
89
10
16
18
52
Management of Stress
108
Fire Marshal
66
22
27
41
19
41
CIEH Level 2
42
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.
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.
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.
Directorate Health and Safety Groups and DMTs are regularly informed of
key issues and progress in implementing the standard and achieving
continuous improvement.
13
15.
Contact:
Report to:
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
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 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.
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.
Sep-09
Oct-09
29/09/2009
06.10.09
Audit
Plan
Date
Audit
Carried Out
Nonconformities Identified
Action points
Status
A link to Bexley's 'DSE and U' leaflet has been forwarded for
information to be drawn to staffs attention.
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 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 Risk assessments have been completed but those for Fire
and DSE are in need of reviewing/updating.
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 A link to Bexley's 'DSE and U' leaflet was forwarded for
information to be drawn to staffs attention.
Apr-09
29/04/2009
Oct-09
Jul-08
a
g
g
Audit
Plan
Date
Audit
Carried Out
Action points
Status
02/07/2009
None
N/A
11-Jan-10
May-09
Jun-09
Jul-08
Nonconformities Identified
Legal
Legal Services - Angela Hogan (Brian
West)
Dec-09
Apr-10
Jul-08
Mar-10
26-Feb-10
See 3.1.2.1
a
g
Audit
Plan
Date
Audit
Carried Out
Nonconformities Identified
Action points
Status
Jul-08
ICT Services
ICT Design and Commissioning
Richard Matthews (Maria Goba)
Feb-10
03-Feb-10
See 3.1.2.1
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
a
HR and OD
Payroll and HR Systems - Mandy
Vennard
OD and Internal Communications
Anne-Louise Clark (Terry Wills)
Dec-08
03/12/2008
Audit
Plan
Date
Audit
Carried Out
Nonconformities Identified
Action points
Status
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)
Audit
Plan
Date
Audit
Carried
Out
Nonconformities Identified
Action points
Status
March
2010
09/03/10
None
March
2010
24/03/10
g
Emailed to all staff 24/03/10
Audit
Plan
Date
Audit
Carried
Out
Nonconformities Identified
Action points
Status
March
2010
30/03/10
March
2010
23/03/10
March
2010
09/03/10
None
TBA
February 17/02/10
2010
None
February 17/02/10
2010
Brendan Ring - Pri Off Clust Coord Child Ctrs Ext Serv
Jisola Oluwole - Ext Serv in &
Around Sch Supp Officer
TBA
March
2010
TBA
TBA
TBA
30/03/10
Audit
Plan
Date
Audit
Carried
Out
Nonconformities Identified
Action points
Status
TBA
February 24/02/10
2010
TBA
TBA
February 23.02.10
2010
Audit
Plan
Date
Audit
Carried
Out
Nonconformities Identified
Action points
Status
Audit
Plan
Date
Audit
Carried
Out
Nonconformities Identified
Action points
Status
Mar-10
Jun-10
Feb-10
18/02/2010
(7.3.1.3) Have all users and operators completed a DSE Selfassessment questionnaire?
See (7.3.2.8)
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?
Sep-10
Jan-11
May-11
Jun-10
Jul-10
Feb-10
15/02/2010
Action points
Status
See (7.10.1.1)
Audit
Plan
Date
Dec-10
Nov-10
Audit
Carried
Out
Nonconformities Identified
Action points
Status
As for 7.1.1.1
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.
Apr-10
Jul-10
Feb-20
15.02.10
Audit
Plan
Date
Audit
Carried
Out
Nonconformities Identified
Action points
Status
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.
As 7.3.1.3
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
As 3.1.2.1
As 7.10.1.6
a
a
Audit
Plan
Date
Oct-10
Jun-11
Audit
Carried
Out
Nonconformities Identified
Action points
Status
As 7.10.1.6
As 7.10.1.6
As 7.10.1.6
a
a
May-10
Dec-10
Mar-11
Oct-10
Feb-10
04/03/2010
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.
This will be carried out when the Safety Review Checklist for all
Nolas areas of responsibility are completed.
See 7.3.1.3
See 7.3.1.3
See 7.3.1.3
See 3.1.2.1
Status
See 7.10.1.7
Audit
Plan
Date
Audit
Carried
Out
Nonconformities Identified
Action points
See 7.10.1.7
See (5.2.1.1)
Status
Sep-10
Aug-10
Feb-10
04/02/2010
See (2.1)
See 7.3.1.3
a
Audit
Plan
Date
Audit
Carried
Out
Nonconformities Identified
Action points
Status
Link sent to the Health and Safety BexWeb site where the
policy can be found on the front page.
r
g
Jun-10
Feb-10
25/02/2010
Feb-10
Apr-11
Feb-10
11/02/2010
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)
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.
See 7.3.1.3
See 7.3.1.3
See 7.3.1.3
See 7.3.2.4
See 7.3.2.4
Action points
Status
See 5.2.1.1
g
a
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
Grade
Status
Finding
Process
Date
BSI Ref
XLRQA
Open
Evaluation of
compliance
May 09
4.5.2
Minor NC
Open
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
Report to be submitted to
Management Board April 2010
Management
review
Mar 10
4.6
Objectives and
programme(s)
4.3.3
Minor NC
New
Risk assessment
Mar 10
4.3.1
XHSS
New
Risk assessment
Feb 10
4.3
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
HSS, DH (Internal
Audit)
Minutes of meetings,
reports
Aug 10
JM, AB
July 10
HSMZO3
JM, AB
Question sets
HSMZO4
Evaluation of Compliance
MZ
Notes, Minutes
HSMZO5
HSS
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
MZ
Completed
HSMZO7
MZ
Completed
HSMZO8
AB
Completed assessments on
website
Ongoing
Ongoing
Delegate
numbers/documentation
Ongoing
Docs on website
Ongoing
HSMZO9
HSMZ10
HSMZ11
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
MZ
completed
HSMZ13
MZ
completed
HSMZ14
JM/AB/MZ/NH
Delegate
numbers/documentation
Ongoing
JM
Delegate
numbers/documentation
Ongoing
Action Required
HSMZ15
HSMZ16
HSMZ17
Action By
Performance Indicator
Status
Service
Areas/JM/AB
Ongoing
JM
Delegate
numbers/documentation
Ongoing
Docs on website
Ongoing
JM/MZ/AB
Programme
Objective
Comment
HS01
Premises
HS02
Fire Drills
HS03
Training/information
HS04
DSE Assessments
HS05
HS06
Completed 20/7/09
HS07
Electronic storage of
HS08
Completed
HS09
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
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
HS05
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
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
HS11
Management of Contractors
1.
2.
2.
Contact:
Reporting to: