QSA AUDIT REPORT

Oxfordshire Fire and Rescue Service

(23 June - 27 June 2014)

AUDIT TEAM: Nigel Probert (Isle of Wight FRS) Nick Burchell (Hampshire FRS) Lee Gunner (Kent FRS)

Graham Rudman (East Sussex FRS)

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Contents Section Subject Page 1 Summary 3 2 Introduction 3 3 Policy 4 4 Organising 6 5 Planning and Implementation 14 6 Measuring Performance 23 7

Audit and Review

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8 Score Summary and Radar Chart 27 9 Key Recommendations 29 10 Action plan 32 11 Acknowledgements 33 Appendix 1 34

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1. Summary This report details the findings from a Royal Society for the Prevention of Accidents (RoSPA) Quality Safety Audit (QSA) audit of Oxfordshire Fire and Rescue Service (OFRS), conducted between 23 June and 27 June 2014. The Organisation achieved an overall Health and Safety Performance Rating of 87% Section 8 on page 26 details the scores from this audit and the scores from previous audits. This clearly demonstrates an improvement over a five year period of which Oxfordshire Fire and Rescue Service can be truly proud. OFRS are fully aware of the majority of their shortcomings. This report should not provide any great shocks or complete surprises to the organisation. Where shortcomings were identified, evidence was found to show that OFRS are already working within those areas to improve the situation. This report should be seen as fine tuning of the Health and Safety Management System (HSMS) and as such some of the recommendations might be seen as trivial or pedantic. RoSPA themselves acknowledge that careful consideration should be given to the amount of work required to improve a high score balanced against what would be gained by the organisation in doing so. OFRS have scored well within policy, organising, planning and implementing. There are some lower scoring areas which OFRS could focus its improvement upon, namely measuring performance and performance review. Auditors found a large number of new policies and procedures being put into practice. What is now required is a period of consolidation where performance measurement can take place to ensure adequate control measures are in place. This can then be fed into the review process so that the organisation is able to learn from itself to improve its own performance. 2. Introduction In accordance with the South East region CFOA audit protocol, Nigel Probert as Lead Auditor was commissioned to carry out a QSA audit of Oxfordshire Fire and Rescue Service. The audit was carried out using issue 4 of the QSA system, developed by RoSPA. This system is primarily based on the HSE publication HSG 65 ‘Successful Health and Safety Management’. It additionally incorporates all the elements of OHSAS 18001. The system is also based on BS 8800 ‘Guidance on Occupational Health and Safety Systems’, and the methodology of the audit is of that described in ISO 10011 (formerly BS 7229) for quality system auditing. Traditional monitoring systems have focused on the reporting and investigation of accidents, together with detailed compliance inspections of workplaces. Research has shown, however, that in 70% of accidents the underlying causes have been failures in the (HSMS). The QSA audit therefore concentrates on the HSMS, but also includes an examination of compliance with a number of key areas of legislation. More details of the QSA system can be found in Appendix 1.

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The purpose of this report is not intended to criticise individuals, but to examine and comment on the HSMS of the organisation. Although every effort was made to identify relevant documentation, it was the responsibility of the client to bring this to the attention of the auditor. Audits are by nature sampling exercises; therefore the auditor cannot guarantee to identify all possible breaches of legislation or areas of good practice. Absence of comment on any issue should not be taken to imply full compliance with legislation. The structure and aims of the audit were discussed at an opening meeting at the start of the audit with; DCO Nathan Travis ACO Simon Furlong Nigel Probert AM John Lloyd SM Gary Coupar Nick Burchell GM Richard Smith Kate Hurdwell Lee Gunner GM Rob MacDougall Graham Rudman

Some initial feedback, principally the main audit results, was given at a closing meeting on the 27 June 2014 attended by; CFO Dave Etheridge DCO Nathan Travis ACO Simon Furlong GM Richard Smith GM Rob MacDougall Steve Dutton WM Steve Johns FBU SM Gary Coupar Matt Frank Nigel Probert Nick Burchell Lee Gunner Graham Rudman

Observations on the HSMS, together with detailed recommendations for improvement, follow in the body of the report. These are summarised into key recommendations in an action plan at the end of the report. A summary of section and sub-section scores is also given, with the QSA ‘radar chart’ giving an overall view of results. 3. Policy

Overall 93% General 100% Commitments 90%

The Health and Safety policy should consist of two levels of documentation; a short policy statement describing overall responsibility and commitments, followed by a larger document outlining specific responsibilities and general arrangements. In the context of the latter, it may also either contain or refer to detailed Health and Safety arrangements (i.e. procedures), in a similar fashion to a quality manual.

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3.1 Policy (General) The policy statement for OFRS is divided into 3 key parts. All three policies were signed and dated. PT1 is the overarching statement from Oxfordshire County Council (OCC) and is signed by the Chief Executive and dated February 2014. PT2 of the policy is the statement of intent, signed by the Chief Fire Officer on behalf of OFRS which clearly states the commitment OFRS has to Health and Safety. PT3 of the policy confirms OFRS Health and Safety arrangements and is signed by the DCFO and ACFO, dated May 2014. The three signatures give a powerful statement from the Senior Leadership Team about their commitment to Health and Safety. The policy statement was found clearly displayed in all locations visited by the auditors. The Audit Team accepted that OFRS have continued to make progress in conjunction with OCC in formulating Health and Safety policy. However the team felt that the policy was disconnected in places so that an individual reading the policy would have to look up key information in different parts of the policy rather than in one. By shortening PT2 into just a statement of intent and linking this across to PT3 which could include all areas of policy giving the reader a “one stop shop” for Health and Safety policy, even if this means some duplication from PT1. The Audit Team feel that OFRS could take this back to OCC in an attempt to steer them and be at the forefront of any discussion on Health and Safety policy. The Audit Team also identified that the roles and responsibilities of OFRS H&S team are not included in the PT2 policy. Some of the policy arrangements do not cross reference each other, where there is a direct link. For example the Management of Occupational Road Risk Policy identifies the risk of an employee driving a vehicle that breaks down and correctly identifies that the employee maybe lone working but does not link this across to the Lone Working Policy. The PT4 policy needs to link to the accident reporting policy. Some policies do not link to the legal requirement. For example the risk assessment policy does not link to specific legal requirements. 3.2 Policy Commitments The writing of a Health and Safety policy is a legal obligation for any organisation employing five or more people, but its purpose should be much greater than simply satisfying a statutory duty. The policy should communicate the beliefs and commitment of the organisation to the principles of protecting and promoting the Health and Safety of its workforce. The Health and Safety policy statement serves as a mission statement for the policy. It should be produced, approved and authorised by the highest level of management in the organisation; to demonstrate that such commitment to Health and Safety starts at the very top where the legal responsibility ultimately lies. Once having produced the policy, the organisation should then ensure that it effectively brings it to the attention of its workforce. The audit recognised a strong commitment to Health and Safety throughout OFRS and a commitment to review and revitalise policy and procedures.

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Recommendations: 1. Consider reviewing the PT2 and PT3 Health and Safety policy with a view of combining

them into a more succinct document for OFRS commitments specifically. For example, “the explanation of how the policy can contribute to business performance e.g. by reducing injuries and ill health, protecting the environment and reducing unnecessary losses and liabilities”, is found in the PT1 policy and should also be in PT2.

2. Consider revising the PT2 Policy, Roles and Responsibilities, 2.0 Chief Fire Officer, bullet 2,

to change the wording to “overall responsibility”. The Audit team scored this positively but by adding in the additional wording would ensure clarity to the reader.

3. Consider revising the PT2 Policy, Roles and Responsibilities to identify the management

appointee with special responsibility for co-ordinating Health and Safety. “Quoted directly from the QSA question set”.

4. When reviewing PT2 and PT3 add in the roles and responsibilities of OFRS H&S team. 5. Consider adding a commitment to include Health and Safety performance details within the

annual report. 6. Consider a process for reviewing H&S policies. This would ensure that links to other

policies and links to legal requirements are included. Editors Notes The Lead Auditor found evidence within the policies to answer some of the QSA questions, and after reviewing this with the team, agreed to change the scoring. Therefore this section has a slightly different score to the one given in the closing meeting which ultimately affected the overall score. 4. Organising Section Overall 93% Organising for Health and Safety i.e. allocation of responsibilities 94% Organisational Procedures 92%

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

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4.1 Organising for Health and Health Safety - Roles and Responsibilities Sub Section Overall 94% Policy Makers 91% Planners 100% Implementers 100% Health and Safety Assistance 85% Employees Duties 100% H & S Organisational Chart 100%

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

a) Policy makers b) Planners c) Implementers

Typically, the policy makers would comprise of the chief executive and executive management team, the planners would comprise of senior managers, whereas the implementers would be first line managers and supervisors. The HSE also describe the role of safety advisors, who assist the three levels of Health and Safety management described above. Such division of duties is intended to ensure that responsibility starts at the very top of the organisation and is then cascaded down through the various levels of management. Implicit in this is the understanding that the implementation of Health and Safety arrangements is a line management responsibility and not something that is ‘looked after’ by a Health and Safety department, whose role should be advisory. The allocation of employees’ legal responsibilities is also examined in this section. The key source of information for this section was found in the PT2 Health and Safety policy signed and dated by the Chief Fire Officer. Recommendations: 7. To improve scoring within section 2.1, RoSPA suggest specifying a structure to clearly

identify who and which groups they control, are responsible for planning and implementing. 4. As above, when reviewing PT2 and PT3 add in the roles and responsibilities of OFRS H&S

team. 8. The roles and responsibilities of OFRS H&S team need to include the elements of QSA

section 2.4 for maximum marks in this area.

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4.2 Organisational Procedures Organisational Procedures - Overall 92% Control 89% Co-operation 97% Communication 100% Competence 97%

There is a legal requirement to have a written Health and Safety management system, where five or more are employed. In the same manner as for a policy, however, such a system should go beyond legal obligations to communicate the importance of Health and Safety to employees, and guide compliance with both legislation and best practice. The HSE describe four ‘building blocks’ of a Health and Safety culture, as follows:

a) Control of the elements of the Health and Safety management system b) Co-operation between the parts of the organisation and with external bodies c) Communication channels into, around and out of the organisation d) Ensuring and maintaining the Competence of employees

Organisations are often putting more into action than would be suggested from the extent of their written Health and Safety management system (i.e. ‘doing more than they say they are doing’). Whilst actual implementation is clearly vital to safeguarding Health and Safety, it would also clearly be improved by comprehensive and relevant guidance provided in the form of procedures. Such written guidance also helps to ensure that controls are consistently applied. From the foregoing, it can be appreciated that procedures should be based on the results of risk assessment to ensure relevance.

4.2.1 Control of the HSMS Control Overall 89% Development and Control of the HSMS 95% Supervision 58% Measuring Performance – Active Monitoring 77% Measuring Performance - Reactive monitoring 99% Auditing of the SMS 100% Reviewing Health & Safety Performance 83%

Control procedures should address issues such as the development and control of the Health and Safety management system and the elements of supervision within the organisation to ensure that these are adequate for the risks and competencies involved. Procedures are also required to address the other elements of the Health and Safety management system included in the structure described by the HSE (i.e. planning, active and reactive monitoring, auditing and review of performance). Planning procedures will be discussed in the planning section of this report.

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Development and Control of the HSMS Within a HSMS, there should be a mechanism or procedure for the formulation and development of that system to ensure that it meets the requirements of the organisation and continues to do so. The controlled production and distribution of procedures and guidance documents is essential to ensure that all employees of the organisation operate to the same system and standards. It is a concept recognised in the field of quality systems and the requirement for such a discipline is equally pertinent when dealing with Health and Safety systems. Recommendations: 4. As above, when reviewing PT2 and PT3 add in the roles and responsibilities of OFRS H&S

team. The roles and responsibilities of OFRS H&S team need to include the expected results or outputs in the form of a description of the roles and responsibilities for those involved in the process.

9. Control of the HSMS document system is unclear. Ownership could be identified within the

PT3 policy which could include the process for reviewing (as above) and a version control mechanism.

Editors Notes A high score has been recorded for this sub section although the team feel that they have been generous in this area, giving the potential to improve the HSMS policy and system but without improving the scoring. QSA Section 2, 2.7.5 & 2.7.6 (2.7.6.1 – 2.7.6.7) specifically). Supervision The provision and extent of supervision is a fundamental part of the control mechanism of any organisation and should seek to ensure that employees are provided with a level of supervision that is appropriate to their activities, level of expertise and any additional needs they have. Evidence was found regarding levels of supervision within the training documents for the development/induction process and the training blueprint. However they particularly focused on new entrant uniformed staff. It did not include non-uniformed staff or provide guidance on special needs of new employees, on the job training, supervision to accommodate the special needs of any specific legal requirements, i.e. young persons or pregnant women. Recommendations: 10. Review all training documents that refer to levels of supervision and ensure that they are

appropriate to both uniform and non-uniformed staff and provides guidance on special needs of new employees, on the job training, supervision to accommodate the special needs of any specific legal requirements, i.e. young persons or pregnant women, as per QSA system section 2.8

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Editors Notes It is possible that these areas are already covered but the audit team could not find evidence to support positive scoring. This is a low scoring subsection that could easily be improved when reviewing policies within this area. Active Monitoring Active monitoring comprises one aspect of measuring the Health and Safety performance of an organisation (reactive monitoring being the other). Active monitoring seeks to identify the degree of compliance with Health and Safety requirements and arrangements before an accident or incident occurs. It includes:

a. Systematic inspections of workplaces b. Examination of Health and Safety documentation c. Procedures to monitor specific objectives d. Observation of activities and behaviour by first line supervisors e. Consideration of reports on performance by senior management f. Health and Safety tours by senior managers g. Health and Safety attitude and behaviour questionnaires

OFRS is carrying out some active monitoring systems. The inadequacies of this section lie within the more specialist monitoring processes, the use of environmental monitoring, objectives for groups and rewards for achieving the required objectives and the lack of Health and Safety attitude and behaviour questionnaires. The service does not appear to utilise incentive schemes to encourage Health and Safety performance. This is identified in industry as an effective way of encouraging improved Health and Safety performance and awareness in the organisation. The use of/reference to periodic attitude surveys and their results would also enhance an awareness of Health and Safety culture throughout the organisation. Recommendations: 11. Consider introducing Health and Safety attitude, behaviour and culture surveys to

demonstrate an improvement in knowledge or attitude. 12. Investigate the benefits of implementing some form of Health and Safety rewards scheme. Reactive Monitoring Reactive monitoring systems are designed to identify, report and investigate events after they have happened. As such they play a complimentary role to active monitoring systems but are often the focus of attention in assessing Health and Safety performance. Such systems should include:

Injuries and cases of ill-health Other losses, including property damage Incidents with the potential to cause injury/damage (‘near-misses’) Hazard reporting Weaknesses or omissions in standards

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The audit team identified solid evidence within the safety event policy 001 dated 2014-17. Auditors were met with a positive culture in reporting safety events and a robust procedural mechanism. The score reflects some of the more intricate points asked for by the QSA system and evidence that was presented during the audit. Auditing the HSMS An audit is: ‘The structured process of collecting independent information on the efficiency, effectiveness and reliability of the total Health and Safety management system and drawing up plans for corrective action’ (HSG 65) To fulfil the criteria detailed above, HSG 65 specifies that the audit should examine all the elements of the Health and Safety management system as examined in this report. The ultimate aim of any such audit should be to promote continuous improvement of the Health and Safety management system. Audits should be carried out by competent auditors (ideally independent of the activities or areas being audited) and the methodology of the audit should be as per ISO 19011 (formerly BS 7229). It is the umbrella activity that may include workplace inspections but operates at a higher and more systemic level. It is thus important to make the distinction between audits and inspections when considering this issue. As with quality systems the operation of an internal audit programme is required irrespective of any external audits carried out. Evidence for this section was found in HST POL 032 which provides a general overview of requirements and procedures for internal and external auditing of OFRS. Evidence of an internal QSA audit in August 2013 shows a strong corporate commitment to the process. It is evident that there have been improvements in this process since the last full audit in 2009. Reviewing Performance In the context of the Health and Safety management system, review is defined as: ‘The process of making judgements about the adequacy of performance and taking decisions about the nature and timing of the actions necessary to remedy deficiencies’ and, ‘The aims of the review process reflect the objectives of the planning process’ (HSG 65).

In the context of this audit, review covers:

a) Assessment of the degree of compliance with organisational procedures; b) Identification of activities where procedures either do not exist or provide inadequate

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

both immediate and underlying causes, trends and common features. This can then be fed back into policies, procedures and plans to ensure not only compliance with legislation and standards, but to promote the continuous improvement recommended in HSG 65. Whilst overall this section scored well. Some marks were lost due to the lack of regional and national benchmarking and other comparators.

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4.2.2 Co-operation

Health and Safety Committees 97% Co-operation procedures should principally address how the organisation consults with its workforce (which is a legal requirement for all organisations whether unionised or not) but would also cover co-operation with other organisations that may share the workplace. The commonest form of consultation is through a formal Health and Safety committee. Evidence of this was found from interview with the representative bodies. OFRS demonstrates a comprehensive commitment to the co-operation of its workforce, therefore meeting the requirements of The Safety Representatives and Safety Committee Regulations 1977 and the Consultation with Employees Regulations 1996. The only marks lost in this area were due to safety representatives stating that they had not received consultation on the outcomes of the action plan following the HSE Inspection in 2009/10. Recommendation:

13. Consider reviewing the communication strategy to ensure that all individual personnel and

groups are consulted/communicated with. 4.2.3 Communication Dissemination of Information 100%

Communication procedures should describe how the organisation obtains Health and Safety information (and what this consists of), how such information is distributed around the organisation and the dissemination of Health and Safety information to external bodies such as enforcement authorities and even the general public. Communication of Health and Safety information throughout any organisation is a challenge requiring continual review. The audit only samples information accessible during a limited period; this provides an external independent assessment of the effectiveness of the communication process being used. There is a communication strategy in place and OFRS promulgates a mass of Health and Safety in various formats. The audit team found sufficient evidence to warrant a very high score in this area. Evidence was found however, that information was not necessarily getting through to all appropriate individual staff and/or groups of staff. For example; a non-uniformed manager was completely unaware of the policy on occupational road risk (emphasised as this person undertook a lot of travelling out of county), a group of individuals were unaware of H&S bulletins that were aimed specifically at them and individual staff were unaware of the new employee assistance programme or PAM. It is therefore evident that managers at all levels are either not sharing this information or not verifying that messages are received and understood.

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Recommendations: 14. Review the communications strategy to ensure that appropriate staff are appointed to verify

that H&S messages are received and understood. 15. OFRS has a range of policies on performance and auditing of the HSMS. Ensure that the

process of verifying H&S messages are received and understood is contained within these documents.

16. Review the 1 to 1 process to ensure that H&S policies and messages are being received

and understood by individuals.

4.2.4 Competence Competence Overall 97% Recruitment and Placement Procedures 100% Identification of Training Needs 93% Provision of Training 100% Provision of Health and Safety Assistance 100%

This section of the audit is not an examination of the actual level of competence of individuals, but rather the ability of the HSMS to develop and maintain the high level of personal competence required to meet organisation and personal responsibilities. It looks at the procedures for recruitment and placement, identifying training needs, providing training, and the role and competence criteria for Health and Safety assistance (i.e. advisors) Recruitment and Placement The methods by which people are recruited into, or otherwise placed in, the organisation are important in ensuring that suitable competencies exist. A maximum score was achieved for recruitment and placement procedures. However a lot of emphasis was placed on operational staff and little on non-uniformed staff. Identification of Training Needs Organisations need to systematically assess the training needs of their employees to maintain and develop personal competencies and allow for specific needs to be addressed. The audit identified strong evidence based on Grey Book employees that training needs have been recognized and implemented into individual training programs. The week link for uniformed services is always how to apply the same level of attention to the training requirements of Green Book employees. Provision of Training Training should be provided in a structured manner based on the needs of the organisation and any specific needs of individuals within it to assist the effective implementation of policy and procedures.

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Evidence of this was found in the Training and Development Strategy TRNPOL001 and the Training and Development Policy TD POL 004. Health and Safety Assistance The appointment of competent persons to assist the organisation in meeting its Health and Safety responsibilities is a legal requirement. This is described as Health and Safety assistance and can be provided by external or internal personnel. Their profile and remits are detailed in inset 9 of HSG 65 and include the provision of advice and co-ordination on Health and Safety matters. Summary A high score has been achieved for competence. However anecdotal evidence gained during interviews would suggest that Green Book staff were unsure of their training needs and requirements and some suggested that they received very little training or refresher training. Evidence was found that specific H&S training was missing in areas such as CoSHH and noise. The H&S team are in the development of power point lectures to be used in “Toolbox Talks”. Recommendations: 17. Review and improve general training and refresher training for Green Book staff. 18. Review and improve specific H&S training. 19. Develop a structured programme for the development and delivery of Toolbox Talks. 5. Planning and Implementation Section Overall 91% The Planning Process 95% Implementation of Organisational Procedures 93% Risk Control Performance Indicators 89%

5.1 The Planning Process The Planning Process - Overall 95% Corporate Planning 100% Operational Planning - Risk Assessment Procedures 92% Implementation of Corporate Planning Procedures 91% Implementation of Operational Planning – Risk Assessment Procedures 97%

As with other aspects of management, planning is crucial to ensure that the relevant issues are adequately addressed, that sufficient resources are allocated and that meaningful objectives and performance standards are set to achieve the aims and obligations of the organisation. It is important that any objectives are SMART (Specific, Measurable, Agreed with those involved, Realistic, and Time based with appropriate deadlines). The audit distinguishes between two categories of planning, i.e. corporate and operational.

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Corporate Planning Procedures Corporate planning is concerned with establishing and maintaining policy, organisation and culture necessary for effective risk control at management level. It also includes actions to get the long-term objectives integrated at functional and individual level. These objectives should encompass the following:

(a) Defining, developing and maintaining the Health and Safety policy; (b) Developing and maintaining organisational arrangements; and (c) Developing and maintaining systems of risk control to meet defined performance

criteria. Evidence was found within OCC PT1 Health and Safety Policy. OFRS received a maximum score in this area. Operational Planning Procedures Operational planning is concerned with the implementation of corporate plans through the assessment of the risks arising from work activities plus the establishment and maintenance of suitable control measures. The service has a Risk Assessment process, detailed in the HST Procedure 006 and the operational ARA document. Missing from the policy were specific references to legal requirements which establish the minimum levels of risk control. Recommendations: 20. Review the Risk Assessment policy to ensure specific references to legal requirements

which establish the minimum levels of risk are included, for example; working at height, CoSHH, Confined Space Regulations.

Implementation of Corporate Planning OFRS are following OCC’s 5 year Health and Safety plan. Priorities have been established for Health and Safety. Evidence was found of previous plans and objectives and the service learning and developing from these with 75% to 99% of those objectives being completed. Implementation of Operational Planning The audit identified strong evidence of commitment to risk assessments throughout the organisation. There is no evidence to support that a risk assessment has been completed for energy sources used by the organisation (Section 3, 3.4.3.4 & 3.4.4.4). Recommendation 21. Carry out a risk assessment on the different energy sources used by the organisation.

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5.2 Implementation of Organisational Procedures Overall 93% Control 100% Co-operation 100% Communication 84% Competence 91%

Control Control Overall 100% Development and Control of the HSMS 100% Supervision 100%

Implementation of Development and Control There is solid evidence of an effective safety management system. Responsibility for control of the HSMS policies is delegated to the H&S team. The documents are electronic and are placed on the service intranet system for all employees to access. Implementation of Supervision The service scored very highly in this area and it was evidenced that managers were providing a high level of supervision. Co-operation

The audit provided good evidence to support a high standard of co-operation with employees on Health and Safety issues. Evidence shows this is actively integrated systemically throughout OFRS.

Communication OFRS H&S team have responsibility for communicating Health and Safety within the organisation. Evidence of this responsibility was found within their individual job descriptions. No evidence was found for sources of information that could be utilised when formulating or reviewing policy. Evidence to prove effective communication was limited and the evidence that was found provided mixed results. Meetings at very low level do not specifically agenda Health and Safety and did not always provide regular Health and Safety reminders. Please refer to the previous comments made on page 12 (4.2.3 Communication) with regards to the recommendations contained within.

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Recommendation: 14. Review the communications strategy to ensure that appropriate staff are appointed to verify

that H&S messages are received and understood. 15. OFRS has a range of policies on performance and auditing of the HSMS. Ensure that the

process of verifying H&S messages are received and understood is contained within these documents.

16. Review the 1 to 1 process to ensure that H&S policies and messages are being received

and understood by individuals. Competence Competence Overall 91% Recruitment and Placement Procedures 100% Identification of Training Needs 82% Provision of Training 93% Provision of Health and Safety Assistance 91%

Implementation of Recruitment and Placement OFRS are following two significant paths in terms of recruitment: OCC policy for Green Book staff and the National Firefighter selection process for operational staff.

However there was evidence during a station visit that groups of employees (transferees and firefighters that were wholetime with another service and on call with OFRS) were being overlooked in terms of induction and not receiving H&S training.

Recommendation:

22. Review the induction process to include transferees and firefighters that are wholetime with

another service and on call with OFRS.

Implementation of Identification of Training Needs Evidence of the implementation of training needs was evidenced within the training blueprint. No evidence was found for the identification of training needs to non-employees, employees who work for long periods, employees with special needs and employees who cover absence. No evidence was found for prioritising the training.

Implementation of Provision of Training

This was another high scoring section and the current training plan was provided for evidence. Marks lost in this section were for lack of evidence for employees transferred to different work areas with regards to H&S induction training and the use of pre training briefings for delegates.

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Implementation of Health and Safety Assistance

OFRS has a well-resourced Health and Safety department with a range of competence to meet the services requirements. Staff at various levels throughout the organization always spoke highly of OFRS’s Health and Safety team. 5.3 Risk Control Performance Indicators As part of the QSA audit ten areas of legislative issues are considered in relation to the client. These are selected from a collection of indicators on the basis that they are relevant to the organisation and therefore provide a measure of how well the organisation is managing specific legal requirements. They can be equated to the Risk Control Systems referred to in HSG 65 which are systems designed to address particular areas of risk that may not be adequately covered by the general Health and Safety management system. Each of the ten issues is examined in terms of both procedural control and actual implementation. An audit score is assigned to each of these areas and they are referred to as Risk Control Performance Indicators. The ten areas are commented on below. RCPI’s Overall 89% Manual handling Control of Substances Hazardous to Health Personal Protective Equipment Provision and Use of Work Equipment, Machinery and other items of Plant Noise Working at Heights Use of Breathing Apparatus Display Screen Equipment The Management of Stress

97% 80%

100% 100% 89%

100% 93% 98% 63%

Management of Occupational Road Risk 79% Manual Handling Operations

Auditors found strong evidence that the management of Manual Handling is comprehensive. It was refreshing to find that some of the most vulnerable employees, i.e. newly employed on call firefighters have received quality manual handling awareness and training.

Evidence in this area was gained from the Manual Handling and Musculoskeletal Injuries Procedure, evidence from RedKite and interviews.

There was insufficient evidence to show that 100% of detailed assessments have been completed of those activities identified to present a significant risk. Auditors have estimated this to be between 50% and 74%.

Control of Substances Hazardous to Health Evidence in this area was gained from the Control of Substances Hazardous to Health Regulations 2002 (CoSHH) policy HST PROC 007 and from CoSHH risk assessments.

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The Audit team did not have sufficient time to allow for a thorough examination of CoSHH substances out in the work areas and so the score was averaged to reflect this. Evidence was found of very limited training of all personnel specifically to CoSHH. Training appeared to be at induction only. No refresher training is taking place. OFRS realise this and a Toolbox Talk is already in development to address this issue. No evidence was found to show that results of the Health Surveillance Programme are used to evaluate the effectiveness of the risk control measures. Recommendation: 23. Implement a programme of training specifically for CoSHH aimed at all members of staff. 24. Ensure that information is exchanged between OFRS and its Occupational Health providers

so that they can ensure CoSHH control measures are effective. Editor’s Notes OFRS anticipated that they would not score well in this area and there would be room for some improvement. Personal Protective Equipment (PPE) OFRS have contracted out a total care package to cover their largest risk for PPE, the operational firekit. Policies were also identified which cover the assessment and purchase of equipment and provision and use of work equipment. Evidence was found to include groups of staff when consulting and trialing new PPE. Evidence was also found for specialist PPE for workshop mechanics. The high score is a reflection of the continuous effort put into this area covered by the audit. Provision and Use of Work Equipment, Machinery and other items of Plant (PUWER) OFRS have again scored highly within this area of the audit. Evidence was gained from within the policy on Provision and use of Work Equipment and examples of various pieces of plant in workshops and on fire stations. One very minor point is within the policy. Links to other policies refer to procedures no longer in use or are out of date. Please refer back to page 6, recommendation 6. Recommendation: 6. Consider a process for reviewing H&S policies. This would ensure that links to other

policies and links to legal requirements are included. Noise Evidence was found within the policy Noise at Work – Assessment and Control, training records and during station visits.

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Marks lost in this area are based on training. Noise training appears to be carried out at induction for operational personnel. No evidence was found for other types of personnel or refresher training in noise and/or noise awareness. A Toolbox Talk is in development but is not completed. Please refer back to a previous recommendation. Recommendation: 19. Develop a structured programme for the development and delivery of Toolbox Talks. 25. Carry out Noise Awareness training. Working at Heights This was also a high scoring area. Evidence for this was found from the Working at Height Policy and Working at Height Procedure, test records, station visits and samples of a variety of equipment throughout the service. Use of Breathing Apparatus OFRS have scored well with evidence gained from standard operating procedure, BA policy documents, GRA’s, ARA’s, DRA’s and risk assessments. The risk assessment for breathing apparatus did not make any reference to; Confined spaces, (but is covered on day 2 of the BA initial course).

• If there are any difficulties in maintaining command and control and any potential communication black spots.

• Provision of specific rescue or access equipment. • Provision of specific atmospheric monitoring equipment.

The audit team believed that the breathing apparatus training was broken down into elements of either phase 1, 2 or 3 and it appeared that individuals could potentially cancel an element which would not be noticed or acted upon (QSA book 2, 3.32 BA, page 3.158). Recommendation: 26. Review the risk assessment for BA to include; (i) Confined spaces. (ii) If there are any difficulties in maintaining command and control and any potential communication black spots. (iii) Provision of specific rescue or access equipment. (iv) Provision of specific atmospheric monitoring equipment. Display Screen Equipment OFRS scored highly within this area at the time of the audit. Evidence was gained from OCC DSE safety policy and DSE H&S guidance, specific equipment provided for individuals and furniture and interviews.

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The only marks lost were the auditing of employees who are DSE users at the home address, which is a difficult area for any employer to overcome. The Management of Stress OFRS are working within the OCC Stress at Work policy. There is some evidence to suggest that OFRS have attempted or are undertaking work in this area. Some of the evidence found or provided was of poor quality and limited use. Within the policy is a risk assessment. No evidence could be found of its use. An Oxford Brookes University survey was provided but it was not dated (believed to be from 2009) and appeared to be more of a staff survey with little evidence of questioning staff regarding stress. There was a staff survey from 2010/12 which only had tenuous links to stress. There was also an Engagement Survey from 2012 offered as evidence but the results were too generic to be able to extract anything of relevance from it. All the different types of staff were not as knowledgeable about OFRS’s occupational health provider (PAM) and the Employee Assistance Programme (PAM Assist). Managers stated that all personnel had received key fobs (with a helpline number) when being trained in the use of the new programme. Evidence suggested that not all personnel had received the training or the key fobs. It was also found that some staff were carrying the key fob at all times and that the PAM & PAM Assist was advertised on the front page of benefits to staff on OFRS’s intranet. Some of the awareness training carried out appeared to be ineffective particularly with Green Book staff. OFRS have insufficient data to monitor absence from work due to stress because of the new processes involved and the new occupational health provider. Therefore they cannot state whether sickness absence due to stress is rising or falling or whether any action taken in terms of stress is having any effect. Operational staff highly praised OFRS on its debriefing procedure. They openly talked about hot debriefs at scene, technical debriefs, defusing and critical incident debriefing. Most of the group spoken to had undergone some form of defusing back on station with a few of those going on to critical incident debriefing. Recommendations: 27. Carry out a specific stress survey to assess which areas need to be addressed. 28. Carry out stress risk assessments on individuals or groups. 29. Improve communication of PAM & PAM Assist particularly with Green Book staff 30. Ensure that information is exchanged between OFRS and its Occupational Health providers

so that they can ensure stress control measures are effective. Editor’s Notes OFRS suspected that they might score poorly within this area and action is planned/underway to quantify the problems they are experiencing with this.

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Management of Occupational Road Risk OFRS has a Management of Road Risk Procedure in place however it is not mentioned within the PT2 or PT3 policy. Marks lost within this area were due to the MORR procedure not meeting the RoSPA requirements as per QSA system, Book Two, section 3.42, page 3.208. The procedure did not include;

• Arrangements for specifying vehicle maintenance. This referred to a different procedure, a vehicle maintenance procedure but was not listed as a document for consideration in the current MORR procedure.

• Requirements covering the actions to be taken in the event of a breakdown, an emergency or an accident or crash. This is all contained within the vehicle accident procedure but was not listed as a document for consideration in the current MORR procedure.

• Arrangements for auditing the MORR procedure. The MORR procedure or the driver training manual did not cover personal safety and security as a lone driver. There was no evidence to show that the organisation regularly has its management of ORR reviewed by auditors independent of the activities being audited. Again different types of personnel had varying knowledge of the MORR procedure. Evidence was found that information was not necessarily getting through to all appropriate individual staff and/or groups of staff. For example; a non-uniformed junior manager was completely unaware of the policy on occupational road risk (emphasised as this person undertook a lot of travelling out of county). It is again evident that managers, at all levels, are either not sharing this information or not verifying that messages are received and understood. Recommendations: 14. Review the communications strategy to ensure that appropriate staff are appointed to verify

that H&S messages are received and understood. 15. OFRS has a range of policies on performance and auditing of the HSMS. Ensure that the

process of verifying H&S messages are received and understood is contained within these documents.

16. Review the 1 to 1 process to ensure that H&S policies and messages are being received

and understood. 17. Review and improve general training and refresher training for Green Book staff. 18. Review and improve specific H&S training.

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31. Review the MORR procedure to include; (i) Arrangements for specifying vehicle maintenance. (ii) Requirements covering the actions to be taken in the event of a breakdown. (iii) Requirements covering the actions to be taken in the event of an emergency. (iv) Requirements covering the actions to be taken in the event of an accident or crash. (v) Arrangements for auditing the MORR procedure.

32. Ensure auditing of the MORR procedure takes place, an audit report produced and an

action plan developed to show corrective actions. 33. Ensure the MORR procedure or the driver training manual covers personal safety and

security for lone drivers. Editors Notes OFRS scored reasonably well in this area. Unfortunately the person sampled for knowledge of the MORR procedure did not know it. The individual was however applying a lot of common sense and did not seem unsafe. This should not be seen as an example of the whole service. The majority of the recommendations (14-18) have been repeated from earlier with reference to improving communication and ensuring H&S messages are received and understood. The remainder (31-33) whilst seem minor in nature are more of a fine tuning exercise which would ultimately improve this area. 6. Measuring Performance Overall 77% Active Monitoring 70% Reactive Monitoring 88%

In order to monitor Health and Safety performance to identify strengths and weaknesses, and areas for improvement, an organisation needs to operate systems to collect relevant data and statistics. This will also provide crucial information for planning and review activities. Such systems are in addition a legal requirement. This section does not include operational incident monitoring. 6.1 Active Monitoring Satisfactory evidence was found at audit of workplace inspections. Senior managers are also carrying out safety tours. Both of these have written procedures for managers and employees to follow.

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Workplace inspections follow a programme which is reviewed to ensure progress. The plan could be updated with further detail on frequency and who has responsibility. The workplace inspections follow a preset station audit form. It is a generic form and is not tailored to specific areas to be inspected. There was no evidence that the station audit form was based upon control measures found to be necessary by risk assessments in each area. Following the workplace inspection an action plan is completed with a 6 monthly review. Evidence suggested that between 50% and 99% of those recommendations/actions were completed. Action plans are dated but not signed by the managers completing the audit form, although the H&S Manager signs the covering letter. OFRS have introduced a new inspection programme; therefore the service cannot review the effectiveness of the workplace inspection programme. Evidence was found to verify that Health and Safety documentation is being regularly examined to ensure compliance with H&S procedures. Evidence was also found of other active monitoring procedures, i.e. noise assessments, local exhaust ventilation and substances hazardous to health. Auditors were unable to find evidence to suggest that any Health and Safety attitude, behavior and culture surveys have ever taken place; therefore there is no evidence to show an improvement or decline in knowledge or attitude. The auditors were unable to identify where managers have highlighted and rewarded good practice or provided incentive rewards for those individuals or groups of staff making that extra effort to achieve full compliance and improve safety in the workplace. Recommendations: 34. Review the workplace inspection programme to ensure its effectiveness. 35. When reviewing the workplace inspection programme and audit forms consider amending

the form so that it is tailored to specific areas. This would confirm that control measures found to be necessary by risk assessments in each area, were providing the adequate control required.

11. Consider introducing Health and Safety attitude, behaviour and culture surveys to

demonstrate an improvement in knowledge or attitude. 36. Consider implementing reward schemes for initiative/good achievements, for individuals or

groups of staff that improve Health and Safety within the organisation. 6.2 Reactive Monitoring OFRS are following their own Safety Event (Accident, Ill Health, Near Miss) Investigation and Reporting Procedure. Marks for the policy were lost due to; the reporting of accidents causing property damage is not contained within the above policy. It is mentioned in the PT4 OCC policy. The policy does not mention the reporting of non-compliances. There was no evidence to suggest that the organisation had investigated incidents of non-conformity.

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Accident investigations were carried out in a competent manner by trained individuals nominated to do so. Following investigations, action plans are formulated with between 50% and 99% of remedial actions being carried out. Accident and incident performance reports are analysed quarterly by OFRS’s Senior Leadership Team with an annual report being produced. The quarterly and annual reports are not cross referenced with other sources of information or benchmarked from inside the FRS industry or outside of it. Recommendations: 37. Review the Safety Event Reporting Procedure to include the mention of reporting of

accidents causing property damage and the reporting of non-compliances. 38. Consider benchmarking quarterly and annual reports within the FRS community. 39. Consider utilising other sources of information when analysing annual reports such as

Occupational Health reports, maintenance reports for buildings, maintenance reports for vehicles and fire and/or insurance claims.

7. Audit and Performance Review Overall 77% Auditing 94% Performance Review 66%

The last two elements of the Health and Safety management system structure examined in the audit relate to the activities of the organisation in auditing its HSMS and reviewing its overall performance. 7.1 Audit OFRS have several good examples of audit; the CFOA No5 SE Regional Audit in 2009, the HSE report of 2009, the Fire Peer Challenge of 2014 and their own internal audit utilising the QSA system in August 2013. The audit team found evidence of action plans developed afterwards for both the internal audit 2013 and the HSE report of 2009. The audit team estimated that between 50% and 99% of the identified corrective actions had been completed. OFRS have stated intent to carry out an internal audit annually in the Organisational Assurance Policy. Scoring of the HSMS (following the RoSPA QSA system) has improved over five years from 2009 (76%), the internal audit 2013 (85%) and this audit (88%). Caution is advised when carrying out internal audits as the audit team may not be able to provide an impartial and accurate assessment.

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7.2 Review Evidence of performance review was found but auditors felt it did not meet the range of requirements to fulfil the QSA process. OFRS publish an annual report of the whole organization (evidence seen was the 2013-2014 report) which included H&S on pages 38, 39 and 40. The level of detail required to satisfy the QSA process would not normally be the sort of detailed H&S information in a document aimed at the general public. OFRS could produce its own internal annual H&S report with the detail required and extracts from this used in the public report Information omitted from the annual report included detailed analysis of information from active monitoring, the costs of accidents, the cost of preventative action, the cost of monitoring Health and Safety performance and lessons learned from real emergencies or drill to test emergency procedures. A trend analysis of the available data on accident and ill health performance showed that the trend has remained static with Riddor reportable incidents increasing. OFRS should be showing a decline. It would appear that lessons are not being learnt from accident or ill health information. OFRS have the information available but are not setting themselves meaningful objectives to drive down accident figures. Setting of objectives would “complete the circle” when formulating strategic objectives for Health and Safety. There was no evidence found to support benchmarking within the FRS industry or outside of it. CFOA SE Region H&S practitioners group are working on a benchmarking process which OFRS personnel are already involved in. Areas for development include publishing and assessing the results of management audits and inspections and analysis of information gleaned from active monitoring. Recommendations: 40. Consider the development of an annual H&S report. OFRS have already committed

themselves to an annual audit which could form the basis of this report. 41. Set meaningful objectives when formulating strategic objectives for Health and Safety

based upon information from within the annual H&S report.

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8. Score Summary The overall results are summarised in the following table and reproduced graphically using the QSA radar chart. Policy 2009

External 2013

Internal 2014

External Section Overall 86% 92% 93% Policy General 100% 94% 100% Policy Commitments 81% 90% 90% Organising 2009

External 2013

Internal 2014

External Section Overall 70% 87% 93% Organising for Health and Safety 95% 86% 94% Organisational procedures 64% 87% 92% Planning and Implementation 2009

External 2013

Internal 2014

External Section Overall 80% 89% 91% Planning Process 79% 96% 95% Implementation of Organisational Procedures 86% 95% 93% Risk Control Performance Indicators 78% 84% 89% Measuring Performance 2009

External 2013

Internal 2014

External Section Overall 65% 75% 77% Active monitoring 46% 67% 70% Reactive Monitoring 91% 88% 88% Audit and Performance Review 2009

External 2013

Internal 2014

External Section Overall 74% 77% 77% Audit 81% 89% 94% Performance Review 68% 68% 66% The Health and Safety Performance Rating ( HSPR )

2009 External

2013 Internal

2014 External

76% 85% 87%

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Health and Safety Performance Rating 87

RoSPA Award Level 3

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9. Key recommendations 1. Consider reviewing PT2 and PT3 Health and Safety policies with a view of combining them

into a more succinct document. For example, “the explanation of how the policy can contribute to business performance e.g. by reducing injuries and ill health, protecting the environment and reducing unnecessary losses and liabilities”, is found in the PT1 policy and should also be in PT2.

2. Consider revising the PT2 Policy, Roles and Responsibilities, 2.0 Chief Fire Officer, bullet 2,

to change the wording to “overall responsibility”. The Audit team scored this positively but by adding in the additional wording would ensure clarity to the reader.

3. Consider revising the PT2 Policy, Roles and Responsibilities to identify the management

appointee with special responsibility for co-ordinating Health and Safety. “Quoted directly from the QSA question set”.

4. When reviewing PT2 and PT3 add in the roles and responsibilities of OFRS H&S team.

Plus (on page 8);The roles and responsibilities of OFRS H&S team need to include the expected results or outputs in the form of a description of the roles and responsibilities for those involved in the process.

5. Consider adding a commitment to include Health and Safety performance details within the

annual report. 6. Consider a process for reviewing H&S policies. This would ensure that links to other

policies and links to legal requirements are included. 7. To improve scoring within section 2.1, RoSPA suggest specifying a structure to clearly

identify who and which groups they control, are responsible for planning and implementing. 8. The roles and responsibilities of OFRS H&S team need to include the elements of QSA

section 2.4 for maximum marks in this area. 9. Control of the HSMS document system is unclear. Ownership could be identified within the

PT3 policy which could also include the process for reviewing (as above) and a version control mechanism.

10. Review all training documents that refer to levels of supervision and ensure that they are

appropriate to both uniform and non-uniformed staff and provides guidance on special needs of new employees, on the job training, supervision to accommodate the special needs of any specific legal requirements, i.e. young persons or pregnant women, as per QSA system section 2.8.

11. Build in a program of behavioural surveys to assess inherent Health and Safety culture

across the service. 12. Investigate the benefits of implementing some form of Health and Safety rewards scheme. 13. Consider reviewing the communication strategy to ensure that all individual personnel and

groups are consulted/communicated with.

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14. Review the communications strategy to ensure that appropriate staff are appointed to verify that H&S messages are received and understood.

15. OFRS has a range of policies on performance and auditing of the HSMS. Ensure that a

process of verifying that H&S messages are received and understood is contained within these documents.

16. Review the 1 to 1 process to ensure that H&S policies and messages are being received

and understood by individuals. 17. Review and improve general training and refresher training for Green Book staff. 18. Review and improve specific H&S training. 19. Develop a structured programme for the development and delivery of Toolbox Talks. 20. Review the Risk Assessment policy to ensure specific references to legal requirements

which establish the minimum levels of risk are included, for example; Working at Height, CoSHH, Confined Space Regulations.

21. Carry out a risk assessment on the different energy sources used by the organisation. 22. Review the induction process to include transferees and firefighters that are wholetime with

another service and on call with OFRS. 23. Implement a programme of training specifically for COSHH aimed at all members of staff. 24. Ensure that information is exchanged between OFRS and its Occupational Health providers

so that they can ensure COSHH control measures are effective. 25. Carry out Noise Awareness training. 26. Review the risk assessment for BA to include; (i) Confined spaces. (ii) If there are any difficulties in maintaining command and control and any potential communication black spots. (iii) Provision of specific rescue or access equipment. (iv) Provision of specific atmospheric monitoring equipment. 27. Carry out a specific stress survey to assess which areas need to be addressed. 28. Carry out stress risk assessments on individuals or groups. 29. Improve communication of PAM & PAM Assist particularly with Green Book staff. 30. Ensure that information is exchanged between OFRS and its Occupational Health providers

so that they can ensure stress control measures are effective.

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31. Review the MORR procedure to include; (i) Arrangements for specifying vehicle maintenance. (ii) Requirements covering the actions to be taken in the event of a breakdown. (iii) Requirements covering the actions to be taken in the event of an emergency. (iv) Requirements covering the actions to be taken in the event of an accident or crash. (v) Arrangements for auditing the MORR procedure. 32. Ensure auditing of the MORR procedure takes place, an audit report produced and an

action plan developed to show corrective actions. 33. Ensure the MORR procedure or the driver training manual covers personal safety and

security for lone drivers. 34. Review the Workplace Inspection Programme to ensure its effectiveness. 35. When reviewing the Workplace Inspection Programme and audit forms consider amending

the form so that it is tailored to specific areas. This would confirm that control measures found to be necessary by risk assessments in each area were providing the adequate control required.

36. Consider implementing reward schemes for initiative/good achievements, for individuals or

groups of staff that improve Health and Safety within the organisation. 37. Review the Safety Event Reporting Procedure to include the mention of reporting of

accidents causing property damage and the reporting of non-compliances. 38. Consider benchmarking quarterly and annual reports within the FRS community. 39. Consider utilising other sources of information when analysing annual reports such as

Occupational Health reports, maintenance reports for buildings, maintenance reports for vehicles and fire and/or insurance claims.

40. Consider the development of an annual H&S report. OFRS have already committed

themselves to an annual audit which could form the basis of this report. 41. Set meaningful objectives when formulating strategic objectives for Health and Safety

based upon information from within the annual H&S report.

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10. Action Plan

Key Recommendation Timescale Review the PT2 and PT3 Health and Safety policies. Recommendations: 1, 2, 3, 4, 7, 8, 9.

Short Term

3-6 Months Review and develop a robust strategy for the communication of Health and Safety information. The strategy should be applicable to all the different types of staff within OFRS and should not miss out groups or individuals. There should be an auditable trail of evidence that information has been received and understood. Recommendations: 13, 14, 15, 16, 29.

Short Term

3-6 months

Training for Health and Safety. Consideration should be given to general refresher training, specific H&S training such as noise and CoSHH, further developing the Toolbox Talks, the reviewing of training documents to include appropriate levels of supervision and reviewing the induction process. Recommendations: 10, 11, 12, 17, 18, 19, 22, 23, 25.

Medium Term

12 Months

Develop strategic objectives and effective targets with a range of performance measures and a program of active monitoring to support performance. Consideration should be given to developing an annual H&S report which could be included in OFRS’ annual report, benchmarking with other FRS, workplace inspections performance reports, Occupational Health performance measures, staff culture surveys and reward schemes. Recommendations: 5, 15, 24, 34, 35, 36, 37, 39, 40, 41, 42.

Long Term

3 Years

Consider a process for reviewing H&S policies and procedures. The full audit report refers to the fine tuning of various policies and procedures. A review process would ensure consistency and methodology is applied to all of the HSMS documents. Recommendations: 6, 20, 21, 26, 38.

Long Term

3 Years

Review Management of Stress OFRS are working within the OCC policy Stress at Work, but they have no method of quantifying the size or scale of this issue. Once this is known a range of activities can be carried out which could include communicating results, risk assessments on individuals or groups and the development of performance measures monitored by OFRS Occupational Health providers to ensure adequate control measures are in place. Recommendations: 27, 28, 29, 30.

Long Term

3 Years

Short Term within 3-6 months Medium Term within 1 year Long Term within 3 years

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11. Acknowledgements Nigel Probert and the rest of the Audit Team would like to thank Oxfordshire Fire and Rescue Service, particularly the Health and Safety Department, Gary Coupar, Kate Hurdwell and Matt Frank for their hospitality and assistance during the conduct of this audit.

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APPENDIX 1 THE QSA AUDIT

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

The Management of Health and Safety at Work Regulations 1999, Regulation 5 states:

“Every employer shall make and give effect to such arrangements as are appropriate, having regard to the nature of his activities and the size of his undertaking, for the effective planning, organisation, control, monitoring and review of the preventative and protective measures.”

In practical terms, organisations should develop a Safety Management System which contains appropriate policies and procedures.

Another HSE Publication HS(G) 96 “Cost of accidents” identifies other implications of poor Health and Safety performance, examples include:

A construction site recorded a loss of over 8% of the original tender price of £8 million.

An NHS Hospital had losses amounting to 5% of annual running costs.

A transport Organisation was experiencing losses that amounted to 37% of their annual profits.

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

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

Policy Organisation Planning and Implementation Measuring Performance Audit and Performance Review

Each of the questions must be answered ‘yes’ or ‘no’ and marks have been allocated to reflect the importance of the matter under scrutiny. Further weighting factors are applied to each section according to its importance in the whole system to give a final overall Health and Safety Performance Rating. This enables single number comparisons to be made between sites, or from year to year.

QSA is a means by which the capability and performance of the management system for Health and Safety can be gauged and is not intended to give a comprehensive review of the adequacy of risk control measures. However, the effectiveness of implementation of selected control measures is examined as part of the exercise.

It should be noted that this audit could act as the initial and / or periodic safety management system status review suggested in BS 8800 ‘ A Guide to Occupational Health and Safety Management Systems’.