National Health and Safety Function, WHWU, Human Resource Division.

Audit
REF: 001:014 Ref: Level 1 Audit Tool
Issue Date May 2016 Review Date: January 2018
Author(s) National Audit and Inspection team
Date:
Location:
Interviewees:
Manager:
Group of
employees who
report to this
line manager:
Number of staff:
Type of service:
Capacity:
Number of
patients:
Floor level:
Auditors:
Agency Staff:

Audit Score:
Trace Number:

Date and Score of previous audit:

17 12 14 Aud Level 1:001:014 Page 1

 Level 1 Department/Service Health & Safety Audit for Health Service
Executive
Auditing is a structured process of collecting independent information on the efficiency,
effectiveness and reliability of the total health and safety management system and drawing up plans
for corrective action.

Auditing examines each stage in the health and safety management system by measuring
compliance with the controls the organisation has developed, with the ultimate aim of assessing
their effectiveness and their validity for the future.

(Successful Health and Safety Management HS(G)65)

As part of the new national Health and Safety Function the Audit and Inspection Team have been
tasked with developing a suite of health and safety audit tools relevant to each level of management
within the HSE. This audit tool is the first in this suite, and is aimed at ward/department level.

The audit tool is divided into four sections:

Section A: Health and Safety Management System – 9 QUESTIONS

 Health and Safety Management
 Training
 Accident reporting and investigation

Section B: Hazard Identification and Risk Assessment– 42 QUESTIONS

 Physical hazards
o Equipment
o Manual handling
o Display Screen Equipment
o Electricity
o Radiation
o Noise
o Slips, trips and falls
o Use of HSE vehicles for work
o Security
o Lone Working
o Night Workers

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  Behavioural Hazards
o Management of Violence and Aggression
o Stress

 Chemical Hazards
o Chemical Agents
o Medical Gases
o Natural/Bottled Gas

 Biological Hazards
o Biological Agents
o Sharps

Section C: Health and Wellbeing – 3 QUESTIONS

o Information on Staff Services
o Pregnant Employees
o Welfare Facilities

Section D: Consultation – 2 QUESTIONS

o Methods for Consultation
o Safety Reps

As per Office of Quality and Risk Documents OQR 01, OQR 012 (which are available on the
HSE webpage), there must be only one hazard per page and each page must be dated and
risk rated.

Questions are marked out of 100 marks. Some with single yes/no responses, and some
divided into 20/25 marks per response.

Some questions are included for information purposes and do not carry any marks.

Where a question asks for % completed, marks are awarded for the % of the total number
completed e.g. 50 % approximately of staff who have signed the safety statement – 50
marks awarded.

Verification is obtained by also ticking one of the boxes marked “IOD” i.e. Interview,
Observation, Documentation.

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The auditor should calculate the audit score as a percentage.

This is explained by a worked example as follows:

Number of questions in audit: 56

Maximum Audit Score (MAS)

Total Number of Questions (56) x Maximum Score (100) = 5600 (56 x 100)

Actual Audit Score (AAS) (Sum of the total scores for each question)

Audit Score as a percentage = AAS/MAS x 100/1

Note: Where a question in a section is not applicable, it will not be given a score.

Example:

In the above case; if there were only 50 questions applicable (instead of 56) then the
maximum audit score (MAS) would be 5000 (50x100)

Audit score as a percentage would then = actual audit score /maximum audit score) x 100/1

The scoring for the audit provides a bench mark against which further audits can be
compared.

To demonstrate an acceptable level of compliance a bench mark score of 85% - 100 %

should be achieved.

A template to develop a quality improvement plan has also been provided in Appendix 1.

Scores achieved on each audit are colour coded to assist managers and hospital
management to implement a plan for improvement.

Traffic light system for audits.

85-100% Compliant – Repeat self audit/ peer audit on annual basis as

determined by hospital/service

51- 84% Follow up by hospital/service. Repeat self audit/peer audit 6/12.

26-50 % Immediate action by hospital –repeat self audit at 3 months -

repeat audit by Audit and Inspection team at 6/12

0-25% Critical – Immediate action by hospital/service - Repeat audit by

Audit and Inspection Team at 3/12

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Date: Location:

SECTION A: HEALTH AND SAFETY MANAGEMENT : Safety Health and Welfare at Work Act 2005 Part 3 Chapter 3 Section 20
N/A Score Comments
I 1. Is there access to the corporate safety NO YES
A O statement, 2014? 0 marks 100 marks
D √
I 2. Is there access to the site specific safety NO YES
A O statement? 0 marks 100 marks
D √
I 3. Is there an organisational chart for the NO YES
A O ward/department/services that clearly identifies the 0 marks 100 marks
D √ current manager and deputies?
I 4. Have the risk assessments been signed off by all 0% 25% 50% 75% 100%
A O current/floating/bank staff within the last 12
D √ months
5. Are current national occupational health and Manual Handling 20 marks
I
safety policies easily accessible to all staff? Stress 20 marks
Violence and Aggression 20 marks
A O
Lone Working 20 marks
Latex 20 marks
D √
None 0 marks

TRAINING: Safety Health &Welfare at Work Act 2005 Part 2 Chapter 1 Section 10
I 6. Have training needs been identified based on NO YES
A O legislation and risk assessment within the last 3 0 marks 100 marks
D √ years?
I 7. Are there records to show % of training NO YES
A O completed and repeated based on policy? 0 marks 100 marks
D √
I 8. Have those with managerial responsibility NO YES
A O attended training in the management of health & 0 marks 100 marks
D √ safety/risk assessments?
INCIDENT REPORTING AND INVESTIGATION: Safety Health & Welfare at Work Act 1989 (General Applications) Regulations 1993 Notifications of
Accidents and Dangerous Occurrences Part 10

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Date: Location:

I √ 9. Can managers explain the process for recording NO YES

A O and investigating accidents, incidents and near 0 marks 100 marks
D misses?
How many employee accidents/incidents have been
recorded in the previous 12 months

How are accidents /incidents reported to the HSA

TOTAL SECTION A:

SECTION B: HAZARD IDENTIFICATION AND RISK ASSESSMENT: Safety Health and Welfare at Work Act 2005 Part 3 Chapter 2 Section 19. To download a
copy of the general risk assessment please click here

PHYSICAL HAZARDS

EQUIPMENT: Safety Health and Welfare at Work (General Application) Regulations 2007 Part 2 Chapter 2 Work Equipment
I 1. 1. Is there a list of equipment available on the NO YES
B O unit/ward/dept compiled within last 12 months? 0 marks 100 marks
D √ (Electrical and non electrical)
I 2. Has a risk assessment been completed on the use NO YES
B O of workplace equipment within the last 12 0 marks 100 marks
D √ months using the national template.
I 3. Do control measures include: Instructions for use/sop 20 marks
Visual inspection 20 marks
O
Servicing/ maintenance 20 marks
B
Training 20 marks
D √ Other 20 marks
None 0 marks

MANUAL HANDLING: Safety Health and &Welfare at Work (General Application ) Regulations 2007 Part 2 Chapter 4 Manual Handling of Loads
I 4. Have risk assessments been completed for NO YES
B O inanimate manual handling tasks within the last 0 marks 100 marks
D √

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Date: Location:

12 months using the national template

I 5. Is there a system in place for assessing manual NO YES
B O handling activities for individual patients/service 0 marks 100 marks
D users, reviewed as required?
DISPLAY SCREEN EQUIPMENT: Safety Health and Welfare at Work (General Application) Regulations 2007 Part 2 Chapter 5 Display Screen
Equipment. To download a copy of the Display Screen Equipment risk assessment please click here.
I 6. 6. Have the employees identified as DSE habitual NO YES
B O users completed the DSE Users E-Learning 0 marks 100 marks
D √ programme on HSELanD?
I 7. Have the employees identified as DSE habitual NO YES
O users completed the DSE workstation assessment 0 marks 100 marks
B
D √ forms with the last 2 years using the national 0
template?
ELECTRICITY: Safety Health and Welfare at Work (General Application) Regulations 2007 Part 3 Electricity
I 7. 8. Has a risk assessment been completed on NO YES
B O electricity within the last 12 months using the 0 marks 100 marks
D √ national template ?
9. Do control measures include: Visual inspection of
I 20 marks
electrical outlets
Visual inspection of
electrical equipment prior 20 marks
O to use
Access to Technical
20 marks
B Services
System for reporting
20 marks
defects
D √ Other 20 marks
None
0 marks

RADIATION: Radiological Protection Act 1991

B I 10. Has a risk assessment been carried out on the NO YES

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Date: Location:

O potential exposure to radiation within last 12 0 marks 100 marks

D √ months using the national template?
11. Do control measures include? Identification of potential
I 20 marks
exposure
Procedure for each
20 marks
exposure identified
O
Consideration of Pregnant
20 marks
B Employees
Access to relevant
20 marks
expertise
D √
Other 20 marks
None 0 marks

NOISE: Safety Health & Welfare at Work (General Application) Regulations 2007 Part 5 Chapter 1 Control of Noise
I 12. Has a noise survey been carried out where there NO YES
B O is a potential exposure to noise within the last 3 0 marks 100 marks
D √ years?
I 13. Is a copy of the noise survey report available for NO YES
B O review? 0 marks 100 marks
D √

SLIPS, TRIPS AND FALLS: Safety Health & Welfare at Work Act 2005 Part 2 Chapter 1 Section 8 and Part 3 Section 19
I 14. Has a risk assessment been completed on risk of NO YES
B O slips trips and falls internal to the building within 0 marks 100 marks
D √ the last 12 months using the national template?
I 15. Do control measures include: Suitable Footwear 20 marks
Signage 20 marks
O Reporting defects 20 marks
B
Housekeeping 20 marks
Other 20 marks
D √ None 0 marks
I 16. Has a risk assessment been completed on risk of NO YES
B O slips, trips and falls external to the building within 0 marks 100 marks
D √ the last 12 months using the national template?
B I 17. Do control measures include: Pedestrian Walkways 20 marks

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Date: Location:

External lighting 20 marks

O
Signage 20 marks
Maintenance including
control of inclement 20 marks
D √ weather
Other 20 marks
None 0 marks

WORKING AT HEIGHTS: Safety Health & Welfare (General Applications) Regulations 2007 Part 4 Working at Heights
I 18. Has a risk assessment been completed on the NO YES
B O risk of working at heights with the last 12 months 0 marks 100 marks
D √ using the national template?
19. Do control measures include? Identification of work
I activities that involve 20 marks
working at heights
(Work at height is defined as working in a place Identification of
(except a staircase in a permanent workplace) equipment used for these 20 marks
where a person could be injured by falling from it, activities
O even if it is at or below ground level) Assessment of
environment to ensure
20 marks
B task can be carried out
safely
Identification of footwear
suitable for the tasks 20 marks
undertaken
D √
Other 20 marks
None
0 marks

USE OF VEHICLES: Safety Health & Welfare at Work Act 2005 Part 2 Chapter 1 Section 8 and Part 3 Section 19 and 20
I 20. Has a risk assessment been carried out on the NO YES
B O use of HSE vehicles for work within the last 12 0 marks 100 marks
D √ months using the national template?
21. Do control measures include: Visual inspection prior to
I 20 marks
B each journey
O Driving Licence 20 marks

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Date: Location:

Breakdown procedure 20 marks

Statutory Checks 20 marks
D √ Other 20 marks
None 0 marks

SECURITY: Safety Health & Welfare at Work Act 2005 Part 2 Chapter 1 Section 8 and Part 3 Section 19 and 20
I 22. Has a risk assessment been completed on NO YES
B O management of unit/ward/building security within 0 marks 100 marks
D √ the last 12 months using the national template?
I 23. Do control measures include: Controlled access 20 marks
Security Checks e.g.
20 marks
windows/doors
O √
Safety of valuables/
20 marks
B personnel belongings
Documented procedure for
20 marks
security breaches
D
Other 20 marks
None 0 marks

LONE WORKING: Safety Health and Welfare at Work (General Applications) Regulations 2007 Part 2 Chapter 3 Lone Working
I 24. Has a risk assessment been completed on the NO YES
B O risk posed by lone working within the last 12 0 marks 100 marks
D √ months using the national template ?
25. Do control measures include: Identification of lone
I workers including on call 20 marks
staff where applicable
Register of information on
20 marks
O workers identified above
B Procedure for lone working 20 marks
Training on
implementation of 20 marks
D √ procedure
Other 20 marks
None 0 marks

NIGHT WORKERS: Safety Health and Welfare at Work (General Applications) Regulations 2007 Part 6 Chapter 3 Night Work and Shift Work
B I 26. Has a risk assessment been completed on Night NO YES

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Date: Location:

O Workers within the last 12 months using the 0 marks 100 marks
D √ national template ?
27. Do control measures include: Identification of staff
I 20 marks
deemed as night workers
Health Surveillance 20 marks
O
B Security measures 20 marks
Adequate breaks 20 marks
D √ Other 20 marks
None 0 marks

SENSITIVE RISK GROUPS: Safety Health & Welfare (General Applications) Regulations 2007 Chapter 1 Part 6 , Chapter 2 Part 6 & Chapter 3 Part 6
I 28. Has a risk assessment been completed on NO YES
O sensitive risk groups. E.g. Placement Students, 0 marks 100 marks
B
D √ Volunteers, Young Person 16 -18 yrs within the last
12 months using the national template?
29. Do control measures include: Identification of sensitive
I 20 marks
risk groups
Induction 20 marks
O
B Supervision 20 marks
Defined duties 20 marks
D √ Other 20 marks
None 0 marks

BEHAVIOURAL HAZARDS

VIOLENCE AND AGGRESSION: Safety Health & Welfare at Work Act 2005 Part 2 & 3, Safety Health & Welfare at Work (General Applications)
Regulations 2007 Part 2 Chapters 1. Safety Health & Welfare (General Applications) Regulations 1993 Part 10
I 30. Has a risk assessment been completed on the NO YES
O potential for violence and aggression in the 0 marks 100 marks
B
D √ workplace within the last 12 months using the
national template?
I 31. Do control measures include: Training 20 marks
Documented response
20 marks
B protocol
O
Testing of response
20 marks
protocol

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Date: Location:

Patient/service user
assessment of potential for 20 marks
D √ risk factors
Other 20 marks
None 0 marks

STRESS: Safety Health & Welfare at Work Act 2005, Part 3 Chapter 2 Section 19. E.C. Framework Agreement on Work Related Stress, Work Positive
Project 2005-2007
To Download a copy of the Stress Risk assessment please click here
To download a copy of the sample stress risk assessment please click here
I 32. Has a risk assessment been completed on work NO YES
B O related stress using national template within the 0 marks 100 marks
D √ last 12 months?
CHEMICAL HAZARDS

CHEMICAL AGENTS: Safety Health & Welfare at Work (General Applications) Regulations 2001 Chemical Agents. Chemicals Act 2008 & 2010. Safety
Health & Welfare at Work (General Applications) Regulations 2007 Part 6 Chapter 2 Protection of Pregnant Post Natal and Breast Feeding
Employees. To download a copy of the chemical risk assessment form please click here.
I 33. Is there a list of chemicals for the dept/service? NO YES
B O 0 marks 100 marks
D √
I 34. Are appropriate safety data sheets available and NO YES
B O accessible and all dated within the previous 5 years? 0 marks 100 marks
D √
I 35. Where a chemical is deemed to be potentially NO YES
O √ hazardous has a detailed risk assessment been 0 marks 100 marks
B
D completed within the last 12 months using the
national chemical risk assessment template?
MEDICAL GASES: Safety Health & Welfare at Work (General Applications) Regulations 2001 Chemical Agents.
I 36. Has a risk assessment been completed on the NO YES
B O use of medical gases within the last 12 months using 0 marks 100 marks
D √ the national chemical risk assessment template?

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Date: Location:

NATURAL /BOTTLED GAS: Safety Health & Welfare at Work (General Applications) Regulations 2001 Chemical Agents. Safety Health & Welfare at
Work (General Applications) Regulations 2007 Part 6 Chapter 2 Protection of Pregnant Post Natal and Breast Feeding Employees.
I 37. Has a risk assessment been completed on the NO YES
O use of natural/bottled gas within the last 12 months 0 marks 100 marks
B
B
D √ using the national chemical risk assessment
template?
BIOLOGICAL HAZARDS

BIOLOGICAL AGENTS: Safety Health & Welfare at Work (General Applications) Regulations 2013 Biological Agents.
To download a copy of the Biological Risk Assessment please click here
I 38. Has a risk assessment been completed on the NO YES
B O potential exposure to biological agents using the 0 marks 100 marks
D √ national template within the last 12 months?
B
Date of last hygiene audit:

SHARPS: European Union (Prevention of Sharps Injuries in the Health Care Sector) Regulations 2014
I 39. Has a risk assessment been completed on the NO YES
B O use of sharps within last 12 months using the 0 marks 100 marks
D √ national template?
I 40.Do control measures include: Training 20 marks
Sharps policy 20 marks
O
Needle Safe System 20 marks
B
PPE 20 marks
D √ Other 20 marks
None 0 marks
I 41. Has a sharps audit been completed within the NO YES
B O last year? 0 marks 100 marks
D √
I 42. Is a copy of the sharps audit available for NO YES
B O review? 0 marks 100 marks
D √

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Date: Location:

TOTAL SECTION B:
SECTION C: HEALTH AND WELFARE: Safety Health & Welfare at Work Act 2005 Part 3, Chapter 2 Section 19 & 22. Safety Health & Welfare at Work
(General Applications) Regulations 2007 Part 6 Chapter 2 Protection of Pregnant Post Natal and Breast Feeding Employees.
To Download a copy of the Pregnancy Risk Assessment please click here
I 1. Is up to date information related to staff services NONE EAP Occ. Health
C O readily available? 0 marks 50 marks 50 marks
D √
I 2. Are pregnancy risk assessments completed and No Completed Reviewed
C O reviewed as appropriate on all relevant? 0 50 50
D √

WELFARE: Safety Health & Welfare at Work (General Applications) Regulations 2007 Part 2 Chapters 1 Workplace Layout and Welfare.
I 3.Do staff have access to the following: Potable water 25 marks
Rest areas for meals 25 marks
O
Separate toilets for staff 25 marks
C
Hot and cold running
25 marks
D √ water in staff facilities
None 0 marks

TOTAL SECTION C:
SECTION D: CONSULTATION: Safety Health & Welfare At Work Act 2005 Part 4 Section 25 & 26
1. Describe methods used for exchange of Staff meetings – health
I 50 marks
information and consultation with staff. and safety on agenda
O Staff Notice board 50 marks
D
Specify any other methods of communication :
D √

I √ 2. Is interviewee aware of the identity of the safety NO YES

D O rep in their area? 0 marks 100 marks
D

TOTAL SECTION D:

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Date: Location:

HAZARD ESCALATION

Following risk assessment, how many issues have been escalated to

your line manager since your safety statement and risk assessments
were last updated.

How many issues remain open?

Where an issue has been escalated through your line manager have No feedback
you received documented feedback on its status?
Limited feedback

Feedback on all issues

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Date: Location:

SCORING

Section Number of Not Score for section

Applicable Questions
A Total number of questions : 56 -
B
C AAS/MAS x 100/1
D
Total

Signed: ______________________________

Title: _______________________________

Date: _______________________________

Example

Section Number of Not Score for section

Applicable Questions
A 0 630 Total number of questions : 56
B 8 3200 Subtract number of n/a questions = 9
C 0 200 56-9 = 47
D 1 100 Maximum Audit Score = 4700 (47 x 100)
Actual Audit Score = 4130
Score in % = AAS/MAS x 100/1
i.e. 4130/4700 x 100/1 = 88 %
Total 9 4,130

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APPENDIX 1 – QUALITY IMPROVEMENT PLAN
Section Question Review of
Area of Non Compliance Corrective Action to be taken Responsible Person Timeframe implementation
No No
of Action

SECTION A: HEALTH AND SAFETY MANAGEMENT : Safety Health and Welfare at Work Act 2005 Part 3 Chapter 3 Section 20

TRAINING: Safety Health &Welfare at Work Act 2005 Part 2 Chapter 1 Section 10

INCIDENT REPORTING AND INVESTIGATION: Safety Health & Welfare at Work Act 1989 (General Applications) Regulations 1993 Notifications of
Accidents and Dangerous Occurrences Part 10

SECTION B: HAZARD IDENTIFICATION AND RISK ASSESSMENT: Safety Health and Welfare at Work Act 2005 Part 3 Chapter 2 Section 19
PHYSICAL HAZARDS
EQUIPMENT: Safety Health and Welfare at Work (General Application) Regulations 2007 Part 2 Chapter 2 Work Equipment

MANUAL HANDLING : Safety Health & Welfare at Work(General Application)Regulations 2007 Part 2 Chapter 4 Manual Handling of Loads

DISPLAY SCREEN EQUIPMENT: Safety Health & Welfare at Work(General Application) Regulations 2007 Part 2 Chapter 5 Display Screen Equipment

17 12 14 Aud Level 1:001:014 Page 17

RADIATION: Radiological Protection Act 1991

NOISE: Safety Health & Welfare at Work (General Application) Regulations 2007 Part 5 Chapter 1 Control of Noise

SLIPS, TRIPS AND FALLS: Safety Health & Welfare at Work Act 2005 Part 2 Chapter 1 Section 8 and Part 3 Section 19

WORKING AT HEIGHTS: Safety Health & Welfare (General Applications) Regulations 2007 Part 4 Working at Heights

USE OF VEHICLES FOR WORK: Safety Health and Welfare at Work Act 2005 Part 3 Chapter 2 Section 19 and 20

SECURITY: Safety Health and Welfare at Work Act 2005 Part 3 Chapter 2 Section 19 and 20

LONE WORKING: Safety Health and Welfare at Work (General Applications) Regulations 2007 Part 2 Chapter 3 Lone Working

NIGHT WORKERS: Safety Health and Welfare at Work (General Applications) Regulations 2007 Part 6 Chapter 3 Night Work and Shift Work

SENSITIVE RISK GROUPS: Safety Health and Welfare (General Application)Regulations 2007 Chapter 1 Part 6, Chapter 2 Part 6 & Chapter 3 Part 6

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BEHAVIOURAL HAZARDS
VIOLENCE AND AGGRESSION : Safety Health & Welfare at Work Act 2005 part 2 and 3, Safety Health & Welfare at Work ( General Applications)
Regulations 2007 Part 2 Chapter 1, and Part 6, SHWW(General Application) Regulations 1993 part 10

STRESS: Safety Health and Welfare at Work Act 2005 Part 3 Chapter 2 Sections 19. E.C Framework Agreement on Work Related Stress, Work Positive
Project 2005-2007

CHEMICAL HAZARDS
CHEMICAL AGENTS: Safety Health & Welfare at Work Act (General Applications) Regulations 2001 Chemical Agents. Chemicals Acts 2008 and 2010.
Safety Health & Welfare at Work (General Applications) Regulations 2007 Part 6 Chapter 2 Protection of Pregnant Post Natal and Breast Feeding
Employees

MEDICAL GASES : Safety Health & Welfare at Work Act (General Applications) Regulations 2001 Chemical Agents

NATURAL GAS: Safety Health & Welfare at Work Act 2005 Part 2 Chapter 1 Section 8. Safety Health & Welfare at Work Act (General Applications)
Regulations 2001 Chemical Agents. Safety Health & Welfare at Work (General Applications) Regulations 2007 Part 6 Chapter 2 Protection of Pregnant
Post Natal and Breast Feeding Employees

BIOLOGICAL HAZARDS
BIOLOGICAL AGENTS: Safety Health & Welfare at Work Act (General Applications) Regulations 2013 Biological Agents

SHARPS: European Union (Prevention of Sharps Injuries in the Health Care Sector) Regulations 2014

SECTION C: HEALTH AND WELFARE: Safety Health & Welfare at Work Act 2005 Part 3 Chapter 2 Section 19 and Section 22. Safety Health & Welfare at
Work (General Applications) Regulations 2007 Part 6 Chapter 2 Protection of Pregnant Post Natal and Breast Feeding Employees

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Welfare : Safety Health & Welfare at Work (General Applications) Regulations 2007 Part 2 Chapter 1 Work Place Layout and Welfare

SECTION D: CONSULTATION: Safety Health & Welfare at Work Act 2005 Part 4 Chapters 3 Sections 25 & 26.

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