Any member wishing to raise an issue is asked to notify the Committee Secretary by 8th September
Author – TK Osborne
Date – 16 August 2017
HSSC17-M2
1
Minutes
HSSC17-M2 Minutes of the meeting held on 18 May 2017
Attendance
Present: Andrew Burgess (Chair), Neil Budworth, Chris Riley, Paul Walker, Steve Warren, Nik Hunt
In attendance: Tanya Osborne (Secretary)
Apologies received from: James Stapleton, David Howell
Business of the Agenda
No items were unstarred.
17/12 Minutes
The Committee RECEIVED the minutes of the previous meeting
HSSC17-M1
12.1 The minutes of the meeting held on 11 January 2017 were CONFIRMED.
SECTION A – Items for Discussion
17/13 Construction Small Works Policy
The Committee RECEIVED a revised Construction Small Works Policy and RESOLVED to endorse it to Health, Safety and Environment Committee.
HSSC17-P9 – Construction Small Works Policy
13.1 The policy had been previously seen by the Committee (minute 17/3.1 refers). The Committee
discussed the revisions, and supported the policy being endorsed to the Health, Safety and
Environment Committee subject to a number of minor revisions:
i) Making clearer the reasoning behind the value amounts and changing this for a ceiling price
that would specify the costs of all works undertaken within the project, to avoid people taking
on excessive administrative burden to keep small projects under the cost threshold;
ii) Making clearer that university procurement rules were also applicable to projects;
iii) A number of minor typographical errors.
Health, Safety and Environment Statutory Compliance Sub-
Committee
HSSC17-M2
2
13.2 The Committee discussed in brief the current practice of re-charging departments for
Construction Small Works valued at under £10,000, and noted that the University is currently in
the process of removing the 10% fee for these works in order to make the service more cost-
effective. Schools and Services would still be able to hire insured contractors to undertake
works, particularly in cases where capacity to undertake the work centrally was not available.
13.3 The Committee agreed to ENDORSE the policy to Health, Safety and Environment Committee
subject to the above changes.
Action: James Stapleton to make amendments to the policy before submitting it to Health,
Safety and Environment Committee.
17/14 Update on Lifting Operations and Lifting Equipment Regulations (LOLER) Policy
The Committee discussed a pre-consultation draft of the LOLER policy
HSSC17-P10 – LOLER paper
14.1 The Committee were presented with an early draft of the forthcoming LOLER Policy, for
comment prior to starting the consultation process.
14.2 The Committee noted that the current LOLER Policy was in a different style to the other policies
that had been seen by the Committee. The benefits and disadvantages of the presentation were
discussed. It was emphasised by the Committee that all forthcoming policies should take a user-
focused approach and should follow the format of having a brief overview and then the detail in
appendices so that users can find the most relevant information to them quickly and effectively.
14.3 The Committee noted that the draft document named the COO as the duty holder. It was felt
that this should be noted as the VC.
14.4 The Committee also noted that the draft did not specify a DAP, and felt it was important that
there was a single DAP nominated for the area for consistency.
17/15 Pressure Systems Audit
15.1 The report from the Pressure Systems Audit was not available to the Committee. The Chair
gave an oral update about the ongoing changes in this area.
15.2 It was reported that a full report will be available by Summer and that this would be circulated to
the Committee before the next academic session.
15.3 As a result of the audit, the University are moving the asset list so that it can be managed in-
house, in order to ensure that the data is robust and appropriate.
17/16 Update on Appointments of DAPs
16.1 The Committee heard that, due to restructuring in Facilities Management, a number of Duty
Authorised Persons had been lost. Progress to identify new DAPs was underway. Other new
areas have emerged that would also require DAPs to be appointed.
HSSC17-M2
3
17/17 Schedule for Compliance Questionnaires
HSSC17-P13
HSSC17-P13a
17.1 The Committee heard the plan for the forward schedule of compliance questionnaires, noting
that the next questionnaire scheduled was the F Gas questionnaire in July. Schedules were set
up until March 2018, but would remain flexible enough to change in the event of external
impetus.
17.2 The Committee felt that the format was improved and helpful.
17.3 The Committee discussed the meaning of the percentages given against compliance areas and
heard that these percentages do not indicate the extent to which there is compliance but are a
measure of the risk assessment in areas of compliance. It was noted that the outcomes of audit
were often subject to circumstance, but that the percentages measures give a degree of
assurance as to the outcome of a potential audit.
17.4 It was confirmed that people only received questionnaires where it was known to be relevant to
their school or service. The Committee were pleased to hear that in some cases the
questionnaires were acting as a prompt for individuals to make changes in order to be
compliant.
17.5 Some discussion was had regarding whether it would be desirable for schools to be able to view
and edit the data held in the maturity matrix. It was agreed that it would be beneficial for schools
to be able to view the data in their Health, Safety and Environment meetings, but that for
assurance purposes editing should only be done by FM staff.
17/18 Burleigh Court Water System Investigation
HSSC17-P14
18.1 The Committee heard an account of the recent incident involving a water systems investigation
at Burleigh Court which was instigated by the Borough Council. The Committee extended their
thanks to those who were involved in the investigation, noting that it was a good test of the
skills, expertise, and hard work involved in improving the management of water safety
compliance at the University.
18.2 The process highlighted areas of potential risk, in particular where certain niche equipment fell
under several different regulations, and where there was potential to be behind on legislative
updates.
17/19 University Safety and Health Association (USHA) Statutory Compliance Document
HSSC17-P15
19.1 The Committee noted the draft document. It was felt useful to have a sense of the variety of
legislation and regulation that was in place, but the Committee felt that the current format
inhibited the use of the document. It was also noted that the purpose of the document was
unclear in its current presentation.
HSSC17-M2
4
17/20 Responsibility for Statutory Maintenance
HSSC17-P16
20.1 The Committee received a draft of a handover document outlining responsibilities for building
maintenance, designed to be generic to any potential new building. The intention of the
document was to make clear to all involved parties who would be responsible for which areas of
maintenance and make clear the requirements in that area.
20.2 The Committee supported the principles behind the document. It was felt that the introductory
text in the document could be clarified slightly so that its purpose is more easily understood.
17/21 Forward Planning for the work of the Committee
21.1 The Committee agreed that it would be helpful to develop an order of business for the upcoming
work of the Committee.
17/22 Audit on Health and Safety Compliance Governance
22.1 The Committee noted that the report from the recent audit on Health and Safety Compliance
Governance was not yet published. The Chair reported that the outcome of the audit was mostly
positive, and that a small number of actions coming out of the report will be the responsibility of
the Committee.
17/23 Compliance with the Dangerous Substances (Explosive Atmospheres) Regulations
23.1 The Committee noted that while a report was available, it wasn’t yet in a state where it could be
shared with the Committee.
23.2 The report is expected to highlight issues with two areas. The first is the quantity of flammable
materials currently stored in laboratories, and the second is the method by which chemical
substances are currently organised when they are stored.
23.3 The report is also expected to make recommendations about the way that natural gas is stored
and distributed across campus, but these recommendations are currently being checked in
order to ensure that they are being made based on a correct interpretation of the current
regulations.
23.4 A full report would be given to the Committee in due course.
SECTION B – Starred Items for Approval
There were no starred items for approval.
SECTION C – Starred Items for Information There were no starred items for information
HSSC17-M2
5
17/24 Any Other Business
Update on F Gas and EMS Non-Conformance
24.1 It was reported that good progress was being made against F-Gas compliance issues, and that
a compliance questionnaire was expected to be sent out soon.
24.2 There were no major EMS Non-Conformances to report, and in the last 9 months there had
been one major non-conformance, 9 minor non-conformances, and 6 opportunities for
improvement.
Agenda Setting
24.3 The Chair reminded the Committee that the agenda was generally set six weeks in advance of
the meeting, and that items for the agenda should be notified to the secretary in advance of this.
Dates of the agenda settings meetings would be notified to the Committee in future.
Terms of Reference of the Committee
24.4 The Chair reported that the terms of reference of the Committee would be reviewed thoroughly
in time for the September meeting of the Committee, with a particular view to ensuring that
Environment and Sustainability issues are being given appropriate levels of representation.
Date of Next Meeting
• Tuesday 12th September 13:30 Pearce Committee Room
• Wednesday 10th January 14:00 Pearce Committee Room
• Wednesday 2nd May 10:00 Pearce Committee Room
Author – Tanya Osborne Date – 19 May 2017
HSSC17-P18
Health Safety and Environment Statutory Compliance Sub Committee
Composition, Membership and Terms of Reference
Composition and Membership Director of Infrastructure & Commercial Services (Chair) Andrew Burgess
Health, Safety and Risk Manager Neil Budworth
Head of Engineering David Howell
Dean (to be nominated by HSEC) Professor Chris Rielly
Operations Manager (nominated by HSEC) Steve Warren
Environmental Manager Nik Hunt
School Technical Services Manager Dr Donna Bentley
Academic representative with expertise in this area Dr Robert Schmidt III
In attendance:
University Compliance Engineer Paul Walker
Deputy Health, Safety and Risk Manager James Stapleton
Secretary Tanya Osborne
Other Duty Authorised Persons, Heads of Professional Services Management Teams, or other specialist advisors by invitation
Terms of Reference • To advise Health, Safety and Environment Committee on compliance with statutory health and safety
across the University relating to facilities in line with the University Health and Safety policy.
• Monitor adherence to governance structure for health and safety management
• Ensure an appropriate audit programme of statutory activities exists
• Governance of compliance in relation to topics listed below to a schedule agreed by the committee:
1. Asbestos 2. Water hygiene 3. Local Exhaust Ventilation Systems (LEVs) 4. Noise 5. Hand arm Vibration 6. Lifting equipment 7. Pressure systems 8. Electrical installation 9. Gas 10. Fire safety
11. Working at height 12. Environment (inc Energy) 13. DSEAR 14. F Gas 15. Food Hygiene 16. Confined Spaces 17. Excavations 18. Permits to Work 19. Personal Protective Equipment 20. Sports Playground Equipment
• Meet three times per annum in advance of HSEC; 2017-18 schedule o 11th September, in preparation for HSEC 27th September 2017 o 10th January, in preparation for HSEC 7th February 2018 o 2nd May, in preparation for HSEC 6th June 2018
HSSC17-P19
1
HSSC17-P19
Subject
Maturity Matrix and Summary of DAP meeting
Origin
David Howell – Head of Engineering– 30th August 2017
Strategic objective met
To differentiate the DAP role with compliance areas better served with SOP’s and to manage and
communicate these areas through schools and professional services. To set a framework to ensure
There is a local School / Professional Service H&S policy that
requires conversion to a single University H&S Policy
Local policy now
converted
Not Applicable In place - no further action required LU Fire Policy in place In place - no further action required In place - no further action required Yes - Annex S Machinery and Equipment In place - no further action required Approved WSP is University wide
The local School / Professional Service H&S policy (identified in
the point above) has been converted to a University H&S Policy
to meet legislation requirements and has been adopted by the
University HS&E Committee
In place - Approved at
June HSE committee
Not Applicable Not in place. LU reviewing schools
responsibility and authority
Not Applicable Not in place and not being worked
on. Draft circulated.
In place - no further action required Identified as requiring conversion to University
Policy and conversion process planned to start
in 2016
Not in place and not being worked on. Audit
scheduled for Summer 2016. Will be updated
after audit.
Campus wide WSP approved
Any School or Professional Service local procedure, that
supports the relevant University H&S Policy, is reviewed at least
every 3 years
No not required due to
new University policy
Not Applicable Not in place and not being worked on.
LU to review schools responsibility and
authority
In place - no further action
required
In place - no further action required In place - no further action required Last reviewed as part of audit in January 2016,
actions identified to undertake
Not in place and not being worked onAudit
scheduled for Summer 2016. Will be updated
after audit.
In place - no further action required
A Duty Authorised Person (DAP) has been appointed in writing
by the Dean or Director to manage the implementation of the
policy / procedure
Current DAP -Paul
Walker
In place - no further
action required
In place - no further action required In place - no further action
required
In place - no further action required In place - no further action required In place - no further action required In place - no further action required In place - no further action required
A competency gap analysis has been undertaken for the DAP,
and a supporting developmental plan produced for the DAP to
close out identified gaps and ensure competency
DAP holds BOHS P405
and BOHS P407
In place - no further
action required
In place - no further action required In place - no further action
required
In place - no further action required In place - no further action required Yes In place - no further action required In place - no further action required
An Authorised Person (AP) has been appointed in writing by the
DAP to ensure the day-to-day implementation of the policy /
procedure
Not Required at this
time
Not in place and not
being worked on
Not in place and not being worked on In place - no further action
required
In place - no further action required In place - no further action required In progress - potential APs identified In place - no further action required In progress Decision awaited from DCOO on
process
A competency gap analysis has been undertaken for the AP,
and a supporting developmental plan produced for the AP to
close out identified gaps and ensure competency
Not Applicable Gap analysis completed
but action plan yet to be
concluded
Gap analysis completed but action plan
yet to be concluded
New training arranged In place - no further action required In place - no further action required In progress - potential APs identified In place - no further action required Gap analysis completed and IOSH training
completed Sept 2016
Any students or technical staff that are appointed to undertake
checks / inspections / tasks have been given the correct level of
supervision and briefing
In place although there
will be no expectation
for students to be
involved
Not Applicable Not in place and not being worked on FM joiners trained to service
and inspect fire doors
In place - no further action required Competant contractor appointed to
carry out annual thorough test and
examination
Gaps identified in January 2016 audit, actions
being worked through
In place - no further action required In place - no further action required
The competency developmental plan has been completed and
appointed persons are competent to undertake their roles
Cat B to be completed
in May and Asbestos
awareness being
carried out now a with
classroom sessions
planned
Gap analysis completed
but action plan yet to be
concluded
Gap analysis completed but action plan
yet to be concluded
In place - no further action
required
In place - no further action required In place - no further action required In progress - potential APs identified A Procedure has been drafted to enable
authorised persons to issue pressure system
permits , this requires approval and training.
In place - no further action required
The relevant University H&S Policy, plus any supporting local
procedures, have been communicated to stakeholders and a
monitoring group (e.g. local H&S Committee) established
Now being
communicated out to
schools and
questionaire sent out
due to be completed
31st March 2017
In place - no further
action required
In progress, Revised policy in progress In place - no further action
required
Not in place and not being worked
onunder draft new issue.
In progress, Implementation plan
for roll out of new LU policy
Will be done when Policy has been updated In place - no further action required In place - no further action required
There are KPIs identified to measure compliance and these
KPIs have been communicated to the team
5 new Kpi's now written New maintenance
contract in place with
stronger ownership and
KPI's
In progress Not in place and not being
worked on
Not in place and not being worked on In place - no further action required No KPIs have yet been established Not in place.True KPI's will follow policy
update after audit. Need to review pressure
systems lists as part of audit.
In place - no further action required
The KPIs are being actively monitored by the School or
Professional Service
We have started to
monitor some Kpi's
Seasonal contract due to
commence summer 17
In progress Not in place and not being
worked on
Not in place and not being worked on In place - no further action required No 3 monthly review with provider (Allianz) .
Minuted meetings where we review items
completed, missed or failed. Reports issued
and followed up!
In place - no further action required
An audit programme has been produced to determine
compliance
All areas have now
been audited and a
reinspection is being
carried on a annual
rotating basis
In place - no further
action required OR N/A
In progress In place - no further action
required
In place - no further action required In place - no further action required Yes In place - no further action required In place - no further action required
Audits are being undertaken in accordance with the audit
programme
External Audit due late
2017 disccussion
taking place with
suppliers
Not in place and not
being worked on
In progress In place - no further action
required
In place - no further action required In place - no further action required Yes In place - no further action required In place - no further action required
The results of the audits are being communicated to the local
H&S Committee
Eurosafe Review of
2013 sent out. All
Lucion audits availible
Not in place and not
being worked on
In progress In place - no further action
required
In place - no further action required In place - no further action required Will be communicated at Feb 2016 FM HSE
Committee
In place - no further action required In place - no further action required
The identified audit actions are being undertaken All actions are closed
out from 2013 audit.
HV Plan being
formulated
In progress Long standing issues are
slowely being adressed
(E/Lighting,)
In place - no further action required In place - no further action required Yes In place - no further action required In place - no further action required
Audits are being closed out and formally recorded as completed Yes and being recorded
on Rag Chart
In place - no further
action required OR N/A
In progress Not in place and not being
worked on
In place - no further action required In place - no further action required Yes, actions are in the process of being
completed
In place - no further action required In place - no further action required
Assurance dashboards are being completed and submitted up
to the University HS&E Compliance sub-group
In place -And regularly
updated
Not in place and not
being worked on
In progress Not in place and not being
worked on
Not in place and not being worked on In place - no further action required No Not in place and not being worked on In place - no further action required
Last updated 01/08/2017 21/02/2017 21/02/2017 14/08/2017 01/08/2017 01/08/2017 01/08/2017 21/02/2017
Overall Score
>/= 70% Green
> 50% amber
< 50% red
Level of Assurance
FM Average Current Position
Scorecard Showing only Procedures and Appointed Persons - used in December meeting
0-25% No Assurance
26-50% Limited assurance
51-75% Reasonable assurance
76-100% Substantial assurance
Key to colours being
used
In place - no further
action required
In progress (1) Not in place and not being worked on
(0)
Not Applicable
Key to Meetings
HSEC Health & Safety Committee
SC Statutory Compliance Commitee
HSESCSC Health & Safety & Statatory Compliance Sub Committee
Paul Walker 23/08/17
Water quality managementFood HygeineMachinery Maintenance Schedules and
2 Current Position ................................................................................................................................. 2
3 In brief ............................................................................................................................................... 2
1.1 A Pressure System audit was conducted by British Engineering Services (BES) November 2016
and issued February 2017 with 11 recommendations. On receipt of the audit the LU DAP for
Pressure Systems had left the University and due to a number of issues the appointment of a
new DAP was not achieved until August 2017. This resulted in a delay in actioning the
recommendations.
1.2 In addition our current insurance inspector (Allianz) lost the contract in July 2017 and
coincidently BES were appointed on 1st August for the next 3 years.
1.3 In addition to Pressure Systems BES were also appointed to inspect equipment across campus
which falls under the PUWER and LOLER regulations. This has resulted in highlighting
substantial shortfalls in LU asset list both across FM, professional services and schools.
Health, Safety and Environment Statutory Compliance Sub-Committee
HSSC17-P24
2
2 Current Position
2.1 Pressure Systems
2.2 The 11 recommendations are detailed in Appendix 1 below.
2.3 The DAP appointment is now allowing these areas to be addressed but it will require training
and assistance from schools and external bodies. The DAP training is booked and the skills and
capability assessed to ensure he has the correct knowledge and support to move forward.
2.4 In parallel FM are working with the BES to identify shortfalls in maintenance, written schemes,
policies and procedures to close the recommendations in appendix 1.
3 In brief
3.1 Recommendation 1 Reg 3 Application and Duties
Assets data is being collected and will be input into the proposed PPM system. The current
policy is under review and all staff associated with Pressure System operation and maintenance
are being identified for training. Conversations are being held with school Ops managers to
explain their obligations and offer support if required.
3.2 Recommendation 2 Reg 4 Design and Construction
This is to be embedded in project delivery methodology and revising the Mechanical
specification issued to contractors at tender stage.
3.3 Recommendation 3 Reg 5 Provision of Information and Marking
DAP to introduce procedures once training is completed
3.4 Recommendation 4 Reg 6 Installation
Specification to be included in M&E specification and added to handover/handback
documentation
3.5 Recommendation 5 Reg 8 Written Scheme of Examination
Asset lists being checked and verified to see where we lack written schemes. Data to be added
to PPM system for future tracking
3.6 Recommendation 6 Reg 9 Examination in accordance with written scheme
All lists being collated and verified followed by the addition of a PPM policy and recording
3.7 Recommendation 7 Reg 11 Operation
Internal FM and school wide appreciation training and discussions on-going
3.8 Recommendation 8 Reg 12 Maintenance
Full PPM review ongoing once asset list are verified
3.9 Recommendation 9 Reg 13 Modification and repair
Staff training and M&E specification under review. Also repair and maintenance contractor
competency and capability to be assessed
3.10 Recommendation 10 Reg 14 Keeping of Records
It is proposed to introduce compliance software and input verified data and asset lists to
manage this regulation
HSSC17-P24
3
3.11 Recommendation 11 Reg15 Precautions to Prevent pressurisation of certain vessels
Included in the full review and for action into PPM
3.12 Whilst not directly connected to the pressure system audit it should be noted that compliance
with PUWER and LOLER regulations has also been highlighted with the appointment of BES.
This is because BES are also employed to inspect these areas of legislation. It has become
immediately apparent that LU fall short in reaching compliance status in these areas and
parallel work streams are underway to verify the extent of the work. It should be noted that most
of the plant and equipment identified is within the schools and initial conversations with Ops
Managers are planned to raise awareness.
4 Conclusion
4.1 The delays in progressing the Audit report have now been resolved and progress is being
made. The full extent of the work and shortfall is not yet known but hopefully this will be
resolved prior to the next meeting. The acceptance from all schools and professional services
across the University is being addressed but currently this is experiencing some resistance
which will need to be overcome. It is expected current budgets will be exceeded in this area for
this financial year. Further details will be provided as the project continues.
HSSC17-P24
4
Appendix 1
Recommendations
1. Regulation 3 – It is recommended to include in your policy [3] or some form of register or other means of identification and assessment is introduced, that recognises systems that may be on site which are excepted from the PSSR by virtue of schedule 1 Part 1 and identifies what other means are employed to ensure their ongoing safety. This could be incorporated into a detailed review and update of the current pressure systems policy. It is recommended that the essential attributes, training (including CPD) and the authorisation process for key pressure systems personnel is reviewed and clearly documented.
2. Regulation 4 - It is recommended that for pressure systems project work and when equipment is replaced, compliance to the PER and PSSR as appropriate is clearly identified and documentary evidence retained such as Declarations of Conformance to relevant EU Directives including the PED/PER. This will assist the competent person in certifying written schemes of examination.
3. Regulation 5 - It is recommended that for repairs or modifications carried out to plant subject to the PSSR, suitable and sufficient documentation is approved and retained. When appropriate, this should involve approval by your competent person who certifies the plant under a scheme of examination. This also links in to Regulation 13 and 14 below.
5. Regulation 8 - It is recommended to conduct an internal audit of the various items of pressure plant at LU to ensure current suitable written schemes of examination are available and readily accessible and to produce a certified written scheme for any that are missing.
Moreover, consideration should be given to reviewing how items get added or deleted from an existing scheme of examination when plant items are replaced or removed from service and how this is communicated both within LU and to your PSSR competent person to ensure the scheme is always current. It is further recommended that all persons holding responsibility for pressure systems compliance receives adequate training relating to their PSSR duties, including identifying PSSR pressure systems to enable an audit to be conducted for plant under their responsibility.
6. Regulation 9 - There does not appear to be adequate controls with LU regarding monitoring of the compliance position with respect to examination due dates and receipt of reports. It is recommend that this receives a high level of focus to ensure due dates are met and when this is not achieved or if you anticipate that it will not be achieved, appropriate action is taken to mitigate any risk to LU.
7. Regulation 11 - It is recommended to conduct a review of the various site systems to ensure suitable instructions are in place and to ensure the relevant personnel who interact with these systems are properly trained in their use with records kept. In addition, for PSSR boilers on site, there does not appear to be boiler operation risk assessment in place to comply with HSE/SAFed/CEA guidance BG01 and it is recommended to put this in place at the earliest opportunity. It is further recommended that boiler and pressure systems operators are adequately trained with suitable records retained, to include planned periodic update training at regular intervals.
8. Regulation 12 – It is considered that compliance with this Regulation is not fully met and it is recommended that the requirements for pressure system maintenance are fully reviewed and a suitable and sufficient PPM program instigated that complies with Regulation 12.
9. Regulation 13 - Inadequate information was available at the time of audit to confirm compliance, however it would appear that as a minimum, improvement is needed in this area to demonstrate a high level of control. Therefore it is recommended that the process for carrying out repairs and modifications to pressure systems is reviewed by LU to ensure they are documented and approved by a competent person.
HSSC17-P24
5
10. Regulation 14 - In order to fully comply with Regulation 14, a review of the various pressure system items should be conducted to ensure that all necessary reports of examination, written schemes, operating instructions / manuals and information on repairs are made available and readily retrievable. This may be in an electronic format provided the information is not subject to unauthorised alteration, is authenticated by the competent person for written schemes and reports of examination, are accessible by those who need it including an Inspector of the HSE and readily printed if required.
11. Regulation 15 - Time did not permit the checking of calorifiers, but should relief devices be fitted to their secondary side for overpressure protection, they should be contained on your written schemes and their operation / set pressure verified at regular intervals. If over pressurisation is prevented by an atmospheric vent only, it is recommended to fit suitable relief devices to the secondary side or otherwise prove the adequacy of the vent for overpressure
HSSC17-P26
1
HSSC17-P26
Subject
ISO14001:2015 Re-accreditation and Transition Audit
Origin
Nik Hunt, Environmental Manager
Strategic objective met
Embedding Sustainability and Environmental Compliance
Committee Action Required
To NOTE the outcome of the audits
Executive Summary
The University’s Environmental Management System was subject to four days of external re-
certification and transition audit to progress from ISO14001:2004 to ISO14001:2015. A further one day
addition to scope audit for the imago venues, which were previously excluded from the scope, was
also undertaken, both audits occurring in August.
On the first audit there were six findings with only one minor non-conformance and five OFI’s, our
lowest and therefore best result yet. This audit highlighted good work in the area of the concept of risk
thus embracing well the spirit of the 2015 standard but with life cycle analysis yet to be fully developed
– it is early days. It also praised the area of Emergency Preparedness for being well managed and a
comprehensive Legal Register. Sustainable Procurement was mentioned as a work in progress, but
with clear evidence of development. Of the six findings two have already been addressed, one is in
hand, one is ongoing and two will require further work. The audit resulted in a recommendation for
recertification and transition to the new ISO14001:2105 standard.
On the second audit there were four findings, all four were noted as AoC’s. An AoC is an Area of
Concern and is new terminology. These areas must be addressed to avoid a non- conformance at the
next audit and are therefore more significant than OFI’s. This audit highlighted that controls in use
were effective but environmental awareness needs to be improved. Monitoring and performance
evaluation is well managed although KPI’s could be reduced. The internal audit was detailed and
covered compliance very well, however the two areas of audit planning and follow up need some
improvement. The audit resulted in a recommendation that the addition to scope areas be
incorporated into the current University accreditation to the ISO14001:2105 standard.
A final addition to scope audit for Loughborough London is scheduled for the 6th September and a verbal
update will be available at the meeting.
Health, Safety and Environment Statutory Compliance Sub Committee
HSSC17-P26
2
1. Re-Certification and Transition Audit
1.1 Loughborough Campus:
• Two auditors spent two days onsite interviewing the Vice Chancellor, Jo Shields, Nik
Hunt, Greg Watts Martin Channell, James Trotter, Lynda Langford and visiting two
operational areas (Campus Living and SSEHS).
• Audit Findings: A total of 1 Minor Non-conformances and 5 OFI’s were raised, our
lowest number since accreditation in 2014.
• The audit executive summary was quite long so here are a few of the positive
comments:
o The concept of risk appears to have been well woven into the various
elements of the EMS, (context, interested parties, aspects, legislation),
thus embracing well the spirit of the 2015 standard. There has been
some life cycle analysis carried out for the aspects and impacts, but this
has yet to be fully developed – it is early days.
o Emergency Preparedness is well managed; very detailed, clear spill
response instructions. This was further verified during the site visit to
Faraday Royce Catering, (Campus Living).
o The Legal Register appears comprehensive, and records how/why the
legislation is applicable to the University. Voluntary obligations are
included, e.g. ISO14001,Data Reporting Requirements for HESA,
Carbon Management Plan and the requirement to notify NQA of any
breaches leading to prosecution.
o Sustainable Procurement is a work in progress, but several issues were clear
during this audit:
▪ Commitment and enthusiasm of the Head of Procurement
▪ Support to local SMEs
▪ Defined objectives to integrate sustainability into contracts and into the
University culture
The audit resulted in a recommendation for recertification and transition to the new
ISO14001:2105 standard.
1.2 The following is the detail of the Audit Findings:
1. OFI: The present policy does not directly commit to the protection of the environment. A
draft policy was evidenced which is being approved in October 2017. In hand.
2. OFI: The University may benefit from centralising its KPIs and targets and reducing their
numbers so that they can better demonstrate a quantitative improvement in environmental
performance. Requires work
3. Minor NC: The University may benefit from contacting their licensed carrier (Ref: Waste
Cycle) to ensure that all waste streams removed off-site are identified by their correct
EWC Code and not one single code for general waste. This non-conformity was
cleared before the closing meeting of the audit; waste cycle provided revised waste
transfer documentation to the satisfaction of the auditors.
4. OFI: Though has gone into life cycle thinking / analysis, but the link with the main register
and hence impact assessment is not clear in all instances. Discussion with the
environmental manager suggests that this could be made clearer in the instances of
occurrence column of the aspects register. A start could be made with one aspect area
e.g. procurement Requires work
5. OFI: The University could consider ensuring that the annual evaluation compliance
document is dated. It might further consider enhancing the detail in the summary of audit
outcomes column e.g. referencing the dates of associated internal audits. Completed.
6. OFI: The University would benefit from ensuring that all contractors F Gas leak test
reports are sampled and checked as part of the internal audit process. Ongoing
HSSC17-P26
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2. Addition to Scope Audit
2.1 imago venues: (Burleigh Court, The Link and Sir Dennis Rooke)
• One auditor spent one day onsite interviewing Nik Hunt, Keith Barber and the
Housekeeping team in Burleigh Court as well as visiting the kitchen at Burleigh Court and
the Sir Dennis Rooke operational areas.
• Audit Findings: A total of 4 AoC’s were raised. An AoC is an Areas of Concern and is
new terminology. These areas must be addressed to avoid a non-conformance at the
next audit and are therefore more significant than OFI’s.
• The audit executive summary was comprehensive but here are a few highlights:
o From the samples taken the operational controls in use can be noted as an
effective process.
o The monitoring and performance evaluation is being well managed;
management reviews are detailed although KPI’s could be reduced in number
and centralised to help better determine environmental performance. The two
areas of environmental performance (Energy and Waste) are well managed
and are used to determine whether environmental objectives and targets
have been achieved.
o The Internal audit conducted on Burleigh Court and the Link Hotel was
detailed and covered legal compliance very well.
The audit resulted in a recommendation that the addition to scope areas be incorporated into
the current University accreditation to the ISO14001:2105 standard.
2.2 The following is the detail of the Audit Findings:
1. AoC: Issues of the communication of the environmental awareness can be improved when it
came to the understanding of the Environmental Policy. This should be now included in
toolbox talk activities.
2. AoC: It was noted that the Training log for M Mizurva did not include any reference to
Environmental Awareness. There is such a computer training programme developed called
“Environmental Essentials” which has not been rolled out at IMAGO. Proof required that this
has been communicated and applied
3. AoC: There is no formal plan in place to ensure that all Campus Sites are scheduled for
internal audit. This should on past history and correct sampling of the risks identified
4. AoC: The Audit Report findings for May 2017 were noted in the report, but there is no formal
method to ensure the improvements are followed up to ensure the implementation of the
audit results
The first two items although specific to an operational area in Burleigh Court have implications for
the campus in terms of awareness and evidence of the EMS, the Environmental Policy and Training.
Quite a lot of work will be required to ensure this can also be evidenced across all operational
areas. The second two areas pertain to the environmental management system itself and can readily
be addressed over the coming weeks.
3. Addition to Scope Audit
Loughborough London.
• This is planned for Wednesday 6th September and a verbal update will be given in the
meeting.
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4. Management of the EMS:
The following table summarises the proposed approach to managing the different areas of the
EMS under the new governance structure.
Area of the EMS Previously reported to: Proposed reporting: By:
For action: Andrew Burgess, Deputy Chief Operating OfficerRichard Taylor, Chief Operating Officer
For information: Andy Stephens, Director of FinanceProfessor Bob Allison, Vice ChancellorAudit Committee
May 2017Internal audit 2016/17
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Estates - Health and Safety compliance
Report classification
Medium risk
Total number of findings
Critical High Medium Low Advisory
Control design - - 1 - -
Operating effectiveness - - 2 1 -
Total - - 3 1 -
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Internal audit 2016/17
Impact of findings on HEFCE opinion areas
Area Impact
Risk Management Our findings do not impact on this area.
Corporate Governance One of our findings impacts on this area.
Value for Money Our findings do not impact on this area.
Internal Control Three of our findings impact on this area.
Data Quality Our findings do not impact on this area.
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Background and scope
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Executive summaryBackground and scope Current year findings Appendices
Internal audit 2016/17
Background
Across the sector, Universities are refocussing their attention on health and safety as reputational damage following failures in this area can be significant. Issues in this area may also have an impact on the student experience and student satisfaction, which may have a negative impact on external survey and league table results.
Health and safety has received some focus in the University following a review in 2015 which identified poor process and management of water hygiene that could have led to an increased chance of Legionella. Since then, a number of significant changes have been made to ensure compliance with all relevant health and safety requirements. The University has made progress over the past 12 months, most notably in establishing a governance structure to oversee assurance over all health and safety compliance areas.
Governance and reporting structure
The governance and reporting structure includes the Health and Safety Statutory Compliance Sub-Committee, which:
• was set up to advise the Health, Safety and Environment Committee on the University’s compliance with statutory health and safety requirements. It focuses on governance and compliance, and makes recommendations to the main committee, which in turn reports directly to Council; and
• includes School deans, School operations managers and technical support from Facilities and Health and Safety staff.
Designated Area People (DAP) are technical specialists, who have been put in place to ensure the right level of technical knowledge for each statutory requirement right the way down through to Schools. They are staff members from across the University who are best placed and experts in their field, and are responsible for writing the new central policies and the corresponding compliance requirements.
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The University has made progress in strengthening its governance structures and assurance processes for overseeing health and safety compliance, but we noted a number of areas for improvement including:
• Effectiveness of the Health and Safety Statutory Compliance Sub-Committee – the effectiveness of this committee would improve if members were provided with more succinct and direct reports on the key areas of health and safety compliance. This should help the sub-committee provide more robust challenge on actions and where assurance is coming from. A dashboard style of reporting is seen as good practice as it helps users identify and challenge any areas of concern. This should be considered further by the University.
• Action monitoring and reporting – an action tracker which shows actions required to ensure compliance should be maintained by each DAP. We found a number of issues with the quality of information included in the tracker, and the level of monitoring by senior staff. Reporting of actions to the sub-committee does not yet take place. The current audit programme covers the period up to July 2017 and doesn’t cover all statutory requirements, but is due for review during summer 2017.
• Cultural challenge - the University has strengthened its tone at the top regarding health and safety, but in a devolved setting, there is an increased risk of staff undertaking work without the involvement of facilities management and the relevant area specialists.
• Asbestos policy – the University recognises that the training provision for existing staff is insufficient. The central policy on the University website also has a number of broken links, preventing users from accessing the information they may require.
During this review, our Health and Safety expert met with the Deputy Chief Operating Officer and other key staff to discuss the University’s processes and changes being implemented. He concluded that compared to other universities, Loughborough University has a more robust structure for considering and monitoring health and safety compliance. He also identified the following good practice:
• senior staff have a good awareness of health and safety, the statutory compliance requirements and the key risks across the University;
• management have completed a realistic assessment of the challenges involved with the University’s devolved structure and positive messages have been communicated on the central heath and safety policies.
• the bottom-up approach to risk registers is positive and having workshops to feed into these is good; and
• contractor management: this is an area where there are often difficulties, but the University is taking steps in the right direction by aiming to reduce the number of contractors on site so there are fewer to monitor.
Executive summary
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Executive summaryBackground and scope Current year findings Appendices
Internal audit 2016/17
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Current year findings
Information flow to provide assurance
Operating effectiveness
1
Finding
The Health and Safety Statutory Compliance Sub-Committee meets approximately once every term. Initially itprioritised higher risk areas (water, electricity, gas, asbestos and LEV) and reviewed policies for each. During this process, a maturity matrix was developed as a management guide to see how advanced each compliance area was and where focus was needed. From the minutes and papers we have reviewed since the start of the year, the sub-committee has discussed:
• policy updates/requirements where these are not in place;
• updates on appointments of DAPs for the compliance areas (not all areas have a DAP in place following a restructure in Facilities Management) ;
• update on School compliance questionnaires (one on each compliance area is being sent to each School to ascertain the current position, and where the gaps in knowledge are);
• outcome of the recent audits – for the gas audit update, the paper submitted was very detailed (five pages), but there is a risk that the key messages are lost within this.
Our key finding is that we feel there is a lack of information to allow the sub-committee to have a good level of assurance over all 16 compliance areas. To help provide the right level of assurance, the University should consider restructuring the format of these meetings to make sure that there is good governance and oversight over each area, for example:
• having a standing agenda item where an update on each compliance area is given, perhaps as a RAG rated dashboard with a few brief supporting comments – for example, key actions taken since the previous meeting, results of any audits, upcoming audits, and details of near misses or accidents and the lessons learnt;
• requesting that DAPs, as accountable subject specialists, prepare the above short update for each meeting;
• implement a work programme for the sub-committee whereby each compliance area is focused on in greater detail once per year – the DAPs for these areas could be invited to the meetings on a rotational basis so that the sub-committee members have a good oversight of where the assurance is coming from.
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Background and scope Executive summary Current year findings Appendices
Finding rating
Rating
Internal audit 2016/17
Medium
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Current year findings
Customer-facing finance function:
Mapped processes
Control design
1
Implications
Those charged with monitoring the University’s compliance with the statutory health and safety areas do not have enough information to be able to make decisions or have assurance that DAPs are acting as required/expected.
Lack of information about where further focus or action is needed to ensure compliance.
Non-compliance not detected in a timely manner, potentially leading to fines, reputational damage and the need for remedial action.
Action plan
The University will:
1. set a sub-committee standing agenda item whereby each DAP provides a brief update on compliance and progress at each meeting. This could be presented as a table, with a RAG rating for each compliance area and a corresponding brief update from the DAPs;
2. define an annual monitoring programme for the sub-committee meetings whereby each compliance area is discussed in greater detail; and
3. ensure that the sub-committee is provided with adequate and sufficient information to enable members to have oversight over the University’s overall compliance in each statutory area. The level of reporting from the detailed DAP meeting to the sub-committee and then to the main committee and ultimately Council should be defined.
Responsible person/title:
1. James Stapleton, Deputy Health, Safety & Risk Manager and David Howell, Head of Engineering.
2. Andrew Burgess, Deputy Chief Operating Officer
3. Andrew Burgess, Deputy Chief Operating Officer
Target date:
1. 30th September 2017
2. 30th September 2017
3. 31st July 2018
Reference number:
H&S1
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Internal audit 2016/17
Background and scope Executive summary Current year findings Appendices
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Current year findings
2
Finding
We have three key findings in the area of action monitoring and reporting:
1 – coverage of compliance areas
An audit programme is in place up to July 2017, with the resulting actions feeding into the action tracker. It does not cover each of the 16 compliance areas (including noise, hand arm vibration, and lifting equipment) because of the prioritisation of higher risk areas as described in finding 1. Also, audits of gas and electricity have not appeared on the programme since May 2015. It is intended that from Q3 this year, there will be a new University-wide audit programme in place. The University should make sure that all 16 compliance areas are covered.
2 – action monitoring and reporting
We have reviewed the action tracker dated 20th February 2017 (the most recent at the time of our work), and found the following issues:
• Dates (actual completed dates, or estimated completion dates): 1). blank or unclear (eg: “Dec”, with no indication of the year); 2). Sometime estimated completion dates are in the past for actions that are still outstanding (with no indication of a revised due date);
• Dates (date raised and date of audit): in many cases, these dates are the same, but in some cases one or the other is left blank. Just one of these fields is likely to be sufficient, meaning the other could be removed.
• Progress updates – 1). undated or unclear, meaning it is not obvious when the last review of the action was.
• Eg 1 - one outstanding action is updated with “Being progressed. Will be discussed at next duty holder meeting.”, with no indication of when the update was given or the date of the next duty holder meeting being referred to.
• Eg 2 – some progress updates are written in short with just the day and the month – given the date of some outstanding actions, it is unclear if the update was in 2015 or 2016.
• Progress updates – 2). insufficient – eg – some outstanding actions have been updated with “no progress” for several months at a time. This is an example of where we would expect challenge from the sub-committee, especially as the actions are now well beyond their due dates.
To demonstrate good practice, the sub-committee should identify and challenge the above issues in their meetings to ensure that actions remain on track, and compliance is not compromised.
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Finding rating
Rating Medium
Action monitoring and reporting
Operating effectiveness
Internal audit 2016/17
Background and scope Executive summary Current year findings Appendices
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Current year findings
2
3 – oversight and challenge
The Excel action tracker should be updated by all DAPs and is used by the Head of Engineering and the Compliance Engineer. Actions on the tracker are not discussed at the sub-committee at present. It is intended that DAPs will have their own compliance meetings to discuss the tracker. In order to be comfortable that the University is compliant, sub-committee members should receive enough information to be able to challenge DAPs on where the assurance is coming from.
In future all missing assurance should be reported to the Health and Safety committee, given the potential for statutory non-compliance.
Implications
Actions are not followed up or challenged in adequate detail or with sufficient frequency to give the University assurance that it is compliant with statutory requirements.
If actions are untracked, there is an increased risk of them not being implemented leading to a greater risk of non-compliance. Serious breaches could result in fines, injury, and reputational damage.
Difficulties in knowing whether actions are overdue by days, weeks, months or longer caused by a lack of information in the action tracker.
Action plan
The University will:
1. review the current format of the action tracker to remove unnecessary fields (eg: date raised vs date of audit); add additional fields (eg: original due date > revised due date > actual completion date); clarify the dates when progress updates are made;
2. discuss the detail of the action tracker at compliance meetings between DAPs, but provide an overview to the sub-committee, focused on overdue, or delayed actions. This should encourage progress on longstanding overdue actions to be challenged appropriately; and
3. perform a mapping exercise to ensure that the new audit programme covers each of the compliance areas on the required basis (be that annually, or more or less frequently).
Responsible person/title:
1 & 2. David Howell, Head of Engineering
3. James Stapleton, Deputy Health, Safety & Risk Manager
Target date:
1 & 2. 30th September 2017
3. 31st December 2017
Reference number:
H&S2
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Background and scope Executive summary Current year findings Appendices
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Current year findings
3
Finding
The University aims to ensure that all work on statutory compliance areas is completed by the central facilities management team and overseen by the DAPs. Although the design of the new governance structure is a definite step in the right direction to encourage cohesion and compliance across the University, a cultural challenge remains. In a devolved environment like a University, it is almost inevitable that some individuals will not follow agreed procedures or policy and will carry out work themselves. The University has recognised this and has taken steps to try and reduce it happening, including:
• having central policies, rather than each School setting their own;
• appointing DAPs, with each one being responsible for setting the procedures, writing the policies, and ensuring roll-out and understanding across the University;
• meetings between the Deputy COO and appointed DAPs to assess what they need to be able to perform this role and if the DAPs have any concerns preventing them from being able to carry out their work adequately;
• monitoring by the Deputy COO, and bringing this to the attention of line managers, of staff who persistently carry out work by themselves without following central policies (although this is informal at the current time);
• running workshops with each School to create local risk registers and boost the profile of Health and Safety across the University; and
• seeking evidence of compliance from Schools by sending compliance questionnaires and identifying gaps where further work is needed.
Management are aware that achieving this cultural shift is likely to take time and continual effort. Communication will play a part in changing the mindset, as will ensuring that there is sufficient training for all statutory requirements (separate recommendations around training are given in finding 4).
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Finding rating
Rating Medium
Cultural challenge
Control design
Internal audit 2016/17
Background and scope Executive summary Current year findings Appendices
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Current year findings
3
Implications
The risk of the University being non-compliant increases if work is carried out by untrained individuals, or generally not in line with agreed policies. Work is less likely to be recorded and monitored if not carried out in line with policy.
Action plan
The University will:
1. Continue to monitor persistent breaches of policy and highlight this to line managers to ensure appropriate action is taken; and
2. Implement a structured communications programme to all staff, explaining the new policies, governance structure, what the University is trying to achieve and why it is important to follow policy. The risks of not following agreed policies and procedures should be clearly defined.
Responsible person/title:
1. Andrew Burgess, Deputy Chief Operating Officer
2. Neil Budworth, Health,Safety and Risk Manager
Target date:
1. 31st May 2017 2017
2. 30th September 2017
Reference number:
H&S3
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Cultural challenge
Control design
Internal audit 2016/17
Background and scope Executive summary Current year findings Appendices
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Current year findings
4
Finding
We reviewed the application of the Asbestos policy in the School of Art, English and Drama (AED). The School has a structure to ensure it follows the central University policy, but we noted:• policy - the University policy on the website has broken links;
• staff training - the new policy states that all “relevant” staff should attend the course, and then complete e-learning refreshers. The expected frequency of this training is not defined. The Senior Technical Officer in the School of AED attended an asbestos awareness course in July 2013. A new course was scheduled for March 2017.
As the University continues its work on improving the way that statutory compliance areas are managed, monitored and reported, it should ensure that adequate training is provided to relevant people across the University on a regular basis to ensure that updates, changes, roles and responsibilities are communicated.
Implications
Staff unaware of what facilities management are responsible for, and what technical officers in Schools are responsible for.
Changes in process and requirements are not communicated to staff in a timely manner.
Potential for the policy not to be followed if it cannot be accessed in full, leading to incorrect actions being taken by School staff, and an increased risk of breaching statutory requirements. Serious breaches could lead to fines, injury to staff, students or the public, and damage to the University’s reputation.
Action plan
The University will:
1. ensure all links in all policies on the website are up-to-date, and that all policies are reviewed once their stated review date is reached;
2. define full training requirements for all statutory compliance areas, including who should attend the training, frequency, and content.
Responsible person/title:
Neil Budworth, Health, Safety and Risk Manager
Target date:
31st July 2017
Reference number:
H&S04
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Finding rating
Rating
Asbestos policy
Operating effectiveness
Internal audit 2016/17
Low
Background and scope Executive summary Current year findings Appendices
Appendices
May 2017
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AppendixAppendix A: Basis of our classifications
Appendix B: Terms of reference
Appendix C: Limitations and responsibilities
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Internal audit 2016/17
Appendix D: Interviews held
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Appendix A: Basis of our classifications
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Critical
High
Medium
A finding that could have a:
• Critical impact on operational performance; or
• Critical monetary or financial statement impact; or
• Critical breach in laws and regulations that could result in material fines or consequences; or
• Critical impact on the reputation or brand of the organisation which could threaten its future viability.
A finding that could have a:
• Significant impact on operational performance; or
• Significant monetary or financial statement impact; or
• Significant breach in laws and regulations resulting in significant fines and consequences; or
• Significant impact on the reputation or brand of the organisation.
A finding that could have a:
• Moderate impact on operational performance ; or
• Moderate monetary or financial statement impact; or
• Moderate breach in laws and regulations resulting in fines and consequences; or
• Moderate impact on the reputation or brand of the organisation.
Individual finding ratings
Appendix A: Basis of our classifications
Appendix B: Terms of reference
Appendix C: Limitations and responsibilities
Internal audit 2016/17
Appendix D: Interviews held
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Appendix A: Basis of our classifications
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Low
Advisory
A finding that could have a:
• Minor impact on the organisation’s operational performance; or
• Minor monetary or financial statement impact ; or
• Minor breach in laws and regulations with limited consequences; or
• Minor impact on the reputation of the organisation .
A finding that does not have a risk impact but has been raised to highlight areas of inefficiencies or good practice.
Individual finding ratings
Appendix A: Basis of our classifications
Appendix B: Terms of reference
Appendix C: Limitations and responsibilities
Report classifications
The report classification is determined by allocating points to each of the findings included in the report.
Findings rating Points
Critical 40 points per finding
High 10 points per finding
Medium 3 points per finding
Low 1 point per finding
Report classification Option A Option B Points
Low risk Satisfactory 6 points or less
Medium riskSatisfactory with exceptions
7 – 15 points
High risk Needs improvement 16 – 39 points
Critical risk Unsatisfactory 40 points and over
Public Sector reports must use Option A, Financial Services sector reports should use Option B. Commercial sector reports can choose either Option.
Internal audit 2016/17
Appendix D: Interviews held
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Appendix B: Terms of reference
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Appendix A: Basis of our classifications
Appendix B: Terms of reference
Appendix C: Limitations and responsibilities
Internal audit 2016/17
Appendix D: Interviews held
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Background and internal audit objectives
Background and internal audit objectives
The Health and Safety Statutory Compliance Sub-Committee has been set up to report to and advise the Health, Safety and Environment Committee on the University’s compliance with statutory health and safety requirements across all University facilities.
There are a number of areas for which the University must ensure compliance:
The sub-committee focuses on governance and compliance, and makes recommendations to the Health and Safety Committee. The Committee reports directly to Council. Membership of the sub-committee is wide, with School deans and technical support as well as Estates.
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Internal audit 2016/17
This review is being undertaken as part of the 2016/17 internal audit plan approved by the Audit Committee.
asbestos water hygiene local exhaust ventilation systems (levs)
substances hazardous to health
occupational health surveillance
noise hand arm vibration display screen equipment
lifting equipment pressure systems electricity gas
fire safety working at height vehicle movement, traffic management and driving
environment
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Scope and approach (1 of 2)
Scope
We will review the design and operating effectiveness of key controls at the University during the 2016/17 academic year over the monitoring and reporting of the University’s compliance with statutory requirements.
The sub-processes, risks and related control objectives included in this review are:
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Sub-process Risks Objectives
Adequate arrangements are in place for testing and recordingcompliance with statutory requirements.
Adequate arrangements are in place for monitoring and reporting to provide management with the assurance that the University is compliant with its statutory requirements.
Areas of non-compliance are identified and addressed in a timely manner.
The University is not aware of statutory requirements with which it must be compliant.
Areas of non-compliance are not identified, leading to shortcomings in health and safety.
Potential physical and reputational damage, and/or fines caused by serious compliance breaches.
We will perform our work in two strands:
1 - overall governance, monitoring and reporting
We will understand, review and assess:
• the governance arrangements in place, including the structure and experience of the sub-committee;
• the processes and controls in place at the University to ensure it keeps up-to-date with the statutory compliance requirements;
• the detailed monitoring arrangements in place within the team and how instances of non-compliance are identified and acted upon; and
• the nature and extent of reporting to senior management to provide them with assurance that the University is compliant with statutory requirements.
2 - detailed work on the Asbestos policy
With particular focus on the Asbestos policy, we will understand and assess how this has been rolled out in one University School, and how the processes and procedures identified in strand one are operating in practice. We will visit the following School:
• The School of Arts, English and Drama
Internal audit 2016/17
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Scope and approach (2 of 2)
Limitations of scope
The scope of our work will be limited to the areas identified within this Terms of Reference.
We will not provide an assessment on whether the University is compliant with its statutory requirements.
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Internal audit 2016/17
Independent assurance approach
Our approach is as follows:
• Obtain an understanding of the controls and processes relating to the governance, monitoring and reporting of the University’s statutory compliance through discussions with key personnel and review of documentation.
• Identify the key risks relating to the scope of this review, including how areas of non-compliance are identified and addressed.
• Assess how the Asbestos policy is being implemented in a sample of three Schools.
• Evaluate the design of the controls in place to address the key risks.
• Test the operating effectiveness of the key controls.
• Provide a draft report to management.
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Internal audit team and key contactsInternal audit team
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Name Title Role Contact details
Richard Bacon Engagement Leader Head of Internal Audit
Agreed timescales are subject to the following assumptions:
• All relevant documentation, including source data, reports and procedures, will be made available to us promptly on request.
• Staff and management will make reasonable time available for interviews and will respond promptly to follow-up questions or requests for documentation.
Please note that if Loughborough University requests the audit timing to be changed at short notice and the audit staff cannot be deployed to other client work, Loughborough University may still be charged for all/some of this time. PwC will make every effort to redeploy audit staff in
such circumstances.
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Appendix C: Limitations and responsibilities
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Limitations inherent to the internal auditor’s work
We have undertaken this review subject to the limitations outlined below:
Internal control
Internal control systems, no matter how well designed and operated, are affected by inherent limitations. These include the possibility of poor judgment in decision-making, human error, control processes being deliberately circumvented by employees and others, management overriding controls and the occurrence of unforeseeable circumstances.
Future periods
Our assessment of controls is for the period specified only. Historic evaluation of effectiveness is not relevant to future periods due to the risk that:
• The design of controls may become inadequate because of changes in operating environment, law, regulation or other changes; or
• The degree of compliance with policies and procedures may deteriorate.
Responsibilities of management and internal auditors
It is management’s responsibility to develop and maintain sound systems of risk management, internal control and governance and for the prevention and detection of irregularities and fraud. Internal audit work should not be seen as a substitute for management’s responsibilities for the design and operation of these systems.
We endeavour to plan our work so that we have a reasonable expectation of detecting significant control weaknesses and, if detected, we carry out additional work directed towards identification of consequent fraud or other irregularities. However, internal audit procedures alone, even when carried out with due professional care, do not guarantee that fraud will be detected.
Accordingly, our examinations as internal auditors should not be relied upon solely to disclose fraud, defalcations or other irregularities which may exist.
Appendix A: Basis of our classifications
Appendix B: Terms of reference
Appendix C: Limitations and responsibilities
Internal audit 2016/17
Appendix D: Interviews held
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Appendix D: Interviews held
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We have undertaken this review subject to the limitations outlined below:
Internal control
Internal control systems, no matter how well designed and operated, are affected by inherent limitations. These include the possibility of poor judgment in decision-making, human error, control processes being deliberately circumvented by employees and others, management overriding controls and the occurrence of unforeseeable circumstances.
Future periods
Our assessment of controls is for the period specified only. Historic evaluation of effectiveness is not relevant to future periods due to the risk that:
• The design of controls may become inadequate because of changes in operating environment, law, regulation or other changes; or
• The degree of compliance with policies and procedures may deteriorate.
As part of our work, we met with:
• Deputy Chief Operating Officer
• Deputy Health and Safety Manager
• Head of Health and Safety
• Head of Engineering
• Compliance engineer
• Operations Manager – School of Arts, English and Drama
Appendix A: Basis of our classifications
Appendix B: Terms of reference
Appendix C: Limitations and responsibilities
Internal audit 2016/17
Appendix D: Interviews held
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This report has been prepared by PwC in accordance with our engagement letter dated 10 December 2013.
Internal audit work was performed in accordance with PwC's Internal Audit methodology which is aligned to HEFCE’s Memorandum of Assurance and Accountability. As a result, our work and deliverables are not designed or intended to comply with the International Auditing and Assurance Standards Board (IAASB), International Framework for Assurance Engagements (IFAE) and International Standard on Assurance Engagements (ISAE) 3000.
Internal audit work was performed in accordance with PwC's Internal Audit methodology which is aligned to HEFCE’s Internal Audit Standards. As a result, our work and deliverables are not designed or intended to comply with the International Auditing and Assurance Standards Board (IAASB), International Framework for Assurance Engagements (IFAE) and International Standard on Assurance Engagements (ISAE) 3000.
In the event that, pursuant to a request which Loughborough University has received under the Freedom of Information Act 2000 or the Environmental Information Regulations 2004 (as the same may be amended or re-enacted from time to time) or any subordinate legislation made thereunder (collectively, the “Legislation”), Loughborough University is required to disclose any information contained in this document, it will notify PwC promptly and will consult with PwC prior to disclosing such document. Loughborough University agrees to pay due regard to any representations which PwC may make in connection with such disclosure and to apply any relevant exemptions which may exist under the Legislation to such [report]. If, following consultation with PwC, Loughborough University discloses any this document or any part thereof, it shall ensure that any disclaimer which PwC has included or may subsequently wish to include in the information is reproduced in full in any copies disclosed.
This document has been prepared only for Loughborough University and solely for the purpose and on the terms agreed with Loughborough University in our agreement dated 10 December 2013. We accept no liability (including for negligence) to anyone else in connection with this document, and it may not be provided to anyone else.
