Five Star Occupational Health and Safety Audit Specification document 2013

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1 Five Star Occupational Health and Safety Audit Specification document Membership Training Audit and Consultancy Policy and Opinion Awards

2 Contents 1 Introduction to the Five Star Audit Model 2 1: Five Star Audit Process 3 1.1: Scoring and Grading System 4 1.2: Audit Report and Action Planning 5 2: Preparing for the Audit 5 3: Standardisation and Quality Assurance 6 4: Specification Details D

3 Introduction to the Five Star Audit Model This document is intended to provide a summary of the British Safety Council Five Star Audit process, together with details of the aforementioned audit specification. The Five Star Audit process involves an in-depth examination of an organisation s entire health and safety management system(s) and associated arrangements, focusing on the key aspects of their approach to managing occupational health and safety in the workplace and offers a structured path for continuous improvement towards best practice. Utilising extensive worldwide industry experience and acknowledging aspects of internationally recognised occupational health and safety management system frameworks, the British Safety Council has developed a unique Five Star Audit model that objectively evaluates health and safety system(s) and arrangements against current best practice techniques. Five Star Audit: 2013 specification Policy and Organisation Evaluation and Review Best Practice s Strategy and Planning Performance Measurement Implementation and Operation improvement 1

4 1. Five Star Audit Process The Five Star Audit is conducted using the following process of objective evidence gathering: The auditor will review key areas of your organisation s health and safety documentation and systems in relation to the requirements of the British Safety Council s Five Star Audit and will include an inspection of the site(s) and associated buildings. This inspection process is used to determine the effectiveness of the implementation of the organisation s health and safety arrangements. During the audit process, management and staff will be interviewed (as agreed) to confidentially discuss aspects of occupational health and safety relevant to their roles and responsibilities. The audit process is intended to ensure all appropriate aspects of occupational health and safety have been considered within an organisation s safety management system(s) and how effectively such arrangements are being implemented. A subsequent report is prepared to identify the strengths and areas for improvement within the organisation s health and safety management systems and also to provide observations and recommendations, together with action planning, for consideration. Five Star Audit: 2013 specification B A C A Review of safety management documentation B Interview with managers and staff C Site tour and inspection 2

5 1.1. Scoring and grading system The Five Star Audit is audit conducted using the British Safety Council s numerical safety grading system. The overall audit grading is as follows: Marks % : Excellent Star Rating : Very Good : Good : Satisfactory : Basic The Five Star Audit process focuses on five sections and two Safety Management s (SMI) as shown below: Section Audit criteria Maximum accredited audit figure 1. Policy and Organisation 750 Points 2. Strategy and Planning 1125 Points 3. Implementation and 1500 Points Operation 4. Performance Measurement 1125 Points 5. Evaluation and Review 500 Points Total: 5000 Points SMI 1 Additional 0.5% 2% on overall SMI 2 grading outcome The five sections of the audit are divided into sixty six (66) elements which attract a maximum numerical value of 5000 points. Several of these elements are considered as core to the relevant section, and some of these core elements are also applicable within more than one section. Wherever an element of the audit is not applicable to the organisation, it is withdrawn from the audit. The Maximum Accredited Audit Figure (MAAF) is the maximum total score available when nonapplicable questions have been removed and the Actual Accredited Audit Figure (AAAF) is the score achieved against such applicable questions. Throughout the audit, two safety management indicators (sub-sections of leadership and continual improvement) are evaluated either as elements within their own right, in certain sections, or alternatively as scoring areas within other elements. The cumulative scoring for these two sub-sections are then converted into a percentage figure which can provide an additional 0.5% - 2% to the overall audit grading. This aspect of the audit process is designed to encourage organisations to focus upon continually developing their safety management systems and culture through demonstration of commitment and robust leadership at all levels. 3

6 1.2. Audit report and action planning Upon completion of the audit process, a detailed report is prepared by the auditor and will be issued within 28 days. The report content will include: Executive Summary (including graphical performance indicators) Overall Star Grading and Sectional Scoring Observations Recommendations for Action Planning Tables The recommendations against the criteria requirements of the Five Star Audit are presented in tabulated colour coded format as per the key below: Grading system table 1: the five audit sections Colour Code Priority Definition High: Differential over 40% in this area Recommendations to be implemented as a priority 1 action Medium: Differential of 1 40% in this area Recommendations to be implemented as a priority 2 action Low: Full marks awarded Not applicable Monitor existing arrangements in this area to demonstrate continuous improvement The requirements of this section are not applicable The red coded differential indicates where significant marks (over 40%) have been lost in respect of the five star audit scoring criteria and the amber coded differential indicates where marks have been lost (1-40%). Wherever this is identified by the auditor, a recommendation will be provided that, if followed and implemented, would assist the organisation in working toward best practice standards. The green coded area indicates wherever full marks have been awarded in respect of the five star audit scoring criteria. The organisation must monitor these elements in order to maintain best practice and demonstrate continuous improvement. The action planning tables are also designed to allow the organisation to plan for implementation of the recommendations by populating the relevant columns as appropriate. If any elements of the audit are not applicable to the audited organisation then this will be left blank within the relevant table and indicated as N/A. As with any time-bound audit, observations and recommendations made are based upon the scope and depth of information reviewed during the process. 4

7 2. Preparing for the audit In order for the audit process to be as effective as possible, it is considered important that pre audit preparations are agreed and completed as required. Once all logistical arrangements have been confirmed with the relevant British Safety Council account manager, the allocated auditor will make contact (no later than 10 days before the audit start date) with the appropriate person within the organisation to discuss and agree the audit details (timings, interviews, site inspections, induction process, security / PPE arrangements, etc). This specification document will outline the various forms of information and documentation that the auditor is likely to request for review, together with personnel who may be requested for interview. It would be advantageous if documentation is readily available (either electronically or hard-copy format) and that some of this material may be retained by the auditor during the audit process. All British Safety Council auditors are mindful of operational demands and requirements and will apply as much flexibility with the audit schedule as is reasonably practicable to accommodate such matters. 3. Standardisation and quality assurance British Safety Council auditors are appropriately qualified, highly experienced health and safety professionals who are subject to a robust internal quality assurance and appraisal process, in addition to the requirements of relevant professional bodies with whom they are members. All audit reports are technically verified and quality-endorsed before being issued to clients and auditors are also subject to on-site (subject to client agreement) on a sampling basis. Annual standardisation meetings are held, at which auditor attendance is mandatory. This specification document is reviewed at least annually to reflect changes in legislation and relevant developments / trends in occupational health and safety management best practice technique. 5

8 4. Specification Details Element Headings (Key: Core Element Within Section) Section 1 Policy and Organisation (750 pts) Section 2 Strategy and Planning (1125 pts) Section 3 Implementation and Operation (1500 pts) Section 4 Performance Measurement (1125 pts) Section 5 Evaluation and Review (500 pts) 1.01 Safety policy statement 2.01 Occupational health and safety objectives 3.01 Risk management and assessment 4.01 Occupational health and safety plan () 5.01 Management review and reporting 1.02 SMS scope, nature and scale (control arrangements) 2.02 Occupational health and safety plan 3.02 SMS controls (general) 4.02 Occupational health and safety objectives () 5.02 Provision of resources 1.03 and commitment 2.03 Benchmarking and initial review 3.03 Work equipment 4.03 Active measurement 5.03 improvement 1.04 Roles and responsibilities 2.04 Provision of resources 3.04 Personal protective equipment 4.04 Inspections and audits 5.04 Legislative compliance and other requirements 1.05 Document management 2.05 Occupational health and wellbeing 3.05 Manual handling 4.05 Risk assessment review 5.05 Occupational health and safety programmes and planning 1.06 Consultation and communication 2.06 Consultation and communication 3.06 Workstation (DSE) ergonomics 4.06 Legal and other requirements compliance 1.07 Competence and capability 2.07 and commitment 3.07 Housekeeping, storage and welfare facilities 4.07 Health surveillance 1.08 Occupational health and wellbeing 2.08 Risk management and control 3.08 Traffic management 4.08 Contractor and supplier 1.09 Change management 2.09 Risk profiling 3.09 SMS controls (specific) 4.09 Documentation management 2.10 Change management 3.10 Permit to work systems 4.10 Reactive measurement 2.11 Legislative compliance 3.11 Safe isolation 4.11 Accident, incident, near miss reporting and investigation systems 2.12 Emergency incident planning 2.13 Procurement and design (including contractor approval) 2.14 Competence and capability 2.15 Sustainable health and safety attitudes and behaviour 3.12 Working at height 4.12 Ill Health and absenteeism 3.13 Lifting equipment 4.13 Loss/damage analysis 3.14 Pressure systems 3.15 Hazardous substances 3.16 Electrical safety 3.17 Management of noise 3.18 Management of vibration 3.19 Safe working/operating procedures 3.20 Competence and capability 3.21 Sustaining occupational health and safety attitudes and behaviours 3.22 Emergency incident management 3.23 Fire safety management 3.24 Management of other potential emergency occurrences/incidents 6

9 4. Specification Details cont. Five Star Audit 2013: Specification Details (Please note: This table contains typical information likely to be reviewed during the audit process but is not a definitive index) Subject Area Policy Statement and Safety Management System (1.1)(1.2) S1: Policy and Organisation (750 PTS) Commitment to: legislative compliance, continual improvement, periodic review, prevention of injury and ill health, provision of adequate resources, management of risk, consultation with staff and others. Policy readily available and provides the framework for OH&S objective setting and is consistent with corporate vision and values. Authorised by top management. Safety Management System (SMS) is defined and scoped. Operational procedures and arrangements are clearly stipulated within SMS. S2: Strategy and Planning Policy statement consistent with subsequent OH&S objectives and planning Training and Induction schedules Framework Document (showing how SMS links to relevant areas) S3: Implementation and Operation (1500 PTS) Policy statement readily available to, and understood by, all levels of management, staff and other interested parties. (verified through interview) Training and Induction S4: Performance Measurement Training and Induction Accident / incident statistics, ill health, etc Management / Corporate reports S5: Evaluation and Review (500 PTS) Evidence that management review influences policy review and setting. Evidence of policy statement reviewed. Evidence that review has considered suitability of SMS scope etc Structure, Roles and Responsibilities, and Commitment (1.3)(1.4)(2.7) Roles and responsibilities defined within SMS. OH&S responsibilities / organisational structure. Organisation chart Appointed top level management for OH&S. Policy statement endorsement Senior management commitment (interview) Roles and responsibilities defined within SMS. Targets / KPIs Appraisal planning Role development Evidence of effective supervision and role competency. Training, CPD, employee understanding and awareness. (verified through interview and site inspection) Appraisal Compare documented roles with actual quality of management involvement. Supervision and resources Training, accident / incident statistics, ill health, etc Statistics of management involvement (meetings attended, investigations, tours, risk assessment, etc) Regular CPD / appraisal reviews Development plans Plans to improve management involvement Plans for changing roles and responsibility 7

10 4. Specification Details cont. Subject Area S1: Policy and Organisation (750 PTS) S2: Strategy and Planning S3: Implementation and Operation (1500 PTS) S4: Performance Measurement S5: Evaluation and Review (500 PTS) Documentation Management (1.5) (4.9) Policy / Process for document control and management. If quality management system is used, clear link / reference to OH&S system requirements Current versions available OH&S planning documents consistent with policy requirements Current versions available in workplace Document policy requirements verified Current versions available Internal / external audit findings Document audit report System refinements Evidence of document review Consultation and Communication (1.6)(2.6) Policy / Process for consulting and communicating with staff and others (including induction). Employee / stakeholder involvement in objective setting Schedule for H&S meetings Terms of reference for H&S forums Effective communication of OH&S controls (inspection, sampling, interview) Evidence of H&S forums taking place (minutes) Communication to others (contractors, visitors, etc) Evidence of meetings, effectiveness of training. Closure of actions / non conformities, achievement of objectives. Audit Stakeholder Involvement in review process Corporate reporting Internal reporting Site Induction Competence and Capability (1.7)(2.14)(3.20) Policy / Process for ensuring competency requirements. Defined roles and responsibilities Organisational structure Training needs analysis. Plan / programme for ensuring competency CPD / Appraisal planning Mentoring / coaching plan Training and induction Evidence of trainer competency Training evaluation Role competency Accident / Incident analysis and investigation reports Audit findings Risk assessment reviews Statutory compliance CPD maintenance Training needs review Appraisal review Review of statutory training requirements Occupational Health and Wellbeing (1.8)(2.5)(4.7) Policy / Process for OH and wellbeing (including first aid) Defined roles and responsibilities OH Plan / schedule Lifestyle / wellbeing promotions Health surveillance schedules Training plan Evidence of first aid provision (including equipment and personnel) (inspection) Training Health surveillance Evidence of OH promotions Accident / Ill health / absenteeism statistics Risk assessment reviews Staff perception and awareness (interviews) First aid OH Plan review Review and setting of OH&S objectives OH policy review Return to work interviews Support mechanisms Risk assessments Change Management (1.9)(2.10) Policy / Process for management of change Defined roles and responsibilities Examples of planning for change (organisational, structural, physical, etc) Design and project plans Risk assessments Physical evidence (inspections) Training Consultation with staff and others Audit findings Project outcomes Inspection Safety surveys Review of policy / process Forward planning Project review 8

11 4. Specification Details cont. Subject Area S1: Policy and Organisation (750 PTS) S2: Strategy and Planning S3: Implementation and Operation (1500 PTS) S4: Performance Measurement S5: Evaluation and Review (500 PTS) Occupational H&S Objectives (2.1)(4.2) Reference to OH&S Objectives Policy / Process for objective setting Documented description of the objectives (SMART) Objectives set at organisational and functional levels Evidence of consultation and involvement of staff (and others) during setting of objectives Awareness of objectives throughout organisation (interview) Evidence of consultation and involvement of staff (and others) Sampling of objective progression Evidence of of objectives (eg audits, departmental and senior management meetings) Review of objective achievement Revised planning for objectives Occupational Health and Safety Planning (2.2)(2.3)(4.1)(5.5) Provision of Resources (including goods, services, including contractors, etc) (2.4)(2.13)(5.2) Reference to OH&S Plan within policy statement Policy / process for planning and review Commitment within policy statement Reference within arrangements Defined roles and responsibilities Policy / process for procurement of goods / services / budget setting Policy / process for approval and management of contractors Documented OH&S plan Link to other operational plans (training, engineering, financial) Audit / Review planning OH&S Plan Evidence of OH&S considerations within budget planning (eg capital expenditure allocation) Documented OH&S budget Project planning Evidence of OH&S factors within project design Sampling of OH&S plan (inspection and interview) Risk assessments Maintenance Statutory inspections etc Effective implementation of OH&S plan / arrangements / controls (inspection, sampling, interview) Risk assessment(s) PTW documentation Evidence of Provision of equipment Site Induction / Training Audit findings Minutes from management and H&S meetings Accident analysis OH&S objective Minutes from project meetings Accident / ill health analysis Audit and inspection reports Non conformance Documented review of plan Forward planning Evaluation of compliance Management review of OH&S plan / objectives External accreditation Financial and project reviews Forward planning Approved contractor / supplier register / index Risk Management (2.8)(2.9)(3.1)(4.5) Commitment to a process of Risk Control within policy statement Policy / process for risk management / assessment and control Procedures for risk profiling, identification, management, and control Risk / Hazard matrix / index / register OH&S Plan Risk assessment (sampling) and evidence of association of these with SOPs and incident reports Effective implementation of controls (inspection and interview) Training Risk assessment / register review Accident / incident / ill health / loss analysis Audit and Inspection Non conformance Records of management review External accreditation Development of risk register Corporate reviews and reports Maintenance OH&S objective Statutory compliance 9

12 4. Specification Details cont. Subject Area S1: Policy and Organisation (750 PTS) S2: Strategy and Planning S3: Implementation and Operation (1500 PTS) S4: Performance Measurement S5: Evaluation and Review (500 PTS) Legislative Compliance and Sector Best Practice (2.11)(4.6)(5.4) Commitment to legal (and other requirements) compliance Policy statement Defined roles and responsibilities Legislative register. Procedure for audit / evaluation of compliance OH&S plan Initial SMS review Statutory Audit and Inspection Training Risk assessment(s) Signage (inspection) Effective implementation of controls (inspection and interview) External accreditation (statutory and otherwise) Audit and Inspection Non conformance OH&S objective Statutory compliance External accreditation Records of management review Evidence of legislative updates to SMS Accident Investigations Emergency Incident Management (2.12)(3.22)(3.23)(3.24) Commitment to manage emergency events, staff welfare, etc Emergency management policy / process Defined roles and responsibilities Disaster Recovery / Emergency Planning. Emergency Procedures. Risk assessments (fire, first aid, security, etc) Training / competency matrix OH&S Plan OH&S Objectives Evidence of emergency procedure testing (fire drills, environmental incidents, recovery tests, etc) Staff awareness (interviews) Signage (escape routes etc) Provision of equipment (fire extinguishers, first aid, etc) Review of evacuation tests Loss / Damage analysis Audit and Inspection reports Records of management review of SMS Improved emergency planning and arrangements Evidence of legislative updates to SMS Inspection and maintenance Training 10

13 4. Specification Details cont. Subject Area S1: Policy and Organisation (750 PTS) S2: Strategy and Planning S3: Implementation and Operation (1500 PTS) S4: Performance Measurement S5: Evaluation and Review (500 PTS) Health and Safety Culture and Behaviours (2.7)(2.15)(3.21) Commitment to develop and continually improve Policy / Process for competency, consultation and communication Defined roles and responsibilities Training matrix / programme CPD development and appraisal Mentoring and Coaching OH&S Plan OH&S Objectives Evidence of stakeholder involvement, empowerment and management commitment (interviews and inspection) Minutes from H&S meetings Staff surveys KPI Accident / Incident analysis and reports OH&S plan External accreditation Stakeholder involvement in SMS reviews External accreditation Forward planning and objective setting Appraisal reviews Specific programmes Training Terms of reference for H&S (and other) forums Audit reports Occupational health and wellbeing plans / programmes Safety Management System Controls (General) and Safe Working Procedures (1.2)(3.2)( )(5.3) Relevant Operational procedures and arrangements are clearly stipulated within SMS. Reference to risk control within policy statement Procedures for relevant controls (including contractor performed operations) For all of the following that are relevant; Work Equipment Personal Protective Equipment Manual Handling Workstation Ergonomics DSE Housekeeping Storage Observation of implementation of procedures and document checks. Signage, guarding, RAs, training, correct processes. For all of the following that are relevant Work Equipment Personal Protective Equipment Manual Handling Workstation Ergonomics DSE Incident report analysis. Staff surveys. OH&S meeting minutes. Control System audits Inspection (statutory) OH&S Plan reviews Compliance audits Records of review of SMS controls Review of OH&S plan / objectives Forward planning Compliance audits Evidence of legislative updates within control system reviews Welfare Housekeeping Traffic Management Storage Risk assessment(s) Welfare Training Plan Traffic Management Audit and Inspection schedules OH&S Plan Training Risk assessment sampling 11

14 4. Specification Details cont. Subject Area S1: Policy and Organisation (750 PTS) S2: Strategy and Planning S3: Implementation and Operation (1500 PTS) S4: Performance Measurement S5: Evaluation and Review (500 PTS) Safety Management System Controls (Specific) and Safe Working Procedures (1.2)(3.9)( ) (5.3) Relevant Operational procedures and arrangements are clearly stipulated within SMS. Reference to risk control within policy statement Procedures for relevant controls (including contractor performed tasks). Permit to Work Safe Isolation Working at Height Lifting Equipment Pressure Systems Hazardous Substances (includes Asbestos, radiation and DSEAR) Electrical safety Management of Noise Management of Vibration Risk assessment(s) Training Plan Audit and Inspection schedules Observations of procedures and document checks (including contractor performed tasks). Permit to Work Safe Isolation Working at Height Lifting Equipment Pressure Systems Hazardous Substances (includes Asbestos, radiation and DSEAR) Electrical safety Management of Noise Management of Vibration Training Risk assessment sampling Incident report analysis. Staff surveys. OH&S minutes. Control System audits Inspection (statutory) OH&S Plan reviews Compliance audits Records of review for SMS Controls Review of OH&S plan / objectives Forward planning Compliance audits Evidence of legislative updates within control system reviews OH&S Plan Active and Reactive Monitoring (2.2)(2.3)( ) (5.1)(5.4)(5.5) Policy / process for performance Commitment to continual improvement within policy statement Reference to corporate reporting Defined roles and responsibilities OH&S Plan Procedures / process / plan for Auditing Inspection Accident Investigation Ill health Incident / loss / near miss reporting Contractor / supplier Training plan Risk assessment Staff awareness (interview) Audit Inspection Accident / Incident PTW documents Contractor Induction Approved contractor / supplier index Risk assessment(s) Site inspection H&S meeting minutes Accident / Incident analysis OH&S plan reviews Website / Corporate information and reporting KPI / Objective Audit External accreditation Statutory Records of management review OH&S objective review and forward planning External accreditation (planning and review) Notice board information Statutory 12

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16 British Safety Council 70 Chancellors Road London W6 9RS United Kingdom T +44 (0) E /company/british-safety-council Ref: MA131 14

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