NON-COMFORMANCE AUDIT REPORT AND ACTION PLAN - 2019

Reference Requirement Outcome Dept. Responsibility Due Date Status DATE

The product composition (ingredients)

1.2.1 Specifications was not listed in descending order of Quality
Minor NC William/ Akhilesh 31/01/2020 In Progress
- General/ B.A 1.1 quantity (e.g. refer to di potassium Assurance
phosphate and glycerol monostearate).

The 'Identification, Labelling and

Traceability' procedure (FS24, revision
0, 01/03/17) did not indicate that the
recording of batch numbers was
1.4 Traceability/ B.A Quality
required on dispatch / distribution Minor NC Choolwe 31/01/2020 DONE 16/01/2020
2.1 Assurance
records. The procedure also did not
detail how traceability of primary
packaging should be maintained in the
various facilities.

The batch code of the foil packaging

Quality
used for Cream-It pouches / sachets on
1.4.5 Traceability - Assurance/ Choolwe/ Siame/
the day of the site inspection had not Minor NC 31/01/2020 DONE 21/01/2020
Records/ B.A 2.3 Production- Brian
been documented on traceability
Creamer
records.

(Observation: A calibration certificate

was not available for the handheld
1.10.1 Device refractometer as there was no Quality
Minor NC Akhilesh/ William 31/01/2020 In Progress
Control/ I.A 8.2 accredited organisation in Zambia to Assurance
conduct these calibration. Records of
verification, however, were in place.)
 The new employee training document
1.11.1 Documented
(FS08-1/3, revision 00, 20/12/18) did Quality
Training Minor NC Akhilesh 31/01/2020 In Progress
not include personal hygiene and code Assurance
Programme/ I.A 9.3
of conduct training.

1.13.3 Verification Certificates of conformance were not

Quality
of Inputs - Raw available for the laminated foil used for Minor NC Akhilesh 31/01/2020 In Progress
Assurance
Materials/ I.A 12.1 Cream-It sachets.

ZMC Nutritional Product Company, the

supplier of Beta Carotene, and NCP, the
I.A 13.1/ 1.14.2 Quality
supplier of Nitric Acid were not Minor NC Choolwe/ Akhilesh 31/01/2020 In Progress
Records Assurance
included on the Approved Supplier List
(FS16-1, revision 01, 21/10/18).

The management review conducted on

1.18.2 Records/ Quality
02/05/2018 did not include review of Minor NC William 31/01/2020 In Progress
GFSI ISO 22000 Assurance
policies and food safety objectives.

The ingredient declaration on both the

1.20.1 Label Cream-It foil pouch / sachet and the Quality
Akhilesh/ Vinod/
Compliance/ outer box did not include all ingredients Minor NC Assurance/ 31/01/2020 In Progress
Stanely/ William
GFSIReg 146 (e.g. sugar, riboflavin and di potassium Production
phosphate).Also, see section 2.13.15.

The Communication procedure (FS06,

1.21.1 Documented
revision 00, 27/03/17) did not
Program Quality
adequately detail the tools and means Minor NC Akhilesh/ William 31/01/2020 In Progress
Documented/ISO Assurance
of external communication (only
22000
facsimile observed).
 The blood spillage procedure, observed
2.5 Staff - Personnel in the 'Personal Hygiene Practices'
Hygiene, Protective procedure (FS10, revision 00, 04/03/17) Quality
Choolwe 31/01/2020 DONE 17/01/2020
Clothing and Medical did not address how affected Assurance
Screening equipment and product would be
handled.
Minor NC

The plaster glove procedure, also in the

'Personal Hygiene Practices' procedure,
Quality
did not indicate that plasters should be Choolwe 31/01/2020 DONE 17/01/2020
Assurance
returned / checked at the end of the
shift.

2.5.6 Observed Quality

Metal buttons were observed on visitors' Akhilesh/ William/
Behaviour - Minor NC Assurance / 31/01/2020 In Progress
and management’s protective clothing. Stanely
Protective Clothing Production

Communication procedures addressing

2.5.7 Infectious actions to be taken in the case of an Quality
Minor NC William/ Akhilesh 31/01/2020 In Progress
Disease Control infectious disease were not in place for Assurance
personnel, contractors and visitors.

Evidence that gloves had been issued

when plasters were issued for hand
2.5.8 Medical injuries were not available. (Also a Quality
Choolwe/ Production
Screening and requirement of the internal personal Minor NC Assurance/ 31/01/2020 DONE 17/01/2020
Supervisors
Incidents hygiene code of conduct procedure.) Production
Records of plaster inspections at the
end of the shift were not available.

The pest control procedure (FS12,

2.9 Services - Pest
revision 00, 07/03/17) did not specify Quality
Prevention and Minor NC William/ Akhilesh 31/01/2020 In Progress
the pests relevant to the site and Assurance
Control
products (i.e. target pests).
 A PCO registration certificate was not
2.9.3 External
available for one of the pest control Quality
Provider William/ Akhilesh 31/01/2020 In Progress
officers from the appointed pest control Assurance
DocumentationPest
company.

Minor NC
The PCO registration certificate for one
of the pest control officers from the Quality
William/ Akhilesh 31/01/2020 In Progress
appointed pest control company (i.e. Assurance
P10983) was not certified.

The bait map was not signed and dated Quality

William/ Akhilesh 31/01/2020 In Progress
by PCO. Assurance

Service records indicated that Doom

2.9.4 Records of was used in production, processing and Quality William/ Akhilesh/
Major NC 31/01/2020 In Progress
Control filling area (e.g. refer to service report Assurance Choolwe
15993 dated 31/03/19).

Quality
2.9.5 Pest Control There were no records on file of annual
Minor NC Assurance/ Choolwe/ Rakesh 31/01/2020 DONE 17/01/2020
Stations UV lights replacements for fly killers.
Maintenance

A Technical data sheet, material safety

data sheet and a certificate / letter
2.10.4 Chemicals Quality
indicating that the Multiclean was Minor NC Choolwe/ Akhilesh 31/01/2020 In Progress
and Their Control Assurance
approved for use in a food facility were
not available.

Records of specific hygiene clearance

2.13.4 Allergen Quality
after allergen production were not yet Minor NC William 31/01/2020 In Progress
Production Control Assurance
in place.
 Cow’s milk was not declared in an
allergen declaration statement on both
2.13.5 Allergen Quality
the Cream-It foil pouch / sachet and Minor NC William/ Akhilesh 31/01/2020 In Progress
Labelling Assurance
the outer box. (Note: Milk powder was
included in the list of ingredients.)

Procedures addressing the requirement

2.14 Process Control Quality
for inspections of delivery vehicles were Minor NC William/ Choolwe 31/01/2020 DONE 21/01/2020
- Receiving Assurance
not in place.

Containers of flavour were observed

stored under cooling units in both cold
rooms.Expired raw materials were
observed in the cold rooms and in
ambient raw material storage area, for
example:- Curt Georgi Coffee Flavour
(expiry date 28/11/18);- Bio-Sil
Antifoam (expiry date 05/07/18);- Pear Quality
Akhilesh/ Vinod/
2.15.3 Storage Puree Concentrate (expiry date Assurance/
Major William/Stanely/ 31/01/2020 In Progress
Practices 08/03/18).The FIFO pallet sheets Production &
Carlos/ Choolwe
displaying the expiry dates of the Raw Materials
product on the pallet did not all
correspond with all of the expiry dates
of the product on these pallets (e.g.
refer to pallets of Propylene Glycol in
the new cold room, and bulk bags of
Creamer in the ambient raw material
storage area).

The batch number of the product

2.17.2 Control of reworked during the night shift at the Production - Victor/
Minor NC 31/01/2020 DONE 17/01/2020
Processing Cream-It facility on 28/06/19 had not Creamer Supervisors/Choolwe
been recorded on processing records.
 Not all regulations listed in the External
Document List (FS01-1, revision 00,
15/05/19) indicated the actual
regulation number and the date of
promulgation (e.g. refer to regulations
3.1.1 Regulatory governing microbiological standards and
Quality
and Customer labelling regulations).Redundant Minor NC Akhilesh 31/01/2020 In Progress
Assurance
Requirements regulations had been identified and
specified (e.g. regulations regarding
acids, bases and salts).Regulations
regarding the grading, packing and
marking of fruit juice had not been
identified and specified.

Not all hazards identified as significant

in the 'Raw Material' hazard analysis
study (FS20/1, revision 02, 20/02/19)
and the 'Cream-It' hazard analysis study
(FS2-1-5, revision 00, 20/02/19) had
3.2.5 Determination been put through a decision tree
Quality
and listing of CCPs / analysis. Minor NC Akhilesh/ William 31/01/2020 In Progress
Assurance
oPRP's
 FSA INTERNAL MEETING
1 Akhilesh Singh
2 William Bento
3 Choolwe Mwiinga

Items Tabled
1
2
3
4
5
6
7
8
9
10
MEETING