HEALTH & SAFETY: NATIONAL AUDIT RESULTS

PURPOSE To ensure provision of the results of the national health and safety audit to all Areas. ACTION Local Areas to take note of the audit and ensure that they comply with the recommendations contained therein. SUMMARY The national audit was conducted between September 2004 & March 2005. It was commissioned by the audit committee to measure compliance with Phase One of the National Health and Safety Strategy. The audit comprised a questionnaire sent to all 42 Areas and in addition 13 Areas were visited to corroborate the results. Detailed audit results have already been provided to the Areas visited by the auditors. In addition all Areas will receive a letter detailing their individual audit results. RELEVANT PREVIOUS PROBATION CIRCULARS PC65/2003 – Health and Safety Strategy Phase One CONTACT FOR ENQUIRIES Kathryn Ball, HR Email: kathryn.ball@homeoffice.gsi.gov.uk Tel: 0207 217 8954 Brenda Pendlebury, HR Email: brenda.pendlebury@ntlworld.com Tel: 07876 131818 Bill Wood, Estates Email: billwood03@onetel.com Tel: 07713 214850

Probation Circular
REFERENCE NO: 26/2005 ISSUE DATE: 7 April 2005 IMPLEMENTATION DATE: Immediate EXPIRY DATE: March 2006 TO: Chairs of Probation Boards Chief Officers of Probation Secretaries of Probation Boards Area Health & Safety Advisors CC: Board Treasurers Regional Managers AUTHORISED BY: Richard Cullen, Joint Acting Head of HR ATTACHED: Annex A: National Health and Safety Audit

National Probation Directorate
Horseferry House, Dean Ryle Street, London, SW1P 2AW General Enquiries: 020 7217 0659 Fax: 020 7217 0660

Enforcement, rehabilitation and public protection

Audit & Assurance Unit

NATIONAL PROBATION SERVICE LOCAL PROBATION AREA HEALTH & SAFETY MANAGEMENT AUDIT 2004 - 05

FINAL REPORT

Date: March 2005

Ref: ND3104

Audit Title: LPA Health & Safety Management

Audit & Assurance Unit

CONTENTS PAGE EXECUTIVE SUMMARY INTRODUCTION OBJECTIVES AND SCOPE OVERALL CONCLUSION DETAILED FINDINGS Health & Safety Policy H&S Competent Person Risk Assessment Inspections First Aid Health & Safety Committee Working Groups/Parties Display Screen Equipment Training Approved Premises 4 4 4 5 6 6 6 7 8 9 10 11 12 13

Date: March 2005

Ref: ND3104

Audit Title: LPA Health & Safety Management Fire Compliance Monitoring Partnership Organisations Working in Partnership with the TUS ACKNOWLEDGEMENTS TERMS OF REFERENCE RECOMMENDATIONS DEFINITIONS OF ASSURANCE LEVELS

Audit & Assurance Unit

14 14 15 16 17 Appendix Appendix Appendix A B C

Date: March 2005

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Ref: ND3104

Audit Title: LPA Health & Safety Management EXECUTIVE SUMMARY INTRODUCTION 1

Audit & Assurance Unit

This Thematic Review of Health & Safety (H&S) was included in the National Probation Service (NPS) 2004-05 Internal Audit Plan at the request of the NPS H&S Manager and approved by the NPS Audit Committee. The last H&S review, conducted in 2002/03, found that many of the Local Probation Areas (LPA) were not compliant with H&S legislation. As a result of the audit findings, the NPD launched the “Revitalising Health & Safety Strategy for the NPS” to be implemented in phases as agreed with the Health & Safety Executive (HSE). The review was conducted to measure progress against Phase One of the strategy, to provide an insight into the general themes and H&S Management Systems of the NPS and included some topics on behalf of the HSE. All 42 LPA were asked to submit a response to a questionnaire sent out by NPD in October 2004. The questionnaire responses were reviewed and scored, and NPD have issued generalised feedback to the LPA through the National H&S Forum based on the questionnaire results. A commitment was made to the LPA via the H&S Practitioners’ Forum that the audit team, as part of this review, would not visit LPA who had included H&S in their local audit plans. Thirteen LPA were selected at random to be included in the fieldwork, covering each of the four quartiles produced from the scoring of the questionnaires. The 13 areas visited in alphabetical order were; Avon & Somerset, Derbyshire, Greater Manchester, Hampshire, Kent, Lancashire, Leicestershire, London, Nottinghamshire, South Wales, South Yorkshire, Thames Valley, West Midlands and the NPD who were also included in this review, making 14 visits in total. This report focuses on the actual LPA visited as part of the fieldwork for the review. It would be inappropriate to comment here on areas not visited as this would be solely based on questionnaire responses and not on evidence gathered. We have included examples of best practice found on the audit visits. We cannot however, list all examples of best practice found but will make these available to the NPD to enable them to continue to work closely with LPA in the development of best practice guidance.

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OBJECTIVES AND SCOPE 7 The agreed objectives of the audit were to ensure the effectiveness of LPA arrangements to mitigate the following key risks as identified in our initial planning and liaison with NPD: • insufficient progress made against Phase One of the “Revitalising Health & Safety Strategy for the NPS”; 4 Ref: ND3104

Date: March 2005

Audit Title: LPA Health & Safety Management • • • • •

Audit & Assurance Unit

failure to comply with the H&S Act Requirements and other H&S related regulations; invalid, inaccurate or incomplete management information, both within the LPA and to the NPD, leading to erroneous management decisions; unsafe and or unhealthy working conditions leading to injuries and or illness; financial loss due to claims against the NPS/LPA from employees or others; and avoidance of criticism from HSE, Audit Commission and/or National Audit Office.

OVERALL CONCLUSION 8 We concluded that there has been a considerable amount of progress across the service since the previous H&S review. The majority of the LPA visited had satisfactory H&S Management Systems and had made good progress towards the implementation of Phase One. There were some LPA who had extremely robust H&S Management Systems. These LPA had either made a huge effort and progressed quickly through Phase One and beyond, or already had a robust system in place for some time. Unfortunately there were also a small number of LPA who had not made sufficient progress at the time of our visit, and did not have fully effective H&S Management Systems. There are a variety of reasons for the differing rates of progress made by areas and this will be explored further as part of the detailed findings. The LPA that tended to have the better systems were those where a H&S Competent Person (H&SCP) had been in place for a number of years. There is still room for improvement. NPD have developed national policies, procedures and guidance and continue to support areas in implementing the strategy. Some LPA visited lacked sufficient involvement and support from the centre i.e. the LPA HQ, to ensure that H&S policies and procedures are implemented consistently, effectively and efficiently at the local level. This is vital in protecting employees, offenders, the public and management from harm and prosecution/litigation. Specifically, we concluded that: • not all of the LPA visited had compared their own local H&S policies, procedures and guidance with the national model; • not all of the LPA visited had implemented the full suite of national or locally reviewed policies; • inspections and Risk Assessments (RA) are still not conducted in accordance with legislation in a small number of the LPA visited; • H&S training and awareness remains a concern. A nationally developed training programme for all staff is still required to raise H&S awareness throughout the service as a whole. (Lack of awareness is a key issue in the LPA where H&S Management is weak); • although H&SCPs have been appointed in all LPA visited many of these LPA have little or no resilience. They rely on a single officer and in some cases the officer is shared between two LPA or is part time with duties 5 Ref: ND3104

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Date: March 2005

Audit Title: LPA Health & Safety Management

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other than H&S. For an effective H&S Management System it is vital that the H&SCP has sufficient resources to enable them to ensure their area is not in breach of regulations; and overall management arrangements for monitoring compliance with legislation remain poor in a small number of areas.

There has been a significant improvement across the service in relation to H&S management. There are still a small number of LPA who are struggling with H&S, but even these have made considerable improvement since our last review. There are also several LPA who are “ahead of the field” and could be considered as H&S flagships for the NPS. We are able to offer an opinion on the effectiveness of the H&S Management Systems of the 13 LPA visited, this is broken down as follows: • 3 LPA were well controlled; • 7 LPA were adequately controlled; and • 3 LPA were less than adequately controlled. [see Appendix C for definitions].

DETAILED FINDINGS 11 Health & Safety Policy. The majority of the LPA had adopted the national Model H&S Policy Manual, or at least reviewed and compared their own local policies to ensure compliance. However, a small number of the LPA visited were found to be behind in this stage and in particular: • had not compared and agreed policies; • had not implemented the full suite of H&S policies; • had reviewed policies, but did not include a review date making the policy appear out of date; and • document control was poor, policies did not include version numbers etc and thus it may prove difficult for staff to be sure they have the most up to date policy. 11.1 Absent H&S policies may lead to unclear roles, responsibilities and accountability. This may prevent H&S being given the appropriate level of importance and attention, resulting in inconsistent approaches throughout the LPA. 12 H&S Competent Person (H&SCP). All of the areas visited had a H&SCP, but in a very small number of areas this person was either shared with another probation area or was part time with other duties in addition to H&S. One LPA who recognised that their part time H&SCP would be unable to cope alone appointed a Competent

Date: March 2005

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Ref: ND3104

Audit Title: LPA Health & Safety Management

Audit & Assurance Unit

Person for Community Punishment and contracted in assistance on a “time basis” from another organisation. All Competent Persons were appropriately qualified and had been in post in the LPA for varying lengths of time. 12.1 H&S legislation states the need for a Competent Person and there is specific guidance on the number of Competent Persons an organisation must have in line with the number of employees. The majority of the LPA visited did not comply with these ratios. The H&SCP is a “one man band” with no assistance or support other than from Management. Some LPA do have a reciprocal arrangement with other LPA in their Region, and cover for the Competent Person could be provided in this way if necessary. Failing to ensure H&SCP’s resources are sufficient may prevent successful fulfilment of the role as prescribed and could lead to a breach of the regulations. There is a risk that areas would be vulnerable to prosecution. We therefore recommend that: [1] All LPA review the current resources available for H&S and where necessary provide additional support, in the form of further trained and experienced individuals, to assist the LPA appointed Competent Person. This will help to ensure that the LPA are protected from prosecution and litigation. 12.2 Good practice • Avon & Somerset have a reciprocal arrangement for covering long absences of the H&SCP arranged through the Regional H&S Group for the South West. • Thames Valley involve the H&SCP in all high risk organisational changes and projects from the outset to help manage and advise on any H&S issues which may arise. 13 Risk Assessment (RA). There were several LPA who had not conducted RA across all functions and in all areas. These LPA again tended to concentrate on “high risk”, namely Community Punishment (CP) and Approved Premises (AP). They stated the reason for this as “office environments are generally safe environments”. Another reason given was the amount of other H&S work they had carried out, and that due to this the RA process and programmes had not been finalised. The majority of the “high risk work areas” such as: • home visiting; • lone working; • late night group work; • reception; and • night cover had been subject to the RA process. 13.1 Approximately half of the LPA visited were unable to evidence that RA had been reviewed on an annual basis. Reviews of RA should be carried out at least annually

Date: March 2005

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Ref: ND3104

Audit Title: LPA Health & Safety Management

Audit & Assurance Unit

and when there is significant change. If documents do not include a date for further review and the date of the last review the RA appears to be out of date. 13.2 Again the main problem relating to RA was that there were no formal arrangements in place for monitoring and reviewing RA. There was no formally agreed annual programme and in some areas RA was approached in a somewhat haphazard manner. 13.3 Another problem appeared to be getting local managers to take responsibility for conducting RA on a regular basis and informing the H&SCP of the results. There was also difficulty in some areas getting local managers to inform the TUS in good time for them to provide a representative to take part in the RA. One of the reasons given for this was that managers felt they had been insufficiently trained in H&S and RA to enable them to discharge their responsibilities effectively. We therefore recommend that: • [2] All LPA produce an annual programme for RA, which is approved by the Board. This programme should be monitored by the H&SCP who should conduct random audits etc, to ensure RA compliance. [3] All managers required to undertake RA should be appropriately trained, e.g. IOSH Managing Safely course, which should focus on the local area methodology.

13.4 Good practice – Lancashire’s H&SCP has developed a database for monitoring the progress of RA undertaken by local managers. The introduction of this process ensures local managers are aware of their responsibilities and held accountable for the implementation of action plans. 14 Inspections. The majority of LPA visited had made sufficient progress, having introduced a full programme of inspections, or been conducting these in accordance with legislation already. However, four of the LPA visited had failed to make sufficient progress. These areas did not have a good process for inspections e.g. a programme of planned inspections with contingency for additional inspections as required throughout the year. (For example, in the event of an incident/accident/near miss, for the purpose of investigation and future prevention.) 14.1 Many LPA conduct inspections, but feel that they are powerless to correct some of the problems highlighted, they stated that “sometimes repairs can a long time and this can compromise H&S in the long term”. One area stated that a pothole in an office floor was reported and not repaired for approximately 18 months, in the mean time a disabled member of staff tripped due to this and was quite badly injured. There is a risk that if repairs are not actioned promptly not only will injury result, but the inspection process will be under valued and may harm any H&S culture. 14.2 There are still a small number of LPA who have not conducted inspections across the whole area. They have again concentrated on the “high risk areas”. The TUS are Date: March 2005 8 Ref: ND3104

Audit Title: LPA Health & Safety Management

Audit & Assurance Unit

not always involved in the inspection process, this is on occasion due to a lack of support for Union Representatives or at times due to a lack of Union Representatives. 14.3 H&S Inspections should be conducted at least annually, LPA who fail to comply with this are in breach of H&S Regulations, and as such are vulnerable to increased accident/incident rates and unsafe working conditions and practices. These risks, if not addressed, leave the NPS exposed to prosecution and litigation. However, these should be conducted quarterly in accordance with the National H&S Policy Manual. 14.4 There was no formal programme for inspections in four of the LPA visited, although they are planning to address this issue, and the process should have been agreed at the time of publishing this report. The H&SCP should be overseeing the inspection process and producing an annual programme. Areas should then be monitored for compliance with this programme and it should be clear who is accountable for ensuring that any actions highlighted are implemented. An audit process led by the H&SCP would help to ensure the LPA discharges its responsibilities for H&S inspections. We therefore recommend that: [4] An annual inspection programme should be produced and monitored by the H&SCP. Inspections must be carried out of all work areas at least annually, in accordance with H&S Regulations. In addition the H&S National Policy Manual requires these to be conducted quarterly. The manager responsible for the area must lead and TUS should be involved at all stages. The H&SCP should oversee the inspection process and take action to ensure compliance with the annual programme. 14.5 Good practice – Avon & Somerset Inspections are carried out locally by management in conjunction with the TUS (when available) on a quarterly basis. The H&SCP conducts annual H&S Audits, which are scored to enable local managers to measure performance and highlights any areas for improvement. This process allows the H&SCP to use his time more effectively and also ensures independence, objectivity and integrity of the audits. 15 First Aid. This was an area that had seen some improvement. There were a very small number of LPA who were unable to confirm what first aid arrangements were in place. This was as a result of poor record keeping and management of first aid training and refresher courses. First aider lists were out of date and some first aid certificates had expired as a result of the above. 15.1 There are still a few LPA who are unsure of the number of currently suitably qualified first aiders they actually have in their employment and whether there are sufficient first aid provisions in all locations. Failing to provide adequate first aid provisions is a breach of H&S Regulations and exposes the service to the risk of Date: March 2005 9 Ref: ND3104

Audit Title: LPA Health & Safety Management

Audit & Assurance Unit

failing to deal efficiently and effectively with staff, offenders or members of the public who are in need of first aid. The LPA are also liable to criticism from HSE and may be vulnerable to prosecution and/or litigation as a result. We therefore recommend that: [5] LPA ensure they have sufficient numbers of trained first aiders in each location to comply with regulations. Details of trained first aiders, their locations and certificate expiry dates should be recorded and maintained in a logical manner to prevent insufficiencies in first aid provisions and future breaches of regulations. 15.2 Good practice – in London some first aiders produce an initial incident assessment. Such practices could act as a guide for other first aiders who may need to deal with similar incidents. 16 Health & Safety Committee and Working Groups/Parties. Three of the LPA visited did not appear to have a fully effective H&S Committee. Although, they meet on a regular basis, actions were not attributed to individuals. One reason given was that the committee only meets quarterly and therefore events are moving on during this time and it was felt that the committee did not have any part to play in actually resolving issues. Without including actions in minutes there is a risk that important issues may not be followed up, monitored or addressed effectively, the committee may be unaware of progress on particular issues. 16.1 All LPA have a H&S Committee in some form, however one area still has a direct link with the Joint Negotiating and Consultation Committee (JNCC). The JNCC sit separately, i.e. at the end of their meeting, as the H&S Committee. The majority of LPA visited did feel that their committees had become more effective, and some of this was attributed to the reviewing and/or introduction of Terms of Reference (TOR) and Board involvement. 16.2 In at least one LPA the H&SCP was expected to take the minutes of the committee meetings. It can be difficult to take an active role in committee meetings and also take the minutes. It would be preferable if secretarial support was provided. The committee is currently chaired on a rotational basis by the TUS representatives for NAPO and Unison. To provide balance it would be preferable if Senior Management were included in this rotation. 16.3 Good practice • Hampshire has a H&S Consultative Committee, which has a strategic role for H&S and is supported by the H&S Steering Group, which takes a more active approach in progressing H&S in a practical manner. The TUS are actively involved and there is evidence of good consultation, communication and good partnership working facilitated by LPA committees and groups.

Date: March 2005

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Ref: ND3104

Audit Title: LPA Health & Safety Management •

Audit & Assurance Unit

South Wales has a number of committees and working groups/parties, which have involvement in various H&S topics. These groups help to support the current H&SCP, enabling his workload to be shared to some extent among these committees. This provides some resilience for the H&SCP as he does not have a deputy. Thames Valley Board Members are actively involved in the H&S Committee and in relevant working parties/groups. This demonstrates commitment and support from the top and helps to build and embed a H&S culture.

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Display Screen Equipment (DSE). The majority of LPA visited comply with the DSE Regulations. However, at least three LPA are not in full compliance. A small number of areas appear to comply with the regulations, but have insufficient methods for recording and evidencing their compliance. Two areas have not completed all workstation assessments, but this is currently being addressed and a programme put in place. The DSE/workstation assessments have been prioritised where a request has been made or where they are aware that a member of staff has been experiencing difficulties. (For example if they have a known disability or have experienced a recent injury or illness.) 17.1 In particular we found: • currently DSE assessments are conducted on a self-assessment basis in three of the LPA visited; • it is also difficult to track when re-assessments may be required, e.g. staff moves; and • there is no formal mechanism for ensuring that actions identified from assessments have been implemented. 17.2 Failure to conduct workstation assessments for users of DSE is a breach of regulations. This also increases the risk of injury and illness related to poor working practices and set up of workstations (such as bad backs and necks, Upper Limb Disorder (ULD) etc). This exposes the LPA to increased sickness absence levels and prosecution and/or litigation in extreme cases. We therefore recommend that: [6] Each LPA nominate an individual(s) with responsibility for ensuring that assessments are conducted in accordance with the regulations, for ALL users of DSE. A record of all staff requiring assessments should be maintained with details of when the last assessment was carried out. This should then be regularly reviewed to ensure that it includes ALL staff, (new staff and staff who move location) and that any subsequent assessments are carried out as required.

Date: March 2005

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Ref: ND3104

Audit Title: LPA Health & Safety Management

Audit & Assurance Unit

17.3 Good practice • At Derbyshire DSE assessments are carried out for all new starters as part of the first week induction programme. In the first instance a self assessment form is completed, this is then forwarded to the local manager for follow up. Local managers conduct all DSE assessments and keep records of who has been assessed etc. • In South Wales there are 21 DSE Assessors who are monitored and coordinated by the H&SCP. Each DSE Assessor is paid £10.00 for each assessment they complete and this is financed through the salaries budget. 18 Training. H&S training remains inconsistent across the NPS as a whole. Nearly all of the LPA visited had made progress with H&S Training, particularly for H&SCPs, who are now at least trained to an approved minimum level. However, there is still a lack of adequate and consistent training provided for local managers to enable them to effectively and competently discharge their H&S duties. We are aware that NPD will be identifying a national training standard as part of Phase Two. 18.1 There has been marginal improvement in the maintenance of H&S training records. However, the majority of LPA do not adequately record training details for individuals and this could lead to perceived skills shortages which do not actually exist or to actual skills shortages which only come to light when it is too late. A prime example of this is first aiders and appointed persons, where certificates are allowed to expire because of inadequate training records. 18.2 A series of Senior Management and Board briefings on H&S legislation, roles and responsibilities was implemented and this is to be repeated at regular intervals. This has helped to raise the profile of H&S with local Senior Management and Boards and assisted in the development of a H&S Culture. It is important that these briefings continue to be given priority, they are particularly useful to convey changing demands, responsibilities or legislative changes. 18.3 Although general H&S awareness has improved significantly across the NPS as a whole, there is still a lack of H&S training available for local managers. It is important for managers who are expected to carry out RA and inspections to be adequately trained to ensure they are competent in discharging their H&S responsibilities effectively. Many areas visited still do not have formal H&S training programmes. Although these are often in existence for specific staff e.g. CP and AP. 18.4 There is a risk that if H&S training for managers is not addressed, proper understanding of H&S legislation, roles and responsibilities may not be achieved. This increases the likelihood of more serious incidents/accidents occurring, and exposes the service to the risk of prosecution and/or litigation. 18.5 Good practice • London’s H&SCP has developed a RA and inspection training programme for line managers and senior managers. This enables evaluation of staff members

Date: March 2005

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Ref: ND3104

Audit Title: LPA Health & Safety Management

Audit & Assurance Unit

current knowledge and an opportunity to ensure management are aware of their H&S responsibilities. In Derbyshire all staff must have Fire Awareness and Manual Handling training, this is in addition to any other H&S training required, which is specific to their role. All local managers are required to attend the IOSH Managing Safely course. This helps to ensure that local managers are confident and competent in discharging their H&S responsibilities.

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Approved Premises (AP). As identified in the previous audit there are still inconsistencies in the way residents’ medication is managed in AP. These inconsistencies relate to how residents’ medication is conveyed to the AP. We found a mixture of approaches, some residents collect their own prescribed medication and these are handed in to comply with AP rules for residents. At other AP staff (usually one member of staff, often on foot and at regular times) will collect the prescriptions and medication. Some of the AP visited have their medication delivered and redundant medication collected by the local pharmacy. There are risks with allowing residents to collect their own medication, it can be difficult to ensure that all medication has been handed in, or to know that residents are even bringing medication into the AP. We accept that allowing residents to collect their own medication can be part of their rehabilitation and help them to accept responsibility. There are also dangers to be considered when allowing staff to collect medication. We would suggest that the best option would be for medication to be delivered and collected by the local pharmacy, failing that a full RA should be conducted for any other options favoured by the AP manager. 19.1 Few AP held methadone on site and where they did it was usually only over the weekend and the amounts were very small. 19.2 There was great improvement in Business Continuity Planning (BCP) and Contingency Planning. All LPA visited had BCP or Contingency Plans in place for AP. Many had reciprocal arrangements with other LPA AP to assist in the long term if AP had to be evacuated for any length of time. 19.3 Portable Appliance Testing (PAT) remained an issue for residents’ equipment. Only residents in residence on the day the contractors conduct the PAT tests have their equipment tested. For AP with rapid turnover of residents it would be preferable if either AP could have their own PAT machines or that they could get the tests conducted by the contractors on an ad hoc basis.

Date: March 2005

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Ref: ND3104

Audit Title: LPA Health & Safety Management We therefore recommend that:

Audit & Assurance Unit

[7] A mechanism for ensuring the provision of PAT of personal electrical equipment for all residents with an occupancy or expected occupancy of six months or longer be developed and implemented on a National/Regional scale. For example training the AP Caretaker to carry out such PAT on an ad hoc basis or getting a local electrician to undertake the work. The latter would have to be funded by the LPA from the AP budget. [8] Copies of BCP/Contingency Plans be held by all partnership organisations who may be involved in the event of a disaster/emergency. 19.4 Good practice • Greater Manchester, Hampshire, Leicestershire and West Midlands are among some of the LPA who have residents’ medication delivered and collected at the AP. • Training for AP staff is generally well managed. Greater Manchester have a Training Matrix spreadsheet for all AP staff. Lancashire AP staff are required to undertake practical refresher training (i.e. by taking part in various H&S routine activities, e.g. fire alarm tests and drills). Both of these arrangements enable evaluation of staff members’ current knowledge of procedures and provide an opportunity to address any weaknesses. • Hampshire AP BCP are also held by the local police to ensure that should they be required to provide assistance they will immediately know the procedure. 20 Fire. Generally the LPA visited have appointed Fire Officers or given the responsibility to the H&SCP for managing fire risks within the LPA as a whole or the individual local offices. As a result LPA we visited had maintained records of fire drills, evacuations or alarm tests. This is an area where much improvement has been made. 20.1 The majority of the LPA trained and made use of fire marshals or other appointed persons to take responsibility in the event of a fire or evacuation drill or incident. 21 Compliance Monitoring. Compliance monitoring can be achieved by either internal review, monitoring or audit. Although generally there has been some improvement of compliance monitoring in LPA of legislation, policy, guidance and other procedures for H&S, this is still an area where further improvement could be made. LPA where a H&SCP has been in post for a considerable time have better systems for measuring compliance. Although LPA with robust systems are generally better in this area, this is not always the case. There were a very small number of areas who were badly let down by poor compliance monitoring and as a result were unable to evidence their H&S Management System as fully effective. This makes it very difficult for management to ascertain whether H&S policies have been properly implemented and that employees and offenders are aware of their statutory duties,

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Audit Title: LPA Health & Safety Management

Audit & Assurance Unit

roles and responsibilities. It also makes it difficult to assess the effectiveness and suitability of policy. 21.1 Compliance monitoring helps to ensure that staff are aware of policy and are implementing it correctly, this is vital where H&S is concerned. If H&S policy is not adhered to employees and offenders may be at increased risk of harming themselves or others. This may in turn lead to prosecution/litigation, which could be very costly and damaging to the Service both in terms of finance and reputation. We therefore recommend that: [9] LPA review their current H&S Management System and compliance measuring techniques to ensure compliance with NPD national guidance and H&S legislation. 21.2 Good practice – Hampshire have commissioned, broad scope annual H&S audits to deal with particular issues. The audits have been valuable for identifying current levels of performance, areas for improvement and highlighting where the LPA is doing well. Hampshire have a very pro-active approach to H&S. The frequency of audits will be reviewed in the future to ensure that value is still being obtained. 22 Partnership Organisations. Some of the offices we visited were unsuitable for the number of staff actually working in them, this was particularly true of one of the offices in a court building in one LPA. There were several problems and in particular; • The office was unsuitable for staff occupation. There were a number of concerns; i. office space insufficient; ii. close proximity of a photocopier; iii. excessive manual handling of photocopier to re-fill paper tray; iv. inappropriate positioning for use of photocopier; v. desk too small; vi. too much furniture in office; vii. laser printer located on the floor under the desk; and viii. poor access/egress to actual office. 22.1 The H&SCP at many of the LPA visited identified some difficulties in ensuring that H&S responsibilities are fully discharged for LPA staff located in offices not part of the LPA estate. They had particular concerns regarding Prisons and the Courts.

Date: March 2005

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Ref: ND3104

Audit Title: LPA Health & Safety Management We therefore recommend that:

Audit & Assurance Unit

[10] LPA H&SCP conducts RA and workplace inspections jointly with the H&SCP, or equivalent, from all partnership organisations. [11] LPA H&SCP writes to all partnership organisations where NPS employees are located to ask them to provide a signed statement of H&S Compliance in line with Regulation 12 of the Management of H&S Regulations 1999. 22.2 Good practice – Avon & Somerset H&SCP writes to all partnership organisations where NPS employees are located to ask them to provide a signed statement of H&S Compliance in line with Regulation 12 of the Management of H&S Regulations 1999. 23 Working in Partnership with the TUS. In the majority of the LPA visited there were good working relationships between management (senior management) and the TUS. There were often problems with Local Line Managers who either did not take the H&S representatives duties seriously or were reluctant to release them for these duties. In a very small number of the areas visited TUS representatives expressed concerns that Local Managers had made adverse comments about having TUS representatives in their units. There were some areas where TUS and Management relationships could be improved, as well as a number of other issues impacting on the effectiveness of joint working on H&S matters. These are outlined below. 23.1 In one LPA concerns were expressed over current relationships with the TUS. Both the TUS and Senior Management would like to improve these, and in particular concerns were raised over the failure to agree the Area’s draft Facility Time Arrangement. The draft Facility Time Agreement has been on the table since June 2004. This appears to be partly due to an issue relating to the time allowed for Inspections for TUS Representatives. The current allowance has been stated as one half day including travel time. There is a risk that this may not be sufficient and operationally achievable at all times. A review is currently being undertaken and a trial of five inspections has been agreed. This should help to identify any areas which need addressing including expected inspection duration. The NAPO Representative did not take part in the audit, despite being offered the opportunity. 23.2 The H&SCP identified some inadequate communication links with the TUS regarding H&S issues. Management and TUS failed to comply with agreed time scales for the consultation period of Phase One launch. Ineffective communication links between local management, local and national TUS hindered the launch of H&S local policies. The Phase One launch was delayed to enable feedback from TUS to be considered. There is a consultation policy in draft form, which should prevent this happening in the future. 23.3 In one of the LPA visited the NAPO H&S representative has not attended the TUS H&S training despite time allowances and workload relief being provided for this

Date: March 2005

16

Ref: ND3104

Audit Title: LPA Health & Safety Management

Audit & Assurance Unit

purpose. In another the H&S NAPO representative identified had not had the training, but intended to undertake this at some time if she felt she needed it. 23.4 Consultation and involvement are key at all stages, and in some LPA this is made difficult due to the lack of trained TUS H&S representatives or a general difficulty in recruiting and retaining TUS representatives leaving areas with an under representation. The reasons for this should be investigated as there appears to be a number of factors affecting this, such as the lack of line management support suggested, but in some areas there may be other reasons. 23.5 Good practice – The HSO in South Yorkshire has good working relationships with Senior Management, the Trade Union (TUS) and other staff. The TUS are very active and proactive in working in partnership with management on H&S issues and this has contributed to the progress already made. ACKNOWLEDGEMENTS The auditors would like to thank the H&SCPs, CP Supervisors, AP Managers, Union Representatives and operational staff for their help and co-operation during the course of this audit. We would also like to particularly thank those who arranged the timetables for the interviews and visits to AP. Denis Heaney Senior Audit Manager, Thematic Team Bonnie Sweet: Auditor, Thematic Team. March 2005

Date: March 2005

17

Ref: ND3104

Audit Title: LPA Health & Safety Management

Audit & Assurance Unit
APPENDIX A

Audit Title: LPA Health and Safety Management 1. INTRODUCTION 1.1 This review of Local Probation Area (LPA) Health and Safety Management was included in the 2004-2005 Internal Audit Plan approved by the NPS Audit Committee in May 2004. The review was commissioned by the National Probation Directorate (NPD) to identify the level of compliance within the NPS with Health and Safety legislation and in particular the NPD Phase One of “Revitalising Health & Safety Strategy for the NPS”. The review will also identify evidence of good practice and of areas developing and implementing a Health and Safety culture. This information will enable the NPD to continue to provide guidance to areas identified, which may require further assistance in complying with the legislation and share good practice across the service as a whole.

1.2

1.3 1.4

2.

BUSINESS/SYSTEM OBJECTIVE. 2.1 The objective of the system as agreed with the NPD is:-

To provide and maintain safe and healthy working conditions, equipment and systems of work for all employees and others under the control of the Local Probation Areas. 3. AUDIT OBJECTIVE AND RISK ASSESSMENT 3.1 The audit review will seek to provide an assurance to the National Director and Chief Probation Officers as Accountable Officers as to the effectiveness of the National Probation Service’s arrangements to mitigate the following key risks which were identified through our initial planning and liaison with management. These are: • • Insufficient progress made against Phase One of the “Revitalising Health & Safety Strategy for the NPS”; Failure to comply with the Health and Safety Act Requirements and other Health and Safety related regulations;

Date: March 2005

18

Ref: ND3104

Audit Title: LPA Health & Safety Management • • • • AUDIT SCOPE 3.2

Audit & Assurance Unit

Invalid, inaccurate or incomplete management information, both within the LPA and to the NPD, leading to erroneous management decisions; Unsafe and or unhealthy working conditions leading to injuries and or illness; Financial loss due to claims against the National Probation Service from employees or others; and Criticism from HSE, Audit Commission and or National Audit Office

The scope of the review will focus on the LPA management and control arrangements for Health and Safety, in particular covering the following areas: • • • • • • • • • Minimum Compliance with National Model Policy; Risk Assessments; Training; Fire; First Aid; Inspections; Reporting and monitoring of incidents; Management information systems; and QA/QC systems.

4.

TIMETABLE AND REPORTING ARRANGEMENTS 4.1 The proposed timetable for the audit is as follows Plan Date August 2004 24 February 2005 11 March 2005 30 March 2005 Resources 115

Stages Commencement of Review: Days End of fieldwork: Draft Report: Final Report:

Date: March 2005

19

Ref: ND3104

Audit Title: LPA Health & Safety Management Audit Methodology 5.1

Audit & Assurance Unit

Questionnaires will be issued to all LPA by NPD. The responses will then be analysed and based on this analysis a sample of LPA will be selected for visits to interview key staff and review relevant documentation. Areas of best practice will be identified and recommendations for improvement made where appropriate.

5.2

5.

CONTACT POINTS Audit & Assurance Unit Thematic Team • • Denis Heaney Bonnie Sweet Senior Audit Manager Phone Number 0121 6165944 Auditor Phone Number 07775 822 154 Director of NPS Head of Human Resources 020 7217 0650 020 7217 0731

Audit Customers • • Roger Hill Richard Cullen

Prepared by: Bonnie Sweet ………………………Date: August 2004 Auditor Authorised by: Denis Heaney………………………Date: August 2004 Senior Audit Manager

Date: March 2005

20

Ref: ND3104

Audit Title: LPA Health & Safety Management

Audit & Assurance Unit
APPENDIX B

RECOMMENDATIONS ACTION PLAN HEALTH & SAFETY MANAGMENT AUDIT 2004/05

Date: March 2005

Ref: ND3104

Audit Title: LPA Health & Safety Management

Audit & Assurance Unit

No 1

Recommendation All LPA review the current resources available for H&S and where necessary provide additional support, in the form of further trained and experienced individuals, to assist the LPA appointed H&SCP. This will help to ensure that the LPA are protected from prosecution and litigation. (para 12)

Significance

2

Risk/Consequence of non implementation There is a risk that H&SCP may become overwhelmed by their duties if there is insufficient resources available to them. This in turn exposes the LPA to the risk that important H&S concerns/issues may not be given the appropriate level of attention. The H&SCP can quickly be drawn into “fire fighting” rather than acting as a central point for advice, guidance and monitoring for compliance.

Management Response Identify Areas whose ratio of H&SCP : staff is less than 1: 500. Areas to ensure sufficient local provision of H&SCP. (See National Health and Safety Policy Manual ref:NPS/HS/30) Accepted Y/N Y Implementation Date Phase Three Responsible

2

All LPA produce an annual programme for RA, which is approved by the Board. This programme should be monitored by the H&SCP who should conduct random audits etc, to ensure RA (para 13)

2

Failure to conduct adequate risk assessments is a breach of H&S legislation. The use of an annual RA programme helps to ensure compliance.

Kathryn Ball Corporate Health and Safety Manager, Chief Officers & Board Chairs Areas to produce a programme to ensure that all appropriate risk assessments are undertaken. This programme to be audited by their H&SCP and approved by their Board. Accepted Implementation Responsible Y/N Date Y By end of 2005 Chief Officers & Board Chairs

Date: March 2005

Ref: ND3104

Audit Title: LPA Health & Safety Management No 3 Recommendation All managers required to undertake RA should be appropriately trained, e.g. IOSH Managing Safely course, which should focus on the local area methodology. (para 13)
Significance

Audit & Assurance Unit

2

Risk/Consequence of non implementation There is a risk that if managers are not sufficiently trained they will not be competent to effectively discharge their H&S duties. They may even fail to carry out these duties at all if they feel they are not adequately supported. Therefore exposing employees, offenders, the public and the LPA to unacceptable levels of risk and possible litigation/prosecution.

Management Response A general guide to H&S training requirements to be produced by the NPD. Areas to ensure that all staff receive appropriate training. Accepted Y/N Y Implementation Date Phase Three

Responsible Kathryn Ball Corporate Health and Safety Manager, Chief Officers & Board Chairs

Date: March 2005

Ref: ND3104

Audit Title: LPA Health & Safety Management No 4 Recommendation An annual inspection programme should be produced and monitored by the H&SCP. Inspections must be carried out of all work areas at least annually, in accordance with H&S Regulations. In addition the H&S National Policy Manual requires these to be conducted quarterly. The manager responsible for the area must lead and TUS should be involved at all stages. The H&SCP should oversee the inspection process and take action to ensure compliance with the annual programme. (para 14)
Significance

Audit & Assurance Unit

Risk/Consequence of non implementation Failure to conduct inspections on an annual basis constitutes a breach of H&S Regulations. In addition failing to conduct quarterly inspections would be in breach of the National H&S Policy Manual. This also exposes the LPA to prosecution and unsafe working conditions increasing the risk of a serious accident/injury or even death occurring as a result. The use of an annual inspection programme helps to ensure compliance.

Management Response Areas to produce an annual inspection programme to be monitored by the H&SCP. Model inspection checklist available in National H&S Policy Manual Section 5 “Measuring & Reviewing Performance.” Accepted Y/N Y Implementation Date By end of 2005 Responsible Chief Officers & Board Chairs

2

Date: March 2005

Ref: ND3104

Audit Title: LPA Health & Safety Management No 5 Recommendation LPA ensure they have sufficient numbers of trained first aiders in each location to comply with regulations. Details of trained first aiders, their locations and certificate expiry dates should be recorded and maintained in a logical manner to prevent insufficiencies in first aid provisions and future breaches of regulations. (para 15)
Significance

Audit & Assurance Unit

Risk/Consequence of non implementation Failure to provide adequate first aid provisions is a breach of H&S Regulations and exposes the service to the risk of failing to deal efficiently and effectively with staff, offenders or members of the public who are in need of first aid. The LPA are also liable to criticism from HSE and may be vulnerable to prosecution and/or litigation as a result.

Management Response Areas to ensure adequate first aid provision as detailed in the national H&S Policy Manual ref: NPS/HS/6. Records of this provision should be kept. Accepted Implementation Responsible Y/N Date Y By end of 2005 Chief Officers & Board Chairs

2

Date: March 2005

Ref: ND3104

Audit Title: LPA Health & Safety Management No 6 Recommendation Each LPA nominate an individual(s) with responsibility for ensuring that assessments are conducted in accordance with the regulations, for ALL users of DSE. A record of all staff requiring assessments should be maintained with details of when the last assessment was carried out. This should then be regularly reviewed to ensure that it includes ALL staff, (new staff and staff who move location) and that any subsequent assessments are carried out as required. (para 17)
Significance

Audit & Assurance Unit

2

Risk/Consequence of non implementation Failure to conduct DSE assessments for users of DSE is a breach of regulations. This may also increase the risk of injury and illness related to poor working practices and set up of workstations such as bad backs and necks, ULD etc. The LPA is thus exposed to increased sickness absence levels and prosecution and/or litigation in extreme cases.

Management Response NPD will conduct a review of the IT H&S Guide. Areas to ensure that all DSE assessments are conducted, reviewed and records kept. Further guidance can be found in the national H&S Policy Manual ref: NPS/HS/18.

Accepted Y/N Y

Implementation Date NPD – As part of Phase Three Areas – By end of 2005

Responsible Kathryn Ball Corporate Health and Safety Manager, Chief Officers & Board Chairs

Date: March 2005

Ref: ND3104

Audit Title: LPA Health & Safety Management No 7 Recommendation A mechanism for ensuring the provision of PAT of personal electrical equipment for all residents with an occupancy or expected occupancy of six months or longer be developed and implemented on a National/Regional scale. For example training the AP Caretaker to carry out such PAT on an ad hoc basis or getting a local electrician to undertake the work. The latter would have to be funded by the LPA from the AP budget. (para 19) 8 Copies of BCP/Contingency Plans be held by all partnership organisations who may be involved in the event of a disaster/emergency. (para 19) 2
Significance

Audit & Assurance Unit

2

Risk/Consequence of non implementation Failing to test residents’ electrical equipment before use may cause several problems; • residents are permitted to use unsafe equipment exposing the staff/resident to the risk of electric shock, • increased risk of fire through use of such equipment, and • difficulty for staff who may wish to refuse the use of equipment, which they feel may be unsafe.

Management Response NPD Estates to consider a national mechanism to ensure the provision of PAT of personal electrical equipment for long term residents as described. Accepted Y/N Y Implementation Date Phase Three Responsible Bill Wood NPD Health and Safety Manager (Estates)

There is a risk that the response Areas to ensure that current business to an emergency will be delayed if continuity/contingency plans are shared with all all partnership organisations likely relevant partnership organisations e.g Police etc. to be involved are not aware of any part they may have to play in these plans. Accepted Implementation Responsible Y/N Date Y By end of 2005 Chief Officers & Board Chairs

Date: March 2005

Ref: ND3104

Audit Title: LPA Health & Safety Management No 9 Recommendation LPA review their current H&S Management System and compliance measuring techniques to ensure compliance with NPD national guidance and H&S legislation. (para 21)
Significance

Audit & Assurance Unit

1

10

LPA H&SCP conducts RA and workplace inspections jointly with the H&SCP, or equivalent, from all partnership organisations. (para 22)

2

Risk/Consequence of non implementation Failure to properly measure compliance with NPD national guidance and H&S legislation makes it difficult for LPA to evidence their level of compliance. This may lead to unsafe working practices developing exposing employees, offenders and the public to unacceptable levels of risk. In turn this may expose the LPA to criticism and possible prosecution/litigation from employees, offenders, the public or the HSE. There is a risk that H&S may be compromised for NPS employees located in partnership organisations’ buildings. Both the partnership organisation and the NPS have a responsibility for the H&S of these employees.

Management Response Areas to ensure that their internal review, monitoring and auditing programmes are adequate and will provide evidence of compliance with H&S legislation. Further advice available in National H&S Policy Manual section 5 “Measuring & Reviewing Performance” & section 6 “Audit.” Accepted Y/N Y Implementation Date By September 2005 Responsible Chief Officers & Board Chairs

Areas to identify all partnership organisations where their staff work and arrange a programme of joint risk assessments & inspections. Accepted Implementation Responsible Y/N Date Y By end of 2005 Chief Officers & Board Chairs

Date: March 2005

Ref: ND3104

Audit Title: LPA Health & Safety Management No 11 Recommendation LPA H&SCP writes to all partnership organisations where NPS employees are located to ask them to provide a signed statement of H&S Compliance in line with Regulation 12 of the Management of H&S Regulations 1999. (para 22)
Significance

Audit & Assurance Unit

2

Risk/Consequence of non Management Response implementation There is a risk that H&S may be Areas to obtain the signed H&S Policy Statement from compromised for NPS employees all partnership organisations where LPA staff work located in partnership organisations’ buildings. Both the partnership organisation and the NPS have a responsibility for the Accepted Implementation Responsible H&S of these employees. Y/N Date Y By end of 2005 Chief Officers & Board Chairs

Significance key: Category 1: Weaknesses in control, which, if not rectified immediately, expose the Organisation/system to a high probability that the objectives will not be met. Category 2: Weaknesses in control, which, if not rectified as soon as possible, expose the organisation/system to a probability that the objectives will not be met

Date: March 2005

Ref: ND3104

Audit Title: LPA Health & Safety Management

Audit & Assurance Unit
APPENDIX C

Definitions of Overall Opinion on Control The definitions for the overall opinion for an audit assignment are: Well controlled: (Green) * Key controls exist and are applied consistently and effectively; * Objectives are being achieved efficiently, effectively and economically (VFM). (Low risk of loss (all asset types), fraud, impropriety, or damage to reputation). Adequately controlled: (Amber) * Key controls exist but there may be some inconsistency in application; * Compensating controls are operating effectively; * Objectives achieved but not with optimum efficiency, e.g. VFM could be improved. (Some risk of loss (all asset types), fraud, impropriety, or damage to reputation). Less than Adequately controlled: (Amber) * Some key controls exist that are not applied, or there is significant evidence that they are not applied consistently and effectively; * Objectives are not being met, or are met without achieving VFM. (An above average probability of loss (all asset types), fraud, impropriety, damage to reputation.) Poorly controlled: (Red) * Key controls do not exist; * Objectives are either not met, or are met without achieving VFM. (A very high probability of loss (all asset types), fraud, impropriety, or damage to reputation).

Date: March 2005

Ref: ND3104