UNIVERSITY PROCEDURE
Corrective and Preventive Action Procedure for
Safety Health and Environment
Document No
CU/11/CPA/Pr/1.01
Area Applicable
All Areas of Cardiff University
Approved by
Director of OSHEU
Review Year
2014
Document History
Author(s)
Mike Turner
Consultation process
 School & Directorate Safety Officers
 Safety Representatives
 Health, Safety & Environment Committee
Revision
Number
.01
Date
07/11/12
Oct 2011
Amendment
Review of structure for escalation,
amended CAR form. Removal of prescribed
timescales.
Name
Mike Turner
Approved by
Mike Salmon
Corrective and Preventive Action Procedure
1.
PURPOSE:
The purpose of this procedure is to ensure that any safety, health or environment
non-conformance is addressed as soon as possible. It defines who has responsibility
and authority for ensuring that any incidence of non-conformance is addressed and
that appropriate corrective and preventive action is taken in line with the
University’s safety, health and environmental management system.
2.
SCOPE:
The procedure explains how non-conformance should be addressed or, if it is not
addressed or the response is inadequate, how the escalation of responsibility
through senior management is effected to ensure that corrective and preventive
action is undertaken appropriately. The procedure applies to all areas of the
University’s activities involving safety, health and environment.
3.
DEFINITIONS:
*Observation
Evidence of non-conformance which is deemed
not to be a systemic failure of the
management system as evidenced by the
general level of conformance but which needs
to be addressed.
Noted but dealt with
verbally or through email
correspondence
/within action plan.
*Nonconformance
A significant deviation from work standards,
practices,
procedures,
regulations,
management system performance etc either in
number of occurrences or in seriousness.
Individual observations that are not addressed
within a given timescale.
A significant number of single observations can
lead to a formal non-conformance.
A situation that requires immediate corrective
action due to a situation which poses
imminent danger; a significant breach in
legislation; previously identified significant
non-conformance(s) that has not been
addressed
or
has
been
inadequately
addressed.
Requires form CAR01
to be issued to DSO /
School Manager (cc to
Head of School /
Directorate).
See Appendix 2 for
Corrective
Action
Request form CAR01.
Requires issuing form
CAR01
directly
to
relevant
Head
of
School / Directorate.
See Appendix 2 for
Corrective
Action
Request form CAR01.
The person who identifies the incidence of
non-conformance and initiates a CAR form.
At University level this is normally a
representative of the Safety, Health and
Environment Unit of HRSHE.
At College or Professional Service level this
would be a designated member of staff who
would be following the local corrective and
preventive action procedure
Action taken to eliminate the cause of an
identified non-conformance or other undesired
situation.
see Appendix 2 for
Corrective
Action
Request (CAR) Form
*Major
Nonconformance
Initiator
Corrective and
preventive
action
*N.B. See Appendix 1 for further guidance on the definitions of observation, nonconformance or major non-conformance.
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Document number CU/11/CPA/Pr/1.01
4.
RESPONSIBILITIES:
Departmental Safety Officer (DSO) / School Manager (or other person
specifically designated for this purpose): is responsible for the coordination of the
response to an identified non-conformance unless it is deemed a major nonconformance.
Pro Vice Chancellors (PVC) of Colleges and Chief Operating Officer (COO) of
Professional Services: are responsible for safety, health and environment within
the areas under their control. As such they have responsibility for ensuring that a
robust monitoring system is developed that effectively addresses safety, health and
environmental corrective and preventive actions and ensures that the Corrective
and Preventive Action procedure is complied with.
Heads of Schools and Professional Services: Heads have a general responsibility to
ensure compliance with all safety, health and environmental obligations and are
accountable to the Pro Vice-Chancellor Colleges (Schools) and Chief Operating
Officer (Professional Services) for the discharge of this duty . Within the terms of
this procedure they are responsible for ensuring that incidence of non-conformance
in their area are addressed as soon as possible and to an appropriate timescale
based on level of risk. Heads are personally responsible for the coordination of
response to any major non-conformance.
It is the responsibility of the Head to ensure that an effective, documented
internal procedure is in place for escalating incidence of non-conformance within
the College or Professional Service to ensure corrective action is taken. This system
must be, as a minimum, comparable to the one described in this procedure.
Director of OSHEU: is responsible for ensuring that senior managers are aware of
their responsibilities with regard to addressing non-conformance and for monitoring
progress against agreed action plans. The Director of OSHEU will ensure that any
non-conformance that is identified through OSHEU audits, inspections etc is
brought to the attention of Schools/Professional Services. The Director of OSHEU is
responsible for the initial escalation of incidents of non-conformance to the Head
of School/Professional Service when they have not been resolved between the
initiator and the relevant responsible person in the School/Professional Service. If
this first stage of escalation does not result in satisfactory resolution and the
appropriate remedial/corrective action being taken, then the Director of OSHEU
will bring to the attention of the Chief Operating Officer for Professional Services
or the relevant Pro Vice Chancellor College any major non-conformance or any
minor non-conformance that has not been addressed within appropriate
timescales.
N.B. If, in the opinion of the Director of OSHEU, there is potential for serious or
imminent danger the Director of OSHEU has the authority to stop the work until
satisfied that the situation has been addressed. Furthermore, in exceptional
circumstances the Director of OSHEU may contact the Vice Chancellor directly.
Deputy Vice Chancellor (DVC) who is Chair of Health, Safety, and Environment
Committee Where, in the judgment of the DVC, a major non-conformance has not
been appropriately or adequately addressed it is the responsibility of the DVC (who
is also the Chair of the University Health, Safety and Environment Committee) to
gain assurance from the relevant Pro Vice Chancellor College or Chief Operating
Officer that the non-conformance will be addressed within a prescribed timescale.
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Document number CU/11/CPA/Pr/1.01
Vice Chancellor (VC): Ultimate responsibility for safety, health and environment
rests with Council who has delegated authority for compliance to the Vice
Chancellor and where a major non-conformance has not been addressed, following
the escalation process described in this procedure, the VC will make direct contact
with the College Pro Vice Chancellor or Chief Operating Officer to ensure that
appropriate action is taken.
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Document number CU/11/CPA/Pr/1.01
5.
PROCEDURE
Observation identified
NO
Resolved
YES
Follow up via
‘update request’.
Confirmation of
action during next
audit visit
Non-conformance identified
Major non-conformance identified
[Initiator of Corrective Action Request form CAR01
see example of form in Appendix 2]
Initiator records details and completes section A of
CAR01. Submits to:
 Departmental Safety Officer (H&S) [cc Head ]
 School Manager (environment) [cc Head ]
or
 to the Head in the case of a major nonconformance.
A timescale, based on severity, is given for response.
Straight to Escalation
Procedure
[DSO / School Manager]
Form returned to the initiator within set timescale
detailing the corrective action proposed and suggested
timescale for completion (Section B of CAR01).
[Initiator of the CAR]
Person initiating the CAR is responsible for evaluating
the proposed actions (Section C of CAR01) and a copy is
returned to the School / Directorate. The CAR remains
OPEN until an effectiveness review has been
undertaken.
OSHEU review the
status of the CAR and
report to senior
management
NO
Agreed
YES
Copy
retained by
CAR initiator
and School /
Directorate
[DSO / School Manager/ Initiator of the CAR]
The corrective action is carried out by the School /
Directorate and effectiveness is reviewed
independently by the person initiating the CAR within
the timescale agreed. When the actions are completed
and there is evidence that they are effective, the CAR
is CLOSED by the initiator and a copy sent to the School
/ Directorate.
[Initiator of the CAR]
Copy of the CAR form
returned to the School
/ Directorate
highlighting concerns.
Consultation on
addressing the concerns
If unresolved within the
prescribed timescale;
progress to the Escalation
Procedure
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Document number CU/11/CPA/Pr/1.01
ESCALATION PROCEDURE FOR MAJOR NON-CONFORMANCE OR
FAILURE TO RESOLVE THROUGH NORMAL CORRECTIVE ACTION
PROCEDURE
Copy to relevant
PVC and COO
Director of OSHEU notifies Head of
School / Professional Service of a
major non conformance or that the
corrective procedure has not been
adhered to and seeks an agreed
resolution of the CAR. Timescale for
response to be agreed in-line with
the urgency of the corrective action
YES
Response
acceptable
NO
Copy to DVC and
COO
Director of OSHEU escalates to
relevant PVC College or COO who
contacts the Head to agree resolution
of CAR.
Timescale for response to be agreed
in-line with the urgency of the
corrective action
YES
Response
acceptable
NO
Copy to VC, Chair of
Council and Director
of OSHEU
PVC College / COO escalates to DVC
who contacts relevant to agree
resolution of CAR. In exceptional
circumstances this may be escalated
by the Director of OSHEU.
Timescale for response to be agreed
in-line with the urgency of the
corrective action
YES
Response
acceptable
NO
DVC escalates to the Vice Chancellor
who writes to relevant Head to agree
resolution of CAR.
Timescale for response to be agreed
in-line with the urgency of the
corrective action
Action agreed to close
out CAR
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Document number CU/11/CPA/Pr/1.01
Appendix 1: Guidance on the definitions of Observation, Non-conformance, Major Nonconformance.
Examples of what might constitute an observation, a non-conformance or a major nonconformance are given in the table below. However each case will be assessed on the
basis of level of risk and significance of the breach and therefore these examples are given
as a guide only. It will be for the initiator to assess the actual classification based on their
professional judgement.
The examples used are:
Risk assessment – undertaking risk assessment is a fundamental legal requirement and a
core element of the University’s SHE management system. Absence of it may constitute a
significant breach of the law.
Inspections of the workplace – checking that controls are in-place and working is a legal
requirement and another core part of the SHE management system.
Portable Electric appliance testing (PAT) – PAT testing is a legal requirement and is a
control measure for a hazard with the potential for significant harm i.e. electricity.
Observation:
Example:
a) Risk assessments -evidence that a small number of risk
assessments are not present or not complete but that the
majority are and that they appear suitable and sufficient
b) Workplace inspections- evidence that a small number of areas
have not been inspected in accordance with University Policy but
that the majority have been and inspections are effective.
c) C) Portable appliance testing- One or two items missed during the
cycle of testing but in general testing is in date.
Nonconformance:
Example:
a) Risk assessment- significant number of risk assessments not inplace or deemed not to be suitable and sufficient
b) Workplace inspections- significant number of areas not inspected
in accordance with University policy and guidance
c) Portable appliance testing - significant number of appliances not
tested or outside their re-test date.
Example:
a) Major breach of the law
b) Situations that pose imminent danger
Major
Non-conformance
Little or no evidence of the management of:
c) Risk assessment – i.e. no or very few suitable and sufficient risk
assessments evident
d) Workplace inspections – i.e. no programme for workplace
inspections in -place
e) Portable appliance testing – i.e. no evidence of testing and
inspection of portable electrical appliances or a system for
managing this process.
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Document number CU/11/CPA/Pr/1.01
Appendix 2: CORRECTIVE ACTION REQUEST FORM (CAR01)
Section A
Date
To be completed by Person initiating the CAR
School / Directorate
Division
Person initiating
CAR
CAR Number
School / Directorate
Representative
Detail of Non-conformance, related objective evidence.
Category (delete where appropriate): Non-conformance /
Major non-conformance
Required Reply Date
Please email reply to the person initiating CAR before the above date
Section B
To be completed by School / Directorate Representative
Detail any immediate Containment Actions taken
Detail the Root Causes of the Non-conformance (system failure)
Proposed Corrective Action (to stop recurrence)
Proposed Implementation
date:
Section C
To be completed by Person initiating the CAR
Evaluation of the corrective action
Date:
Approved by
Section D
To be completed by Person initiating the CAR
Verification and Validation Comments
Reviewed date:
Status: OPEN / CLOSED
Approved by
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Document number CU/11/CPA/Pr/1.01