CCS INTERNAL AUDIT REPORT

Centre: Thompson & Grace Investments Limited (TGI)

Centre address: Km 16, Port Harcourt-Aba Expressway, Port Harcourt

Contact: Ekemini Thompson Amos

Tel No: +234 818 000 4000

Approved Standards: Rigger Stage 1 & 2

Audit Dates: 24th to 25th August 2020 + (Practical Training Delivery TBA)

Audit Number: 001

Audit Type: Internal Audit (Criterion 1.4) incl

Auditor: Chris Wright (Credible Consultancy Services)

Credible
Credible Consultancy Services Ltd Registered In Scotland No. SC617461. 272, Bath Street,
Consultancy
Glasgow G2 4YR
Services Ltd contact
details:

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 PRE-AUDIT BRIEFING

Date: 24th August 2020

Auditor: Chris Wright

Centre Staff: Ekemini Amos, Magdalene Esen, John Davidson

Brief to include:  Duration of audit

 Personnel involved
 Audit process including: references, evidence of compliance/non-compliance, observations,
corrective actions, recommendations.
 Scope of audit (Tick as appropriate): Management Systems 
Physical Resources 
Staff Resources 
Training/Assessment delivery 
MERP Requirements 
 Auditor requirements

Additional At 08.30 an opening meeting was conducted in which CW introduced himself as the CCS auditor and
Comments: went on, to explain the purpose and scope of the Initial Internal Audit against the OPITO Approval
Criteria, the OPITO Rigger 1 & 2 standard and MERP Requirements. CW emphasised that the he was
looking for evidence of compliance during the audit and reminded TGI that safety was paramount during
any practical exercises conducted.
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 The duration of the audit (3 days), the nature of the audit report produced and the requirement for an exit
meeting on each day of the audit were all explained.
The audit scope was discussed and it was agreed that the first 2 days of audit would consist of the audit
of all OPITO Approval & MERP criteria with associated video conferencing staff interviews, followed by
the audit of selective areas of Rigger 1 training delivery which would be delivered by TGI and provided
for audit as video evidence files.
TGI were asked if they had any specific questions about the audit process and the auditor concluded by
asking if there had been any significant changes since the final OPITO accepted desktop submission.
TGI explained that there had been some changes with Management System documentation to meet new
OPITO requirements and also some small changes with course delivery documents. No further changes
were discussed)

Day. 1 EXIT MEETING

Date: Monday 24th August

Auditor: Chris Wright

Centre Staff: Ekemini Thompson, Magdalene Esen, John Davidson

Additional Day 1 of the audit began following the Initial Opening meeting with the systematic review of all current
Comments: documentation provided for audit in Section 1 of the OPITO Approval criteria ‘Management Systems’.
Throughout the day a thorough review of all procedures and associated documentation provided took
place along with a single question & answer session attended by senior TGI management to clarify some
issues raised.
Overall the majority of documentation reviewed was found to be compliant however some areas were
found to contain issues and these are captured in the observations and Non-Compliance sections

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 detailed in this report.
It was noted by the auditor that the OPITO Management System provided was extremely ISO based in
origin which has led to procedure numbering which has no relation to the OPITO requirement and the
production of a Quality Manual which is not required by OPITO. That said the content of most documents
has been tailored to meet OPITO requirements.
The biggest issues highlighted in day 1 of the audit concerned out of date TGI documentation which
does not now meet current OPITO requirements.
It was noted that the first desktop submission from TGI to OPITO occurred on the 18/04/2018 and that
the final closure of the desktop audit by OPITO only occurred on 22/01/2020 after a total of 7
submissions were reviewed by 3 different auditors.
In a period of almost 2 years there have been considerable changes to OPITO requirements and it is not
at all clear if these changes have been implemented within the desktop audit by OPITO auditors, leading
to what looks like a desktop closure against historic rather than current OPITO requirements where
criteria like 1.13.2 have simply not been revisited. This point is demonstrated by the amount of non-
compliance raised on day 1 against the historic MER documentation provided for audit rather than
current MERP documentation which should exist.
Throughout day 1 a number of observations and areas of non-compliance were captured details of which
can be found within this report.

Observations:
 It was noted that the Policy reviewed for criterion 1.1 was titled as a ‘Quality Policy’ as this is an
ISO rather than an OPITO requirement and TGI might be best to re-name this document as an
‘OPITO Policy’ as it is written explicitly to meet the OPITO requirements.
 The organisational chart provided did not detail any third party responsibility for Rigger lifting
equipment and accessory inspection, certification and testing with only NDT detailed which it is
assumed has been added due to testing & inspection of the actual rigger frame. As such it is not
clear to the auditor if equipment inspection, testing & certification has been accounted for. TGI are
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 strongly advised to revise the organisation chart including all 03 rd party responsibility in relation to
the delivery of the standard.
 It was noted that the Complaints Resolution Procedure SOP-15 available at the time of audit also
contained information on the unrelated subject of Appeals in which no official documentation was
available to record an appeal and no ‘Internal Verifier’ was identified in the process of
investigation against an appeal. As OPITO do not state in the approval criteria that criterion 1.6 &
4.6 can be combined TGI are strongly advised to separate the process of complaint and the
process of Appeal to avoid possible N/C and ensure that the two processes are never confused.
TGI are also strongly advised to involve an ‘Internal Verifier’ in any process of Appeal as the title
suggests they would normally verify the assessment process and the assessment results.
 The Records & Database Control Procedure SOP-02 available at the time of audit identified the
‘Training Coordinator’ as the only person to have secure access to Delegate Assessment records,
it is unclear if anyone else has access e.g. the Director/ Training Manager. It is also unclear where
the ‘fire resistant steel drawers’ used for secure storage records is actually located e.g. Admin
Office. To avoid possible Non-compliance during the OPITO Audit TGI are strongly advised to
revise SOP-12 accordingly to detail all persons who have access to secure delegate assessment
records and the actual location of the ‘Fire resistant steel drawers’.
 The Maintenance Schedule F08.2 provided at the time of audit was blank, giving no real indication
of the planned maintenance regime on site. In addition to this it was not clear who would carry out
‘In-House Maintenance’ if required under preventative/ corrective maintenance as no
maintenance function is identified on the organisation chart or why the equipment user instead of
the logistics coordinator is responsible for identifying equipment maintenance requirements under
03rd party NDT process.
 The Course Booking form TGIL/T-F05.1 provided to satisfy the requirement of criterion 1.12
needs to have some further information added to ensure that a NC is not raised by OPITO during
audit. TGI are strongly advised to add further content to the Course Booking Form where the line
‘Special Need(s) of delegate:’ currently exists adding the sub heading examples: ‘English not first
language’, Literacy, Religious considerations, Disability

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  The Safety Procedure TGIL/T-SOP-09 available at the time of audit whilst accepted by OPITO at
the desktop stage did not go far enough to address all relevant ‘General’ Safety issues regarding
training delivery in PH Nigeria and as it stands maybe the source of NC during the OPITO site
audit. TGI are strongly advised to expand the Safety Procedure content to include general detail
on a minimum of the following topics to avoid possible NC: Fire Procedures on location, power
failure procedures, Flood/ Storm/ Lightening procedures, Cold/ Hot weather procedures activity
specific e.g. Practical Rigging Activity, Civil unrest procedures, Security procedures.
 The Medical Emergency Response Plan TGIL/T-F10. Available at the time of audit indicated that
a ‘Tier 2 Company Nurse’ would be dispatched in the event of an emergency. However other
evidence seemed to indicate that a 03rd party organization would be used for the provision of Tier
2 medical staff? To avoid almost certain N/C during the OPITO Audit TGI must clarify how the Tier
2 provision will be satisfied and ensure this is properly documented. It should be remembered that
if the Tier 2 provision is provided internally then evidence of all Tier 2 requirements must be
provided.
 Medical Emergency Drill Schedule TGIL/T-F10.1 available at the time of audit detailed the
outdated MER requirements rather than the current MERP requirements. To avoid certain N/C
during OPITO Audit TGI are advised to revise all details within the document ensuring that the
current requirement of MERP is satisfied.
 It was observed by the auditor that no MERP Equipment maintenance plans/ schedules or
checklists were available at the time of audit. It should be noted that almost all manufacturers
requirements require regular checks and maintenance of defibrillators (AED) which should be
documented, and that if O2 is present on-site this must be maintained and should be
documented. To avoid possible OPITO N/C during audit TGI are strongly advised to develop a
MERP equipment maintenance schedule and associated checklists in line with manufacturers/
legislative requirements.
 It is difficult for the auditor to see how the blank ‘Emergency Drill Report’ TGIL/T-F10.2 provided
at the time of audit would fully satisfy MERP 6.2.2 & 6.2.3 requirements. TGI are advised to have
at least one fully populated MERP drill report available for OPITO Audit which should correspond

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 to the requirements of the correctly populated ‘Drill Schedule’.
 In Criteria 1.13.5 The Accident/Incident Reporting & Investigation procedure SOP-11 mentions the
use of an Accident/Incident Report TGIL/T-F11.1 which was not available at the time of audit for
review. TGI are strongly advised to ensure that all procedures and related documents are
submitted together for the purposes of OPITO audit.
 In criterion 1.13.6 it is not clear to the auditor how the blank Toolbox Talk Report F09.4 will be
delivered consistently on each course without detailed information concerning the ‘specific task
description/ practical exercise to be conducted’ being added. It is also not clear to the auditor why
the ‘HSE coordinator’ is required to deliver all Toolbox Talks which would normally be delivered by
the course instructor. TGI must be careful to ensure that OPITO requirements are met regarding
the content of the Toolbox Talk to avoid possible N/C during the audit.

Day. 2 EXIT MEETING

Date: 25/08/2019

Auditor: Chris Wright

Centre Staff: Ekemini Thompson, Magdalene Esen, John Davidson

Additional Day 2 of the audit began where day 1 had left off with a review of all documentation available connected
Comments: to section 2 of the OPITO approval criteria ‘Physical Resources’. This was followed by the review of all
available documentation provided for section 3 of the approval criteria ‘Staff Resources’ and concluded
with the review of all available documentation provided for section 4 of the approval criteria ‘Training &
Assessment’.
It was immediately apparent to the auditor on day 2 that a lot of the documented information provided by
TGI was incomplete and that despite requests by the auditor on more than one occasion that all the
documentation provided for audit was current and corresponded with the information seen by OPITO to
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 close the recent desktop audit this was simply not the case with large sections of multiple OPITO
requirements where no documentation was provided at all.
In the absence of so much documentation the auditor had no choice but to simply write up Non-
Compliance to highlight where gaps in the documentation provided existed.
Throughout day 2 a number of observations and areas of non-compliance were captured details of which
can be found within this report.

Observations:
 The maintenance schedule F08.2 available at the time of audit was nothing more than a blank
sheet which did not appear to relate to the ‘preventative Maintenance Plan’ (Table 2) of the
Maintenance Procedure SOP-08 and it is not clear to the auditor how these documents are to be
used practically. In addition to this the ‘Contingency plan’ F08.4 contains information on a mobile
crane & forklift which will not be used to deliver the Rigging Standard and it is not clear why a
document created on 01/02/2019 was signed off on 20/06/2019, It is also not clear why the back-
up generator will take 30 mins to start up in the event of power failure, or why lifting equipment
and accessories are not overstocked in the rigging loft preventing a 2 day delay for replacement
supplies. TGI must be careful that all maintenance system documentation is fit for purpose and
clearly shows that a robust maintenance system is in operation ensuring the safe delivery of the
OPITO Standard at all times.
 It is not clear to the auditor why the ‘Rigger Competence Assessment Checklist’ F07.2 available at
the time of audit was provided without any detail regarding the actual Rigger Standard Learning
Outcomes, without the actual learning outcomes written down it is difficult to see how an
instructor/assessor can consistently assess against standard requirements if he is expected to
remember all 44 Learning Outcomes. TGI are strongly advised to populate the Rigger
Competence Assessment Checklist with the 44 learning outcomes as detailed in the standard to
avoid possible N/C during the site audit.
 It was noted by the auditor that the Training Assessment Procedure-SOP-07 only contained part
of the information required by OPITO regarding Verification, missing out information regarding a
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 schedule detailing when verification will take place and how and when their will be meetings with
assessors where support & advice is provided Ref. Criterion 4.7. To avoid possible N/C during
audit TGI are strongly advised to expand the current procedure to include detail regarding
meetings with assessors & sampling of assessment evidence and provide a verification schedule/
calendar which clearly demonstrates when the process of verification will be conducted.

Day. 3 EXIT MEETING

Date: TBA

Auditor: Chris Wright

Centre Staff: TBC

Additional Day 3 of the audit will concentrate on the actual Theory & Practical Rigger Stage 1 Delivery. This section
Comments: of the audit report will be completed when evidence of actual training delivery can be provided for review

Observations:


Report Received and Accepted

Clients acceptance
signature:

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Print Name and Position:

Date:

Auditors signature –

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 1. MANAGEMENT SYSTEMS

The centre has a formally documented, effective system for assuring the quality and content of training and
assessment and compliance with the OPITO approval criteria.

OPITO Requirement Explanation of minimum evidence required Evidence of compliance

1.Management Systems

Management Systems are required to include the following:

1.1 An explicit policy
demonstrating commitment
by senior management to
safely implement and
maintain OPITO standards.
(signed by Senior
Management)
1.2 A Customer Service Statement
which clearly defines the
standards of service which
delegates can expect to
receive from the OPITO
approved centre.
This policy must reflect the organisation’s overall Quality Policy TGIL/T-P-02 Rev02 15/07/2019
philosophy and commitment towards complying with
OPITO’s training and assessment requirements. It must be
explicit to OPITO approval and be signed by senior
management.
This statement must be brought to the attention of Customer Service Statement TGIL/T-P-01 (Rev1, 05 January
delegates by inclusion in course materials and displayed in 2016)
training areas.
A pro forma statement is available at the OPITO Training
Provider Portal

1.3 Organisation chart, roles and The organisation chart must show roles and responsibilities Training Organizational Chart TGIL/T-OC-01 Rev02
responsibilities and authority as well as reporting authority for the management and safe 30/12/2019
for the management and Safe delivery of the OPITO approved standard (training provider
delivery of the OPITO management and all staff involved in the delivery of the
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 OPITO Requirement
approved standard.
Formally documented procedures are required which:
1.4 Ensure frequent internal audits
are conducted by
appropriately trained
personnel with no conflicting
interest in the area(s) being
audited (i.e. auditors must not
audit their own work) of all
system activities and
procedures relative to the
OPITO standard and Approval
Criteria.
1.5 Ensure regular review by
Senior Management of the
organisation’s effective and
safe delivery of OPITO courses
and compliance with OPITO
approval requirements.
Credible Consultancy Services Ltd Registered In Scotland No. SC617461. 272, Bath Street, Glasgow G2 4YR
CCS Internal Audit Form.2,Rev.3 (04/06/2020))
Explanation of minimum evidence required Evidence of compliance
OPITO standard). The roles and responsibilities of any third
parties related to the delivery of the OPITO standard e.g.
facilities and equipment must be indicated
This documented procedure will cover auditing of OPITO Internal Audit Procedure TGIL/T-SOP-12 Rev02 30/12/2019
approval requirements. All the criteria of management Internal Audit Plan TGIL/T-F12.2 Rev00 01/02/2019
systems, staff resources, physical resources and training Internal Audit Schedule TGIL/T-F12.1 Rev03 29/11/2019
and assessment must be subject to internal audit. This is in Internal Audit Checklist TGIL/T-F12.3 Rev00 01/06/2019
addition to actual audit of approved training delivery Internal Audit Report TGIL/T-F12.4 Rev00 01/06/2019
and/or assessment standards which also need to be
audited. Evidence must include valid Internal Auditor
training certification/ qualifications for at least one member
of staff identified as a person with no conflicting interest
and an indicative audit plan. The training provider must
ensure that the internal audit plan captures all existing
OPITO criteria & approved standard requirements, and
include any new standard applications.
Minimum Internal Audit frequency – Annual.
OPITO may also look for an Internal audit schedule which
should be made available
This documented procedure will cover the process for Management Review Procedure TGIL/T-SOP-16 Rev00
Management review of the delivery of OPITO training. The 01/02/2019
management review will cover as a minimum the following Management Review Schedule TGIL/T-F16-1 Rev00
fixed agenda: (1) Review of safe systems of work to ensure 01/02/2019
safety is being maintained, (2) Internal/external audit
Management Review Report TGIL/T-F16-2 Rev00
findings, (3) Customer/delegate feedback, (4) Assessment
results, (5) Incident reports and statistics, (6) Emergency
01/02/2019
Response drill reports, (7) Inspection and maintenance
reports, (8) Competence matrix, (9) complaints (10)
Appeals. Evidence will include management review meeting
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 OPITO Requirement Explanation of minimum evidence required Evidence of compliance
agenda covered within minutes of meetings. OPITO may
also look for a Management review schedule which should
be made available

1.6 Support delegate complaints.* A documented procedure which shows all steps in dealing Complaints Resolution Procedure TGIL/T-SOP-15 Rev01
with delegate complaints, the person(s) responsible, how 01/06/2019
delegates are made aware of the procedure, what records Complaint Report TGIL/T-F15.1 Rev00 01/02/2019
are kept etc. Complaint Register TGIL/T-F15.2 Rev00 01/02/2019

1.7 Control the maintenance,
updating and back-up of
databases (IT and/or
manual).*
1.8 Ensure accurate records of
candidate/delegate
assessment are maintained
and securely stored.*
This may be a single documented procedure which
identifies relevant databases or controls may be included in
other procedures e.g. maintenance, administration etc.
The documented procedure requires to indicate how is this
undertaken, how and where the records are stored, who is
responsible for maintaining the records, what security
provisions are in place, etc. This information may be
included in the general assessment procedure(s) and
would normally be accepted if included as part of the
administration procedure
Records & Database Control Procedure TGIL/T-SOP-02
Rev03 30/12/2019
Records & Database Control Procedure TGIL/T-SOP-02
Rev03 30/12/2019
Records & Database Guide TGIL/T-F02.1 Rev00 01/02/2019
Records & Database Index TGIL/T-F02.1 Rev01 30/12/2019

1.9 Ensure appropriate inspection
maintenance activities for all
facilities and equipment to be
used during delivery of the
OPITO Standard.*
A documented procedure which shows that a system is in Maintenance Procedure TGIL/T-SOP-08 Rev02 23/07/2019
place for planned and unplanned maintenance of all Maintenance Schedule TGIL/T-FO8.2 Rev00 01/02/2019
facilities and equipment.
Training Providers must demonstrate that they are capable
of determining and implementing an effective and safe
maintenance and inspection Regime.
Where local legal or regulatory requirements, industry
standards or recognised good practice, and requirements
defined by the OEM, are insufficient to guide the creation
and assurance of a robust Regime for High-Risk Equipment,
then it is the Training Provider’s duty to demonstrate that

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 OPITO Requirement Explanation of minimum evidence required Evidence of compliance
the Regime fulfils the requirements of the OPITO
Maintenance and inspection Policy.

1.10 Ensure effective liaison and
communication between all
sites where training and/or
assessment is conducted.*
A documented procedure which applies only to centres N/A
having remote sites where training is conducted e.g.
TEMPSC / fire ground areas etc. Procedures are required to
demonstrate that management systems accommodate
these. E.g. administration, maintenance, document control
procedures and emergency response procedures including
communication, equipment, staff etc.

1.11 Ensure that OPITO
administrative requirements
are fulfilled.
These are required to include
the following:
1.11.2 Verification of delegate
pre-requisites (where required)
1.11.3 Dispensation for expired
certificates, including three
month allowance window for
delegates to retake not yet
competent (NYC) outcomes
(where applicable)
A formally documented procedure which shows the
administration process from booking through to
certification is required.
Note for 1.11.1: OPITO will assist in putting an electronic
registration system in place once approval has been
granted.
Administration Procedure TGIL/T-SOP-05 Rev02 23/07/2019
1.11.2, Section 3.1 Course Booking Administration, Step 4
1.11.3, No detail on Dispensation.
1.11.1, No detail on Delegate Registration, Forwarding of
details: Section 3.1 Course Booking Administration, Step 5,
Section 3.2 Post Training Administration, Step 5,
1.11.5 Section 3.1 Course Booking Administration, Step 6/7
1.11.6 Section 3.1 Course Booking Administration, Step 2 &
Course Booking Form TGIL/T-F05.1 Rev00 01/02/2019
1.11.4 Section 3.2 Post Training Administration, Step 2

1.11.1 Delegate registration &

forwarding of delegate
registration details to OPITO on
a weekly basis.

1.11.5 Ensure verification of

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 OPITO Requirement Explanation of minimum evidence required Evidence of compliance
delegate identity by means of
government issued
photographic I.D. e.g. Passport,
Driving Licence, etc.

1.11.6 Obtain delegates current

contact information for next of
kin and/or sponsor for
delegates in case of an
emergency.

1.11.4 Certificate issue

1.12 Facilitate the identification of
resources required by
candidates/delegates with
individual training and
assessment requirements and
ensure availability.
A documented procedure is required. Examples of Administration Procedure TGIL/T-SOP-05 Rev02 23/07/2019
individual training and assessment requirements include: Section 3.1 Course Booking Administration
- English not first language Course Booking Form TGIL/T-F05.1 Rev00 01/02/2019
- Literacy
- Religious considerations
- Disability
This information may be included in the administration
procedure(s).

1.13 Ensure all training is conducted

safely and delegate well-being
is maintained at all times.
Procedures/ documentation
are/ is required to include the
following:
1.13.1 General Safety Procedures Documented Safety Procedures relevant to the OPITO Safety Procedure TGIL/T-SOP-09 Rev03 09/03/2020
Standard(s) being delivered are required. (These should No photographic evidence provided for:
detail general site safety relevant to standard delivery e.g. - Changing rooms, toilets, showers, washing
Fire Procedures on location, power failure procedures, facilities and canteen appropriate to training
Flood procedures, cold/ hot weather procedures standard provided and the number of delegates
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 OPITO Requirement
1.13.2 Emergency Procedure
including external interfaces
and exercises
Medical Emergency Response Planning Requirements (MERP)
MERP A.R.1.1.1
The Training Centre must
have a Medical Emergency
Response Plan (MERP) as
detailed in Section 1.1. Tiered
time-based responses as
detailed in the MERP are to
be indicated clearly in the
Training Centre’s risk
assessment as per the matrix
in Appendix E.
MERP A.R.1.1.2
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Explanation of minimum evidence required Evidence of compliance
activity specific, civil unrest procedures, security - Emergency escape routes
procedures, basic emergency response procedures etc.) - Site Muster Points
Photographic evidence of delegate’s well-being must
include as a minimum:
- Changing rooms, toilets, showers, washing
facilities and canteen appropriate to training
provided and the number of delegates
- Emergency escape routes
- Site Muster Points
A formally documented procedure/ process/ evidence is Emergency Response Procedure TGIL/T-SOP-10 Rev01
required which shows that the Training Provider is capable 01/06/2019
of responding to an emergency within the expected
timeframes, have sufficient competent medical emergency
response staff, and necessary medical equipment and
facilities. Refer to OPITO Medical Emergency Response and
Planning Requirements document for further information
on the evidence required.
.See criterion 1.13.2 & 1.13.3 .See criterion 1.13.2 & 1.13.3
Medical Emergency Response Plan TGIL/T-F10.3 Rev00
01/06/2019
Risk Assessment Form TGIL/T-F09.1 Rev01 01/06/2019
.See criterion 1.13.3 .See criterion 1.13.2 & 1.13.3
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 OPITO Requirement
Each Training Centre’s training
activities are specifically risk-
assessed as per the criteria
noted in Appendix E, and this
forms part of the overall risk
assessment.
MERP A.R.1.1.3
The geographical location of
the Training Centre is
specifically considered as per
Appendix E, and this forms
part of the overall risk
assessment.
MERP A.R.1.1.4
Any additional Training Centre
personnel and equipment as
required by risk assessments
and the MERP are clearly
noted as per the risk matrix in
Appendix E.
MERP A.R.2.1.1
Annual Training Matrix/Plans
are current & available for all
relevant MER staff, this may
be included in the training
providers overall training plan
MERP A.R.2.2.1
Staff training covering Tier 0
(2.2 a-h has been conducted,
training records are available
and current
a) How to raise the alarm
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Explanation of minimum evidence required Evidence of compliance
Risk Assessment Form TGIL/T-F09.1 Rev01 01/06/2019
The training provider must use the MERP link .See criterion 1.13.2 & 1.13.3
https://www.travelriskmap.com/#/planner/locations No evidence provided at time of audit
provided under table.3 ‘Definitions of country profile
ratings’ to determine whether the Country Medical Profile
Risk Rating is Low, Medium, Rapidly Developing Variable,
High, Extreme
Information should be added to Training Risk Assessments
which indicates that this has been done
.See criterion 1.13.3
The training provider must calculate the degree of risk .See criterion 1.13.2 & 1.13.3
according to Appendix. E (Low Risk = A1,A2,A3,B1) (Medium No evidence provided at time of audit
Risk = B2,C1) (High Risk B3,C2,C3) and provide the extra
equipment or staff as required e.g. spinal immobilisation
equipment, Tier 2 Staff. This should be detailed on the Risk
Assessment
.See criterion 1.13.3
An annual training plan/ matrix must be available for all Medical Emergency Drill Schedule TGIL/T-F10.1 Rev01
individuals involved in incident management and medical 15/07/2019
emergency response this plan should be part of other Competence Matrix TGIL/T-F03.1 Rev01 30/12/2019
training plans.
A training matrix denoting that all staff are tier 0 trained Competence Matrix TGIL/T-F03.1 Rev01 30/12/2019
(This information could be included in an existing matrix, No evidence provided at time of audit
see criterion 3.1 and the OPITO MERP Guidance
document) In addition to this internal certification for all
Tier 0 staff may be required and copies of the Tier 0 course
register and course content used to deliver the Tier 0 staff
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 OPITO Requirement Explanation of minimum evidence required Evidence of compliance
ensuring scene safety, training may be requested.
including communication of
site location
b) Nature of incident/
emergency
c) Basic initial casualty
assessment including, basic
Do’s & don’ts such as how to
assure, reassure, ensure
comfort, care of casualty e.g.
Keeping warm/ cool or
limiting movement
d) Site specific hazards (fire,
chemicals etc.)
e) Access routes (e.g. gates/
doors to use & notify
security)
f) Number of casualties,
action taken
g) Recognition of stress in
delegates
h) Type of emergency services
already present or required
MERP A.R.2.3.1 A training matrix denoting which staff are tier 1 trained, in Competence Matrix TGIL/T-F03.1 Rev01 30/12/2019
Designated First Aiders (DFA/ accordance with the centers own risk assessments (This No evidence provided at time of audit
Tier1 staff) hold valid DFA information could be included in an existing matrix, see
qualification as listed on criterion 3.1 and the OPITO MERP Guidance document) In
National websites, or qualified addition to this DFA’s (Tier1 Staff) must provide evidence of
with Red Cross/Red suitable valid, Nationally accepted 3rd party qualification
Crescent/St John (examples as listed in the MERP requirements 40hrs
Ambulance/American Heart training with O2 provision) It should be noted that DFA’s
Foundation. In addition there must also be Tier 0 trained
is evidence that items 2.3 (a –
f) have been covered:
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Credible Consultancy Services Ltd Registered In Scotland No. SC617461. 272, Bath Street, Glasgow G2 4YR
CCS Internal Audit Form.2,Rev.3 (04/06/2020))
 OPITO Requirement
a) Scene assessment and
safety
b) Life Support to include CPR
and AED
c) Airway management (head
tilt, chin lift)
d) Basic First Aid Management
(of burns and minor injuries)
e) Initial treatment of common
medical emergencies
f) Administering O2 using
appropriate O2 equipment
MERP A.R.2.3.2
Records of twice yearly
practical training sessions (for
Tier1 staff) conducted at the
workplace facilitated by a Tier
2 MER Professional. Training
records are to include an
overview of topics covered
MERP A.R.2.4.1
MER Professionals (Tier 2) are
in possession of a valid
international medical
qualification which includes
Basic Life Support (BLS) and
Advanced Life/Cardiac Support
(ALS/ACLS) or equivalent.
Credible Consultancy Services Ltd Registered In Scotland No. SC617461. 272, Bath Street, Glasgow G2 4YR
CCS Internal Audit Form.2,Rev.3 (04/06/2020))
Explanation of minimum evidence required Evidence of compliance
Documented evidence in the form of twice yearly DFA Medical Emergency Drill Schedule TGIL/T-F10.1 Rev01
(Tier1) practical training session plan/s & documented 15/07/2019
evidence of these training sessions taking place e.g. training
reports, attendance logs, photographic evidence etc. A tier
2 professional should be present during these training
sessions or at a minimum be involved in providing the
content for the training plans and overseeing their correct
implementation (i.e. facilitation). Due to this, evidence
must be provided regarding the tier 2 professionals
qualification and any contractual arrangements in place
should the tier 2 professional only be available through a
3rd party and not an employed member of staff.
Suitable, accepted 3rd party qualifications (examples as No evidence required if Tier 2. Medical capability provided
listed in the OPITO MERP guidance document) externally??
N.B. this certification is only required if the Tier 2
professional is an employee.
If the Tier 2 capability is being met by a suitably qualified
3rd party then evidence of the contractual arrangement
and a letter from the 3rd party senior management stating
that staff provided meet the Tier 2 requirement for MER
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 OPITO Requirement
MERP A.R.2.4.2
Medical Protocols are
available for Tier 2 Medical
Professionals (where required)
covering applicable serious
injury scenario’s as identified
in training provider risk
assessment
MERP A.R.2.4.3
Yearly protocol audit records
from a Supervising
Professional e.g. a Doctor are
available and current (where
required)
Credible Consultancy Services Ltd Registered In Scotland No. SC617461. 272, Bath Street, Glasgow G2 4YR
CCS Internal Audit Form.2,Rev.3 (04/06/2020))
Explanation of minimum evidence required Evidence of compliance
should be provided. If the Tier 2 requirement is being met
by a state owned/ government provided ambulance service
evidence of the service provided and how it meets the
requirements of MER should be provided.
Evidence of the minimum of the following medical No evidence required if Tier 2. Medical capability provided
protocols as listed in OPITO MER Guidance document: externally??
Drowning, cardiac arrest, respiratory arrest, burns etc. N.B.
These protocols are only required if the Tier 2 professional
is an employee.
If the Tier 2 capability is being met by a contracted 3rd
party or government/ state provided service, documented
evidence is not required as the training centre has no
governance over the third party service provided or how it
is certified. Documentation could be provided which shows
that the minimum Tier 2 protocols are in place e.g. signed
letter from 3rd party company Senior Management.
Evidence of yearly protocol audits from a doctor and No evidence required if Tier 2. Medical capability provided
evidence of his/her qualifications to confirm that they are externally??
acceptable as a ‘supervising professional’ N.B. This
evidence is only required if the tier 2 professional is an
employee and the tier 2 capability is being managed by
the training center (see A.3.2.2).
If the Tier 2 capability is being met by a contracted 3rd
party or government/ state provided service, documented
evidence is not required as the training centre has no
governance over the third party service provided or how it
is certified. Documentation could be provided which details
and confirms that checks are carried out regarding yearly
protocol audits in the form of email communication
between parties, signed letters from senior 3rd party
management, relevant sections of medical legislation/
charters etc.
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 OPITO Requirement Explanation of minimum evidence required Evidence of compliance

MERP A.R.2.4.4 Evidence of a written agreement or contractual No evidence required as Tier 2. Medical capability provided
MER Tier 2 Medical arrangements in the case of medical training, in place to externally??
Professionals have access to allow the tier 2 medical professional to have access to a
supervising medical doctor medical doctor during training. N.B. This evidence is only
during training. required if the tier 2 professional is an employee and the
tier 2 capability is being managed by the training center. If
the Tier 2 capability is being met by a contracted 3rd party
or government/ state provided service, documented
evidence is not required as the training centre has no
governance over the third party service provided or how it
is certified.

MERP A.R.2.4.5 Documented evidence which clearly shows how skills No evidence required if Tier 2. Medical capability provided
Tier 2 MER Professional maintenance will be achieved e.g. contract or written letter externally??
certification is current & from 3rd party confirming Tier2 attendance in an
maintained ambulance or emergency room (See OPITO MER Guidance
document). N.B. This evidence is only required if the tier 2
professional is an employee. If the Tier 2 capability is being
met by a contracted 3rd party or government/ state
provided service, documented evidence is not required as
the training centre has no governance over the third party
service provided or how it is certified.
If the Tier 2 professional is outsourced documented signed
written confirmation of skills maintenance could be
provided by the external 03rd party that would satisfy this
requirement

MERP A.R.4.1.1 .See criterion 1.13.3 Risk Assessment Form TGIL/T-F09.1 Rev01 01/06/2019
The Risk Assessment shall
identify the location, type and
quantity of medical equipment
available

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Credible Consultancy Services Ltd Registered In Scotland No. SC617461. 272, Bath Street, Glasgow G2 4YR
CCS Internal Audit Form.2,Rev.3 (04/06/2020))
 OPITO Requirement
MERP A.R.4.1.2
All medical equipment
required to satisfy MERP is
maintained as per
manufacturer’s specification
and documented maintenance
records are available.
MERP A.R.4.1.3
The training site layout
includes the locations of
emergency response
equipment. The layout is
explained and visible to
delegates at the training
location.
MERP A.R.4.1.4
Training Providers have
suitable external Tier 3
facilities within the Tier 3
response time
MERP A.R.4.1.5
Training providers have
identified suitable external
Tier 2 facilities within the tier 2
response time. Where tier 2
facilities are not available
within tier 2 response time
Competent Tier 2
Professionals, transportation
Credible Consultancy Services Ltd Registered In Scotland No. SC617461. 272, Bath Street, Glasgow G2 4YR
CCS Internal Audit Form.2,Rev.3 (04/06/2020))
Explanation of minimum evidence required Evidence of compliance
Evidence will be demonstrated via: Maintenance Procedure TGIL/T-SOP-08 Rev02 23/07/2019
- Equipment/facilities checklists
- Equipment inspection and maintenance plans/
schedules based on manufacturers requirements
- 03rd party documented agreements
Documented evidence of the site layout/ plan clearly No evidence provided at time of audit
showing the location of emergency response equipment.
In addition to the plan, photographic evidence must be
provided to clearly show the location of all site layout plans
on location.
Documented evidence which clearly shows how Emergency No evidence provided at time of audit
response times have been assessed and as far as reasonably Google map timings to nearest hospitals?
practicable guaranteed, this can be provided in a number of
different ways e.g. evidence of actual drills, written
confirmation from a 3rd party, government/ state charter
regarding mandatory maximum and minimum response
times etc.. (Refer to OPITO Medical Emergency Response
and Planning Requirements document for further guidance,
Section 1, Table.1)
Documented evidence required which clearly details No evidence required if Tier 2. Medical capability provided
appropriate external Tier 2 response times i.e. 1 hour or 20 externally within acceptable timings see. A.R.4.1.4?
mins if High Risk. If the provision of external Tier 2
transportation and equipment within the tier2 response
time is not available. Documented Evidence should include
qualification of employed tier 2 professional, drivers licence
for the ambulance driver, a full inventory of the medical
equipment available on-board with each item listed
photographic evidence must be provided (this must meet
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 OPITO Requirement Explanation of minimum evidence required Evidence of compliance
and equipment must be the minimum requirement of Tier2 MER equipment in the
available onsite to ensure OPITO MER Guidance document), service/ m.o.t records for
delegate wellbeing on-route to the transportation etc.. N.B. This evidence is only required
Tier 3 facilities. (Where if the training center is in a ‘remote location’ where Tier 2
Required) (N.B. It is not clear response times cannot be met and the TP must acquire its
in the MERP document what is own ambulance, equipment & staff to satisfy the timed
meant by a ‘Tier2 facility’ in Tier responses in the centers risk own assessments based
4.1.5, it is thought that this is on Section.1 Table.1
an error and the requirement
relates to ‘Tier 2 services’
rather than ‘facility’ and
should be audited as such)
MERP A.R.4.2.1 An accurate inventory of all MER equipment required to be Inventory List TGIL/T-F08.1 Rev0 01/02/2019
Sufficient First Aid Equipment used for the safe delivery of the OPITO Standard. The
is available and includes items actual numbers/quantities available require to be listed. All
listed in 4.2 (a-q) items listed in inventory must be supported by
a) Automated external photographic evidence.
defibrillator (AED) The equipment necessary to effectively operate Emergency
b) Barrier devices and Response (including Medical) protocols will be determined
protection (i.e. pocket mask, in accordance with the health risk assessments, tiered
rubber gloves, protective response protocol, and time to nearest adequate
goggles, plastic apron, emergency medical facility. (Refer to OPITO Medical
biohazard waste bag) Emergency Response and Planning Requirements
c) Vital signs equipment (i.e. document for further guidance)
Pulse oximeter, digital
thermometer)
d) Bandages (e.g. triangular,
elastic, roller)
e) Dressings (e.g. gauze pads,
multi-trauma dressings,
adhesive dressings)
f) Alcohol-free cleaning wipes
g) Surgical gloves
h) Scissors
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CCS Internal Audit Form.2,Rev.3 (04/06/2020))
 OPITO Requirement Explanation of minimum evidence required Evidence of compliance
i) Foil blanket (adult size)
j) Splints (e.g. SAM splints)
k) Sterile eye pads
l) Cold pack compress
MERP A.R.4.3.1 An accurate inventory of all MER equipment required to be No evidence required if Tier 2. Medical capability provided
Sufficient Medical equipment used for the safe delivery of the OPITO Standard. The externally?
is available and includes items actual numbers/quantities available require to be listed. All
4.3 (a-y) items listed in inventory must be supported by
a) First aid bag (see first aid photographic evidence.
equipment contents list The equipment necessary to effectively operate Emergency
above) Response (including Medical) protocols will be determined
b) Laryngeal mask or suitable in accordance with the health risk assessments, tiered
alternative response protocol, and time to nearest adequate
c) Bag valve mask (‘Ambu bag’) emergency medical facility. (Refer to OPITO Medical
d) Oropharyngeal and Emergency Response and Planning Requirements
nasopharyngeal airways document for further guidance)
e) Intravenous cannulas and N.B. This evidence is only required if the training center
infusion sets itself is employing a Tier. 2 member of staff who would
f) Intravenous fluids require the use of Tier. 2 equipment.
g) Intramuscular injection
needles and syringes
h) Intraosseous vascular access
system
i) Intraosseous cannulas
j) Medications for pain relief
and emergency resuscitation,
as approved by a supervising
medical professional (with
manufacturer’s prescribing
information)
k) Electronic suction device
l) ECG machine (12-lead)
m) Blood pressure monitor
n) Pulse oximeter
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CCS Internal Audit Form.2,Rev.3 (04/06/2020))
 OPITO Requirement Explanation of minimum evidence required Evidence of compliance
o) Oxygen, tubing and
manometer
p) Blood sugar measurement
q) Pupil torch
r) Suture set
s) Re-hydration sachets
t) Stethoscope
u) Spinal immobilisation board
and headboard
v) Scoop stretcher
w) Current medical protocols
x) Injury and treatment
summary charts and report
forms
y) Container for contaminated
needles and sharps
MERP A.R.4.3.2 Photographic evidence must be provided to show the No evidence provided at the time of audit
A suitable ‘dedicated room’ or dedicated room provided meets the specific requirements
‘dedicated medical room’ is of the OPITO training being delivered associated with the
available during training site risk assessments provided. i.e. Tier1, Tier2 or Tier 3
activities. facility provided.

MERP A.R.6.2.1
Medical Emergency Response
Plans are formally reviewed
and approved annually
Documented information must be provided which clearly Medical Emergency Response Plan TGIL/T-F10.3 Rev00
details how medical emergency response plans are 01/06/2019
reviewed and approved, who is responsible and how the
process will be documented. (Information may be included
in the General MERP procedure written to satisfy criterion
1.13.2) MER plans could be appropriately signed and dated.

MERP A.R.6.2.2 & 6.2.3 Documentation must be provided which clearly details how Emergency Drill Schedule TGIL/T-F10.1 Rev01 15/07/2019
Records are maintained of and when MER Tier 1, 2 & 3 training & drills will be carried Emergency Drill Report TGIL/T-F10.2 Rev01 09/03/2020
Twice yearly MERP Tier 1 & out, who is responsible for providing the training & drills
MERP Tier 2 drills which and overseeing how the drill will be arranged and
include one Tier 3 third party conducted, how feedback is provided and how the process
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CCS Internal Audit Form.2,Rev.3 (04/06/2020))
 OPITO Requirement
emergency services drill
annully Where applicable,
practicing casualty extraction,
First Aid/BLS administration,
basic oxygen therapy, CPR and
defibrillator administration
are to be included
1.13.3 Job Safety Analysis/Risk
Assessments
Credible Consultancy Services Ltd Registered In Scotland No. SC617461. 272, Bath Street, Glasgow G2 4YR
CCS Internal Audit Form.2,Rev.3 (04/06/2020))
Explanation of minimum evidence required Evidence of compliance
will be documented & recorded.
In addition to the above documentation a schedule should
be provided clearly indicating proposed dates of drills
annually and examples of all documentation to be used for
recording purposes.
OPITO requires a procedure which outlines exactly how risk Risk Assessment Form TGIL/T-F09.1 Rev01 01/06/2019
assessments will be developed and who will be responsible
dynamic risk assessments, which will include tiered N.B. The risk assessment document reviewed met the
response appropriate to the level of risk, which includes requirements of MERP A.R. 1.1.1, 1.1.2 in that it
appropriate mitigations to the risks associated with the contained information regarding time based tiered
type and location of the activity being conducted, this will response and information on Training & center activity
enable the training provider to adequately prepare for and
to take the appropriate action at the right time based on
prevailing circumstances. Dynamic risk assessment will
replace any historic generic ‘static’ provision or ‘blanket’
mitigations. As an example of a static mitigation a
declaration that a Training Provider has x number of
medically trained staff or y items of medical equipment is
not sufficient mitigation. The requirement is to dynamically
assess then associate specific mitigation against specific
activity on the day with a defined set of prevailing
conditions, for example the dynamic risk assessment would
contain, scenario specific circumstances e.g. specific
hazards for that exercise have been identified, specific
equipment has been verified on location, equipment is
operational, staff are available with appropriate
qualifications (Advanced Cardiac Life Support (ACLS) or
equivalent qualification) are in date (valid).
The training provider must demonstrate fit for purpose
Emergency Response capable of responding to the highest
risk identified within section 1.13.3 i.e. within the tiered
Page 26 of 43
 OPITO Requirement
1.13.4 Medical Screening
Procedures (where
applicable)
1.13.5 Accident/Incident Reporting
and Investigation Procedure
1.13.6 Toolbox Talks (prior to
specific practical training)
Credible Consultancy Services Ltd Registered In Scotland No. SC617461. 272, Bath Street, Glasgow G2 4YR
CCS Internal Audit Form.2,Rev.3 (04/06/2020))
Explanation of minimum evidence required Evidence of compliance
MER framework (See OPITO MER Guidance Document)
A formally Documented Medical Screening Procedure Safety Procedure TGIL/T-SOP-09 Rev03 09/03/2020
relevant to the OPITO Standard(s) being delivered. Section 3.1 Medical Screening
Refer to OPITO Medical Emergency Response and planning Medical Screening Checklist TGIL/T-F09.5 Rev0 01/02/2019
requirements document for further guidance in
INTRODUCTION (prevention). “Delegates must be made
aware of the physical nature of the training; it must be
ensured that relevant fitness-to-work, associated with in-
company roles and/or fitness-to-train assessments are up
to date at the time of training”. E.g. Joining Instructions,
In addition all copies of documentation detailed within the
Medical Screening Procedure. E.g. Medical Screening form
A formally Documented Accident/Incident Reporting and Incident/ Accident Reporting & Investigation Procedure
Investigation Procedure. It is an OPITO requirement for TGIL/T-SOP-11 Rev02 15-07-2019
training providers to keep records of all incidents.
In the event of a Lost Time Incidents, an incident summary
covering the event, type of injury, initial actions and initial
incident findings, this information is required to be
communicated with the relevant OPITO Regional Manager
as soon as practical, but no later than 48 hours following
the occurrence of the Lost Time Incident, this requirement
is to be contained within the Accident /Incident reporting
and investigation procedure.
All incidents are to be recorded as defined using the OPITO
Medical Emergency Response and Planning Requirements
document Appendix F.
Incident reports and investigation records are to be
maintained and available at the time of audit and if
requested by OPITO.
A formally documented procedure which outlines the Safety Procedure TGIL/T-SOP-09 Rev03 09/03/2020
process and responsibility for toolbox talks ensuring that all Section 3.4 Toolbox Talks
Page 27 of 43
 OPITO Requirement Explanation of minimum evidence required Evidence of compliance
course participants for a particular unit attend a briefing Toolbox Talk Report TGIL/T-F09.4 Rev02 01/06/2019
session and a record of those present is to be maintained.
In addition to the procedure itself the form/s used to record
the toolbox talk must also be available.
The following must be covered and recorded as a minimum
during the toolbox talk:

a) Specific task description/practical exercises to be

conducted, including the individual right of all those
involved in the exercise to intervene and stop exercises
if there are unsafe acts and conditions, including
meaningful engagement to prevent reoccurrence and
the right to raise the alarm with staff if someone is
thought to be in distress
b) Date and time
c) Conditions at training area i.e. weather
d) Identified and explained the exercise risks and
corresponding emergency response
e) Medical provisions – location of equipment and medical
staff including emergency telephone numbers
f) Verification and confirmation of Safety
checks/inspections/pre-use checklists prior to task
commencement

Management System Non-compliance & Corrective Actions Date of signed

completion

 (N/C) The customer Service Statement available at the time of audit was out of date. Ref.

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Credible Consultancy Services Ltd Registered In Scotland No. SC617461. 272, Bath Street, Glasgow G2 4YR
CCS Internal Audit Form.2,Rev.3 (04/06/2020))
 Criterion 1.2
(C/A) TGI must replace the outdated OPITO Customer Service Statement with the most up
to date version available on the OPITO web-site.
 (N/C) The Internal audit Procedure SOP-12 available at the time of audit did not detail who
was responsible for assigning dates for the closure of Non-compliance/ Non-conformances.
In addition to this none of the associated Internal Audit paperwork reviewed was specific to
OPITO requirements and the required process of Internal Audit specifically against OPITO
requirements for documentation and training delivery could not be ascertained. It was also
noted that the Internal audit schedule provided whilst referencing some OPITO criteria did
not cover all requirements and in some instances the requirements detailed were outdated
e.g. document details MER requirements which were replaced by MERP requirements in
August 2019. Ref Criterion 1.4
(C/A) TGI must revise the Internal Audit procedure SOP-12 ensuring it details who has
responsibility of assigning timescales for the closure of Non-compliance/ Non-conformance.
In addition to this TGI must overhaul the Internal Audit Schedule, Audit Plan, Audit Checklist
& Audit report ensuring that the contents of all documents specifically relate to the current
OPITO requirements which must include the audit of actual training delivery.
 (N/C)The Administration Procedure SOP-05 available at the time of audit did not detail who
was responsible for candidate registration of the forms to be used, did not contain any detail
on dispensation and confused the process of forwarding delegate details to OPITO on a
weekly basis between the Training Manager and Training Coordinator. Ref. Criterion 1.11
(C/A) TGI must revise the Administration procedure ensuring that detail exists regarding
actual delegate registration and Dispensation and specify who is actually responsible for
forwarding delegate details to OPITO on a weekly basis.
 (N/C)The Emergency Response Procedure SOP-10 available at the time of audit had not
been updated to bring the contents in line with the current OPITO MERP requirements it
therefore contained misplaced and outdated information throughout all of which must be
revised. Ref. OPITO MERP doc.
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 (C/A) TGI must fully revise the Emergency Response procedure ensuring its contents are
aligned with OPITO’s current MERP requirements.
 (N/C) No evidence was provided at the time of audit for MERP requirements 1.1.2, 1.1.3 or
1.1.4.
(C/A) TGI must create the necessary documentation to ensure that MERP requirements
1.1.2, 1.1.3 & 1.1.4 are satisfied.
 (N/C) The only Staff Competency Matrix available at the time of audit Competence Matrix
TGIL/T-F03.1 did not detail either Tier 0 or Tier 1 staff capability Ref. MERP 2.2.1 & 2.3.1
(C/A) TGI must ensure that the MERP staff capability is detailed in a suitably revised Staff
Competency matrix. In addition to this all Tier 0 internal certification and Tier 1 external
certification must be made available for the purposes of audit.
 (N/C) The risk Assessment Form TGIL/T-F09.1 available at the time of audit did not indicate
that the geographical location the training centre had been specifically considered Ref.
MERP 1.1.3, did not indicate any additional MERP personal or equipment Ref. MERP 1.1.4
and did not identify the location, type and quantity of medical equipment available Ref.
MERP 4.1.1
(C/A) TGI must ensure that the current ‘Risk Assessment Form’ is fully revised to ensure
that all OPITO MERP requirements are satisfied.
 (N/C) No site layout plan was available at the time of audit Ref. MERP 4.1.3.
(C/A) TGI must provide a site location plan which indicates at a minimum: The training
facility layout, Smoking area, Muster points, Fire Call Points, Fire Extinguishers, Emergency
exits, and medical facility. This must be available and explained to delegates during Tool
Box Talks.
 (N/C) At the time of audit no evidence of a suitable Tier 3 facility within acceptable MERP
response times was available Ref. MERP 4.1.4.
(C/A) TGI must provide documented evidence of a suitable Tier 3 facility this could be done
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 via ‘Google Maps’ with a simple location map detailing response times from the training
centre to the nearest acceptable hospital or with a properly documented Tier 2/3 MERP drill
report, signed by the attending ambulance staff.
 (N/C) At the time of audit no evidence was available of a dedicated room/ dedicated medical
room Ref. MERP 4.3.2
(C/A) TGI must provide photographic evidence of a ‘dedicated room’ for MERP
 (N/C) At the time of audit the ‘MERP’ Inventory provided did not accurately detail all of the
required equipment, sufficient equipment numbering or any photographic evidence of the
actual MERP equipment available on site Ref. MERP 4.2.1
(C/A) TGI must produce an accurate MERP equipment inventory which clearly details the full
requirement of MERP 4.2.1 This must be supported with accurate photographic evidence of
all equipment available on-site.

Auditor Signature -

OPITO Requirement Explanation of evidence Evidence of compliance/ non-compliance

required
2.Physical Resources
2.1 Resource needs are identified in For all Facilities and Inventory List TGIL/T-F08.1 Rev0 01/02/2019

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 relation to the specific OPITO
Standard and are available.
2.2 There are sufficient and appropriate
inspection, maintenance and testing
activities to ensure that all training
and emergency response equipment
and facilities are safe and fit for
purpose. The system of
maintenance must include:
2.2.1See 2.1 above
Credible Consultancy Services Ltd Registered In Scotland No. SC617461. 272, Bath Street, Glasgow G2 4YR
CCS Internal Audit Form.2,Rev.3 (04/06/2020))
Equipment where training
and/or assessment is
conducted, the resource
needs are identified as per
relevant sections of the OPITO
Standard and associated
safety and health risk
assessments.
Evidence of compliance with
this criterion will be in the
form of an accurate inventory
of all facilities, equipment,
personal protective
equipment to be used for the
safe delivery of the OPITO
Standard. The actual
numbers/quantities available
require to be listed. All items
listed in inventory must be
supported by photographic
evidence. Details of any & all
media and reference
documentation used during
the delivery of the course will
be included.
Evidence will be 2.2.1 (See above)
demonstrated via: 2.2.2 Maintenance Procedure TGIL/T-SOP-08 23/07/2019
Contingency Plan TGIL/T-F08.4 01/02/2019
- Equipment/facilities Facility Checklist TGIL/T-F08.3F Rev0 01/02/2019
checklists Maintenance Schedule TGIL/T-F08.2 Rev0 01/02/2019
- Equipment 2.2.3 No evidence of 03rd Party Certification provided at time of audit
inspection and 2.2.4 No evidence of inspection & maintenance activity provided at time of
maintenance plans/ audit (completed equipment checklists, proper maintenance schedule
schedules e.g. maintenance calendar, OEM Maintenance manuals)
Page 32 of 43
 - Contingency plans
2.2.2Facility and equipment are also required in
inspection and maintenance the event of
plans/contingency plans (computer equipment
or paper-based). breakdown/failure
- Load test certificates
2.2.3 Third party certification of - Maintenance
facilities and equipment where Management
appropriate (e.g. for lifting Systems
equipment, medical response - OEM Maintenance
equipment, etc). Manuals or
sufficiently risk
2.2.4 Accurate recording of assessed
inspection and maintenance maintenance activity
activities conducted on facilities in accordance with
and equipment used in the delivery the OPITO
of OPITO approved training and/or Maintenance &
assessment plus facilities and Inspection Policy
equipment available to respond to
emergency situations. All high-risk
equipment adheres to the OPITO
Maintenance and Inspection Policy.

Physical Resources Non-compliance & Corrective Actions Date of signed

completion

 (N/C) The Inventory list F08.1 available at the time of audit appeared to list the entire
facility contents rather than the equipment required to safely deliver the OPITO Rigger
standard, with a number of sections of irrelevant items listed which are simply not required.
In addition to this a section titled MER was outdated and did not break down available
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CCS Internal Audit Form.2,Rev.3 (04/06/2020))
 MERP equipment on-site and the random pictures provided at the end of the document did
not clearly show all inventory items so it was not possible for the auditor to ascertain if the
OPITO requirement C.3 & C.4 was being met or not. Ref. Criterion 2.1
(C/A) TGI must fully revise the Inventory List ensuring that the OPITO Rigger standards
and MERP requirements are clearly seen to be met with the listed contents. The inventory
must also contain accurate numbers of all equipment (in-line with OPITO requirements)
and everything must be accurately photographed.
 (N/C) No evidence of any 03rd party certification was provided at the time of audit. Ref.
Criterion 2.2.3
(C/A) TGI must provide 03rd party certification for all equipment used to deliver the OPITO
Standard including commissioning and testing certification for the OPITO Rigging Frame.
In addition to this certification for any MERP equipment such as O2 & defibrillator must be
made available
 (N/C) No evidence was available at the time of audit to demonstrate that accurate
recording of inspection & maintenance was taking place. Ref. Criterion 2.2.4
(C/A) TGI must provide completed maintenance checklists for all facilities and equipment
used to deliver the OPITO standard and where relevant (e.g. MERP equipment O2 &
Defibrillator) provide the OEM manuals demonstrating that the information in the equipment
checklists is in line with the manufacturers requirements.

Auditor Signature -

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Credible Consultancy Services Ltd Registered In Scotland No. SC617461. 272, Bath Street, Glasgow G2 4YR
CCS Internal Audit Form.2,Rev.3 (04/06/2020))
 Explanation of
OPITO Requirement Evidence of compliance
evidence required
3.Staff Resources
3.1 There are sufficient staff (Instructors The relevant sections of Competence Matrix TGIL/T-F03.1 Rev01 30/12/2019
& Assessors) with the appropriate the OPITO Standard No further evidence provided at time of audit
qualifications and experience as clearly indicate the
defined within the OPITO Standard to required skills, experience
deliver effective and safe training. and qualifications for
training delivery and
competency assessment.
Evidence to be sufficient,
valid and must include;
CVs/Résumés, copies of
certificates, staff training
and competency records
to cover all staff roles.
A Competence Matrix for
all staff involved in the
delivery of the standard.

Note: In situations where

an OPITO standard
requires staff to hold an
OPITO certificate as
evidence of competence,
and this initially cannot be
achieved; training
providers could be
approved to deliver the
standard provided the
relevant staff meet the
evidence indicated in this
section 3.1.
Thereafter the relevant

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Credible Consultancy Services Ltd Registered In Scotland No. SC617461. 272, Bath Street, Glasgow G2 4YR
CCS Internal Audit Form.2,Rev.3 (04/06/2020))
 Explanation of
OPITO Requirement Evidence of compliance
evidence required
staff must achieve
certification within a 12
month period.

3.2 There are formal job Job descriptions for all job Job Description TGIL/T-F03.5 Rev0 01/02/2019 (Blank)
descriptions/specifications for all job roles specific to the safe No further evidence provided at time of audit
roles involved in the safe delivery and delivery and support of
support of the OPITO Standard. OPITO Standards. To
include instructors,
assessors, support staff,
medical and emergency
response personnel,
administrative staff,
maintenance staff, etc.
3.3 There are sufficient assessors and As for 3.1 Competence Matrix TGIL/T-F03.1 Rev01 30/12/2019
internal verifiers with the appropriate In addition to the No further evidence provided at time of audit
training and competencies to ensure evidence submitted for
quality and objective assessments of 3.1 Verifier certification
staff and delegate performance. should be available

Formally documented procedures are required which:

3.4 Ensure that staff training and
development needs are regularly
reviewed and a programme is put in
place to meet any requirements
which are identified.*
This procedure relates to
all staff involved in the
training and/or
assessment of OPITO
Standards i.e. full-time,
part-time, sub-contracted,
etc.
Competence & Awareness Procedure TGIL/T-SOP-03 Rev01 01/06/2019
Competence Matrix TGIL/T-F03.1 Rev01 30/12/2019
Training Plan TGIL/T-F03.2 Rev01 01/06/2019 (Blank)
Training Evaluation Form TGIL/T-F03.3 Rev0 01/02/2019 (Blank)
Competence Re-assessment Form TGIL/T-F03.4 Rev0 01/02/2019 (Blank)

3.5 Ensure that regular confirmation of This may be a “stand Competence & Awareness Procedure TGIL/T-SOP-03 Rev01 01/06/2019

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Credible Consultancy Services Ltd Registered In Scotland No. SC617461. 272, Bath Street, Glasgow G2 4YR
CCS Internal Audit Form.2,Rev.3 (04/06/2020))
 Explanation of
OPITO Requirement Evidence of compliance
evidence required
staff competency is undertaken. alone” procedure or be Training Plan TGIL/T-F03.2 Rev01 01/06/2019 (Blank)
part of the training & Competence Re-assessment Form TGIL/T-F03.4 Rev0 01/02/2019 (Blank)
development
process/procedure. To
include instructors,
support staff,
maintenance staff, MER
Staff etc.

Staff Resources Non-compliance & Corrective Actions Date of signed

completion

 (N/C) At the time of audit no evidence was made available to the auditor regarding staff
qualifications & experience i.e. CVs/Résumés, Copies of certificates, Completed staff
training and competency records to cover all staff roles. Ref. Criterion 3.1
(C/A) TGI must ensure that completed staff records exist with sufficient detailed
documented evidence to satisfy the requirement of Criterion 3.1 for the purposes of audit
 (N/C) At the time of audit no evidence was made available to the auditor regarding
completed Job Descriptions for all the staff roles listed on the companies organisation chart
TGIL/T-OC-01 Rev02 30/12/2019. Ref. Criterion 3.2
(C/A) TGI must ensure that detailed job descriptions exist for all staff roles identified on the
TGI Company organisational chart for the purposes of audit.
 (N/C) At the time of audit no staff qualifications (Assessor/ Verifier) were made available to
the auditor Ref. Criterion 3.3
(C/A) TGI must ensure that documented evidence is available in the form of Assessor
qualifications for Rigger Course Instructors & Verifier qualifications for company Verifiers
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CCS Internal Audit Form.2,Rev.3 (04/06/2020))
 for the purpose of audit.

Auditor Signature -

Explanation of minimum
OPITO Requirement Evidence of compliance
evidence required
4.Training & Assessment
4.1 Course Joining Instructions containing This process would normally be No evidence provided at time of audit
information, advice and guidance on included in administrative
training, assessment and safety procedures. Additional
aspects will include course learning documentation may include:
outcomes to ensure delegates have - Course Information sent
information about what they’re to delegates/delegates’
required to know and do, and (where representatives
applicable) that the course is of a - Sample of completion
stressful and/or physical nature. certificate
- Link to course specific
OPITO briefing video
materials e.g. OPITO
BOSIET DVD on the OPITO
website or a TP website

4.2 Delegates are informed of OPITO’s This will be achieved by a No evidence provided at time of audit
role within the oil & gas industry and prominently displayed notice in the
contact points within OPITO. This training centre.
may be achieved by a prominently This is available from the OPITO

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Credible Consultancy Services Ltd Registered In Scotland No. SC617461. 272, Bath Street, Glasgow G2 4YR
CCS Internal Audit Form.2,Rev.3 (04/06/2020))
 Explanation of minimum
OPITO Requirement Evidence of compliance
evidence required
displayed notice. training provider portal. Please
refer to the viewgraph
presentation titled ‘OPITO
Information’

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CCS Internal Audit Form.2,Rev.3 (04/06/2020))

OPITO Requirement
4.3 There is documentary evidence to
confirm that training and assessment
is carried out as specified within the
relevant OPITO Standard. This
documentation must include:
4.3.1 Assessment checklists
including assessment
methods, clearly
referenced against the
relevant OPITO Standard.
4.3.2 Detailed lesson/exercise
plans, clearly referenced
against the relevant
OPITO Standard (including
toolbox talks, delivery
methods
(explanation/demonstrati
on/practice),
instructor/delegate ratios,
resources to be used, time
allocation, location of
training, staff roles etc).
Credible Consultancy Services
CCS Internal Audit Form.2,Rev.3 (04/06/2020))
Explanation of minimum
Evidence of compliance
evidence required
Assessment checklists or written Rigger Initial Training Record TGIL/T-F07.1 Rev02 01/02/2019
assessment papers per the Rigger Assessment Checklist TGIL/T-F07.2 Rev00 01/02/2019
standard requirement, referenced No further evidence provided at time of audit
against the learning outcomes
contained within the standard.
Lesson plans (theory and practical)
referenced against the training
programme and learning outcomes
contained within the standard,
plans need to be sufficiently
detailed to ensure that training is
consistently delivered.
The Theoretical lesson plan sets
out what information is going to be
delivered and the sequence of
delivery to enable a competent
instructor to deliver the lesson plan
consistently and must cover all the
elements of the OPITO Standard,
as a minimum. The theoretical
lesson plan must also contain
facility and equipment required.
The Practical Exercise Plan must
contain:
 A description of the scenario
and staff roles, with supporting
drawings/plans so it is clear
what the delegates will be
expected to practice and
demonstrate. Page 40 of 43
 A list
of PPELtd Registered
required In Scotland No. SC617461. 272, Bath Street, Glasgow G2 4YR
by the
delegates
 Planned timing of exercises
 Facilities, equipment & props to

OPITO Requirement
4.4 A Timetable/Programme to cover
course delivery and enable sufficient
time for effective administration of
the programme in line with the
OPITO Standard.
Formally documented procedures are required which:
4.5 Ensure candidate/delegate
assessment is conducted in alignment
with OPITO Standard requirements.
4.6 Support candidate/delegate appeals
against assessment decisions relating
to treatment within the assessment
process.
4.7 Ensure consistency, quality and
Credible Consultancy Services Ltd Registered In Scotland No. SC617461. 272, Bath Street, Glasgow G2 4YR
CCS Internal Audit Form.2,Rev.3 (04/06/2020))
Explanation of minimum
Evidence of compliance
evidence required
Examples of documentation which No evidence provided at time of audit
reflect the optimum time
allocations set out in the OPITO
Standards must include:
- Course Programme
Timetable
- Administration and break
times
A documented procedure which Training Assessment Procedure TGIL/T-SOP-07 Rev.01 01/06/2019
outlines all steps of the
candidate/delegate assessment
process, to include addressing the
needs of candidates/delegates who
are deemed not yet competent.
This may be combined with the
appeals procedure (4.6).
A documented procedure which Complaints Resolution Procedure TGIL/T-SOP-15 Rev01 01/06/2019
outlines all steps involved in
dealing with candidate/ delegate
appeals against assessment
decisions, (This is a separate issue
from a candidate/ delegate who
wishes to complain about service)
the person(s) responsible, how
candidates/ delegates are made
aware of the procedure, what
records are kept etc
A documented procedure which Training Assessment Procedure TGIL/T-SOP-07 Rev.01 01/06/2019
Page 41 of 43
 Explanation of minimum
OPITO Requirement Evidence of compliance
evidence required
objectivity of assessments. outlines all steps required for Section 3.5 Assessment Verification
quality assurance of the Assessment Verification Checklist TGIL/T-F07-03 Rev.00 01/02/2019
assessment process. i.e.
‘Verification’ This may include:
- Meetings with Assessors
where support and advice
to assessors is provided
- Sampling of assessment
evidence to verify
assessor’s decisions and
assessment
- Record keeping

Training & Assessment Non-compliance & Corrective Actions Date of signed

completion

 (N/C) No evidence was provided at the time of audit regarding course joining instructions or
course certification Ref. Criterion 4.1
(C/A) TGI must ensure that appropriate course joining Instructions and an example of an
appropriate Rigger Stage 1 Course certificate are available for the purposes of audit
 (N/C) A copy of the current OPITO Role Statement was not provided at the time of audit
Ref. Criterion 4.2
(C/A) TGI must ensure that a copy of the current OPITO Role Statement is available for
audit
 (N/C) No Rigger Stage1 Course lesson plans or Rigger Stage 1 Written Assessment were
provided at the time of audit Ref. Criterion 4.3.2
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CCS Internal Audit Form.2,Rev.3 (04/06/2020))
 (C/A) TGI must ensure that Rigger Stage 1 lesson plans are made available for the
purposes of audit these must be sufficiently detailed for Theory & practical delivery, clearly
referenced against the Rigger Stage 1 Standard and must include evidence of toolbox
talks, delivery methods, Instructor/delegate ratios, resources, location of training, staff roles
etc.
 (N/C) No Rigger Stage 1 timetable was available at the time of audit Ref. Criterion 4.4
(C/A) TGI must ensure that a Rigger Stage 1 timetable is available which covers the course
delivery and enables sufficient time for effective administration of the Rigger programme in
line with the OPITO standard

Auditor Signature -

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Credible Consultancy Services Ltd Registered In Scotland No. SC617461. 272, Bath Street, Glasgow G2 4YR
CCS Internal Audit Form.2,Rev.3 (04/06/2020))