Five Star Occupational Health and Safety Audit Specification document 2013 www.britsafe.org Membership · Training · Audit and Consultancy · Policy and Opinion · Awards 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 © British Safety Council Five Star Audit Specification Document 2013 D 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 L e a d e r s hi p Policy and Organisation Evaluation and Review Best Practice Indicators Performance Measurement Co © British Safety Council n t in Implementation and Operation ual improveme Five Star Audit Specification Document 2013 Strategy and Planning nt 1 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 © British Safety Council Five Star Audit Specification Document 2013 2 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 % Star Rating 92 – 100: Excellent 86 – 91.9: Very Good 75 – 85.9: Good 60 – 74.9: Satisfactory 50 – 59.9: Basic The Five Star Audit process focuses on five sections and two Safety Management Indicators (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 Operation 1500 Points 4. Performance Measurement 1125 Points 5. Evaluation and Review 500 Points Total: 5000 Points SMI 1 Leadership SMI 2 Continual Improvement Additional 0.5% – 2% on overall 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. © British Safety Council Five Star Audit Specification Document 2013 3 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 Improvement 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 Monitor existing arrangements in this area to demonstrate continuous improvement Not applicable 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. © British Safety Council Five Star Audit Specification Document 2013 4 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” monitoring (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. © British Safety Council Five Star Audit Specification Document 2013 5 4. Specification Details Element Headings (Key: Core Element Within Section) Section 1 Section 2 Section 3 Section 4 Section 5 Policy and Organisation Strategy and Planning Implementation Performance Measurement Evaluation and Review (750 pts) (1125 pts) and Operation (1125 pts) (500 pts) 4.01 Occupational health and 5.01 Management review and (1500 pts) 1.01 Safety policy statement 2.01 Occupational health and safety objectives 1.02 SMS scope, nature and scale (control 3.01 Risk management and assessment 2.02 Occupational health and 3.02 SMS controls (general) safety plan (monitoring) 4.02 Occupational health safety plan and safety objectives arrangements) 1.03 Leadership and commitment 1.04 Roles and responsibilities (monitoring) 2.03 Benchmarking and initial 3.03 Work equipment 4.03 Active measurement 5.03 Continual improvement 3.04 Personal protective 4.04 Inspections and audits 5.04 Legislative compliance 4.05 Risk assessment review 5.05 Occupational health and review 2.04 Provision of resources equipment 1.05 Document management reporting 5.02 Provision of resources 2.05 Occupational health and 3.05 Manual handling and other requirements wellbeing safety programmes and planning 1.06 Consultation and communication 2.06 Consultation and communication 3.06 Workstation (DSE) 4.06 Legal and other ergonomics requirements compliance monitoring 1.07 Competence and capability 1.08 Occupational health and wellbeing 1.09 Change management 2.07 Leadership and 3.07 Housekeeping, storage commitment 4.07 Health surveillance and welfare facilities 2.08 Risk management and 3.08 Traffic management 4.08 Contractor and supplier control monitoring 2.09 Risk profiling 3.09 SMS controls (specific) 4.09 Documentation 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, management near miss reporting and investigation systems 2.12 Emergency incident 3.12 Working at height 4.12 Ill Health and 3.13 Lifting equipment 4.13 Loss/damage analysis planning absenteeism monitoring 2.13 Procurement and design (including contractor approval) 2.14 Competence and 3.14 Pressure systems capability 2.15 Sustainable health and 3.15 Hazardous substances safety attitudes and behaviour 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 M anagement of other potential emergency occurrences/Incidents © British Safety Council Five Star Audit Specification Document 2013 6 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 S1: Policy and Organisation (750 PTS) Example of Typical Information Required S2: Strategy and Planning (1125 PTS) Example of Typical Information Required S3: Implementation and Operation (1500 PTS) Example of Typical Information Required S4: Performance Measurement (1125 PTS) Example of Typical Information Required S5: Evaluation and Review (500 PTS) Example of Typical Information Required Policy Statement and Safety Management System (1.1)(1.2) 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 statement consistent with subsequent OH&S objectives and planning Policy statement readily available to, and understood by, all levels of management, staff and other interested parties. (verified through interview) Training and Induction records Evidence that management review influences policy review and setting. Leadership Indicator Continual Improvement Indicator Training and Induction schedules Framework Document (showing how SMS links to relevant areas) Training and Induction records Roles and responsibilities defined within SMS. Roles and responsibilities defined within SMS. Evidence of effective supervision and role competency. OH&S responsibilities / organisational structure. Targets / KPIs Training records, CPD, employee understanding and awareness. (verified through interview and site inspection) Policy readily available and provides the framework for OH&S objective setting and is consistent with corporate vision and values. Accident / incident statistics, ill health monitoring, etc Management / Corporate reports Evidence of policy statement reviewed. Evidence that review has considered suitability of SMS scope etc Authorised by top management. Safety Management System (SMS) is defined and scoped. Operational procedures and arrangements are clearly stipulated within SMS. Structure, Roles and Responsibilities, Leadership and Commitment (1.3)(1.4)(2.7) Leadership Indicator Continual Improvement Indicator Organisation chart Appointed top level management for OH&S. Policy statement endorsement Senior management commitment (interview) © British Safety Council Appraisal planning Role development Appraisal records Training records, accident / incident statistics, ill health monitoring, 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 Compare documented roles with actual quality of management involvement. Supervision and resources Five Star Audit Specification Document 2013 7 4. Specification Details cont. Subject Area S1: Policy and Organisation (750 PTS) Example of Typical Information Required S2: Strategy and Planning (1125 PTS) Example of Typical Information Required S3: Implementation and Operation (1500 PTS) Example of Typical Information Required S4: Performance Measurement (1125 PTS) Example of Typical Information Required S5: Evaluation and Review (500 PTS) Example of Typical Information Required Documentation Management (1.5) (4.9) Policy / Process for document control and management. Current versions available Current versions available in workplace Current versions available System refinements OH&S planning documents consistent with policy requirements Document policy requirements verified Internal / external audit findings Employee / stakeholder involvement in objective setting Effective communication of OH&S controls (inspection, sampling, interview) Continual Improvement Indicator Consultation and Communication (1.6)(2.6) Leadership Indicator Continual Improvement Indicator If quality management system is used, clear link / reference to OH&S system requirements Policy / Process for consulting and communicating with staff and others (including induction). Schedule for H&S meetings Terms of reference for H&S forums Evidence of document review Document audit report Evidence of H&S forums taking place (minutes) Evidence of meetings, effectiveness of training. Stakeholder Involvement in review process Closure of actions / non conformities, achievement of objectives. Corporate reporting Internal reporting Audit records Communication to others (contractors, visitors, etc) Site Induction records Competence and Capability (1.7)(2.14)(3.20) Leadership Indicator Continual Improvement Indicator Occupational Health and Wellbeing (1.8)(2.5)(4.7) Leadership Indicator Continual Improvement Indicator Policy / Process for ensuring competency requirements. Defined roles and responsibilities Organisational structure Policy / Process for OH and wellbeing (including first aid) Defined roles and responsibilities Training needs analysis. Training and induction records Plan / programme for ensuring competency Evidence of trainer competency CPD / Appraisal planning Training evaluation Mentoring / coaching plan OH Plan / schedule Lifestyle / wellbeing promotions Role competency records Accident / Incident analysis and investigation reports Audit findings Training needs review Appraisal review Review of statutory training requirements Risk assessment reviews Statutory compliance CPD maintenance Evidence of first aid provision (including equipment and personnel) (inspection) Health surveillance schedules Training records Training plan Health surveillance records Accident / Ill health / absenteeism statistics Risk assessment reviews OH Plan review Review and setting of OH&S objectives OH policy review Staff perception and awareness (interviews) First aid records Evidence of OH promotions Return to work interviews Support mechanisms Risk assessments Change Management (1.9)(2.10) Continual Improvement Indicator © British Safety Council Policy / Process for management of change Defined roles and responsibilities Examples of planning for change (organisational, structural, physical, etc) Risk assessments Audit findings Physical evidence (inspections) Project outcomes Design and project plans Consultation with staff and others Training records Five Star Audit Specification Document 2013 Inspection records Safety surveys Review of policy / process Forward planning Project review 8 4. Specification Details cont. Subject Area S1: Policy and Organisation (750 PTS) Example of Typical Information Required S2: Strategy and Planning (1125 PTS) Example of Typical Information Required S3: Implementation and Operation (1500 PTS) Example of Typical Information Required S4: Performance Measurement (1125 PTS) Example of Typical Information Required S5: Evaluation and Review (500 PTS) Example of Typical Information Required Occupational H&S Objectives (2.1)(4.2) Reference to OH&S Objectives Documented description of the objectives (SMART) Awareness of objectives throughout organisation (interview) Evidence of monitoring of objectives (eg audits, departmental and senior management meetings) Review of objective achievement Leadership Indicator Continual Improvement Indicator Occupational Health and Safety Planning (2.2)(2.3)(4.1)(5.5) Leadership Indicator Continual Improvement Indicator Provision of Resources (including goods, services, including contractors, etc) (2.4)(2.13)(5.2) Leadership Indicator Continual Improvement Indicator Policy / Process for objective setting Objectives set at organisational and functional levels Evidence of consultation and involvement of staff (and others) during setting of objectives 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 Evidence of consultation and involvement of staff (and others) Revised planning for objectives Management reports Sampling of objective progression Sampling of OH&S plan (inspection and interview) Audit findings Risk assessments Minutes from management and H&S meetings Maintenance records Accident analysis Statutory inspections etc Management reports Effective implementation of OH&S plan / arrangements / controls (inspection, sampling, interview) OH&S objective monitoring Evaluation of compliance records Management review of OH&S plan / objectives External accreditation Financial and project reviews Accident / ill health analysis Management reports Management reports PTW documentation Audit and inspection reports Site Induction / Training records Forward planning Minutes from project meetings Risk assessment(s) Evidence of Provision of equipment Documented review of plan Forward planning Non conformance monitoring Approved contractor / supplier register / index Risk Management (2.8)(2.9)(3.1)(4.5) Leadership Indicator Continual Improvement Indicator Commitment to a process of Risk Control within policy statement Procedures for risk profiling, identification, management, and control Policy / process for risk management / assessment 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 records Maintenance records Risk assessment / register review Records of management review Accident / incident / ill health / loss analysis External accreditation Management reports Development of risk register Audit and Inspection records Corporate reviews and reports Non conformance monitoring OH&S objective monitoring Statutory compliance records © British Safety Council Five Star Audit Specification Document 2013 9 4. Specification Details cont. Subject Area S1: Policy and Organisation (750 PTS) Example of Typical Information Required S2: Strategy and Planning (1125 PTS) Example of Typical Information Required S3: Implementation and Operation (1500 PTS) Example of Typical Information Required S4: Performance Measurement (1125 PTS) Example of Typical Information Required S5: Evaluation and Review (500 PTS) Example of Typical Information Required Legislative Compliance and Sector Best Practice (2.11)(4.6)(5.4) Commitment to legal (and other requirements) compliance Legislative register. Statutory records External accreditation Procedure for audit / evaluation of compliance Audit and Inspection records External accreditation (statutory and otherwise) Continual Improvement Indicator Policy statement Defined roles and responsibilities OH&S plan Initial SMS review Training records Risk assessment(s) Signage (inspection) Effective implementation of controls (inspection and interview) Management reports Audit and Inspection records Records of management review Evidence of legislative updates to SMS Non conformance monitoring OH&S objective monitoring Statutory compliance records Accident Investigations Emergency Incident Management (2.12)(3.22)(3.23)(3.24) Leadership Indicator Continual Improvement Indicator 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) 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 Provision of equipment (fire extinguishers, first aid, etc) Inspection and maintenance records Training records © British Safety Council Five Star Audit Specification Document 2013 10 4. Specification Details cont. Subject Area S1: Policy and Organisation (750 PTS) Example of Typical Information Required S2: Strategy and Planning (1125 PTS) Example of Typical Information Required S3: Implementation and Operation (1500 PTS) Example of Typical Information Required S4: Performance Measurement (1125 PTS) Example of Typical Information Required S5: Evaluation and Review (500 PTS) Example of Typical Information Required Health and Safety Culture and Behaviours (2.7)(2.15)(3.21) Commitment to develop and continually improve Training matrix / programme Evidence of stakeholder involvement, empowerment and management commitment (interviews and inspection) Staff surveys Stakeholder involvement in SMS reviews OH&S Objectives Minutes from H&S meetings External accreditation Specific programmes Training records Terms of reference for H&S (and other) forums Audit reports Leadership Indicator Continual Improvement Indicator Policy / Process for competency, consultation and communication Defined roles and responsibilities CPD development and appraisal Mentoring and Coaching OH&S Plan KPI monitoring Accident / Incident analysis and reports External accreditation Management reports Forward planning and objective setting OH&S plan monitoring Appraisal reviews Occupational health and wellbeing plans / programmes Safety Management System Controls (General) and Safe Working Procedures (1.2)(3.2)(3.3 – 3.8)(5.3) Continual Improvement Indicator 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 For all of the following that are relevant Work Equipment Incident report analysis. Records of review of SMS controls Staff surveys. Review of OH&S plan / objectives OH&S meeting minutes. Compliance audits Inspection records (statutory) Evidence of legislative updates within control system reviews OH&S Plan reviews Management reports Manual Handling Compliance audits Workstation Ergonomics DSE Welfare Housekeeping Traffic Management Storage Risk assessment(s) Welfare Training Plan Traffic Management Audit and Inspection schedules Training records Forward planning Control System audits Personal Protective Equipment Storage OH&S Plan © British Safety Council Observation of implementation of procedures and document checks. Signage, guarding, RAs, training, correct processes. Risk assessment sampling Five Star Audit Specification Document 2013 11 4. Specification Details cont. Subject Area S1: Policy and Organisation (750 PTS) Example of Typical Information Required S2: Strategy and Planning (1125 PTS) Example of Typical Information Required S3: Implementation and Operation (1500 PTS) Example of Typical Information Required S4: Performance Measurement (1125 PTS) Example of Typical Information Required S5: Evaluation and Review (500 PTS) Example of Typical Information Required Safety Management System Controls (Specific) and Safe Working Procedures (1.2)(3.9)(3.10-3.18) (5.3) Relevant Operational procedures and arrangements are clearly stipulated within SMS. Procedures for relevant controls (including contractor performed tasks). Observations of procedures and document checks (including contractor performed tasks). Incident report analysis. Records of review for SMS Controls Staff surveys. Review of OH&S plan / objectives Permit to Work Control System audits Inspection records (statutory) Continual Improvement Indicator Reference to risk control within policy statement 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 Safe Isolation Working at Height Lifting Equipment Pressure Systems OH&S minutes. OH&S Plan reviews Management reports Forward planning Compliance audits Evidence of legislative updates within control system reviews Compliance audits Hazardous Substances (includes Asbestos, radiation and DSEAR) Electrical safety Management of Noise Management of Vibration Training records Risk assessment sampling OH&S Plan Active and Reactive Monitoring (2.2)(2.3)(4.3 – 4.13) (5.1)(5.4)(5.5) Leadership Indicator Continual Improvement Indicator Policy / process for performance monitoring Commitment to continual improvement within policy statement Reference to corporate reporting Defined roles and responsibilities Staff awareness (interview) Accident / Incident analysis Records of management review Audit records OH&S plan reviews Auditing Inspection records Management reports OH&S objective review and forward planning Inspection Accident / Incident records Website / Corporate information and reporting OH&S Plan Procedures / process / plan for Accident Investigation Ill health monitoring Incident / loss / near miss reporting Contractor / supplier monitoring Training plan Risk assessment PTW documents Contractor Induction records Approved contractor / supplier index Risk assessment(s) External accreditation (planning and review) KPI / Objective monitoring Audit records External accreditation Statutory records Site inspection H&S meeting minutes Notice board information Statutory records © British Safety Council Five Star Audit Specification Document 2013 12 © British Safety Council Five Star Audit Specification Document 2013 13 British Safety Council 70 Chancellors Road London W6 9RS United Kingdom T +44 (0)20 8741 1231 E ask@britsafe.org www.britsafe.org/audit /britishsafetycouncil @britsafe /company/british-safety-council © British Safety Council Five Star Audit Specification Document 2013 Ref: MA131 14