ISO 45001 AUDITOR/LEAD AUDITOR TRAINING COURSE

The Grange Hotel

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 THE GRANGE

The Grange is a large hotel with two hundred bedrooms and is situated in the New Forest in
Hampshire. Originally a Manor House built in the Tudor style it has been substantially
refurbished to retain its old world charm and attraction but incorporating all modern
conveniences such as a swimming pool, high specification kitchen and advanced internal
and external communications. The Hotel is part of a chain of hotel locations owned by the
Sanderson Leisure Group. The Grange is the premier hotel in the chain and is seeking ISO
45001 certification. The group has realised that they are trailing their competitors who
already have certification and therefore The Grange is the first hotel to request assessment
as part of a rolling program which will see all hotels in the chain with ISO 45001 certification.

The assessment audit is being conducted by one lead auditor (LA), against the Standard
ISO 45001. The LA had provided a detailed audit plan which identified the departments and
areas to be reviewed and showed that he was going to complete an interview with ‘Top
Management’, conduct a tour of the Hotel and review a number of core processes such as
reservations, reception, housekeeping, catering and maintenance.

Interview with Top Management

Present at the interview was a Senior Director (SD) from the Sanderson Group, the Hotel
Manager, Catering Manager and the Housekeeping Manager and the management
consultant who had developed the MS.

LA: “Please could you give me an overview of the Hotel and what you consider to be the
critical service delivery processes and potential health and safety issues. In addition can
you give some details on how you understand the context of your organisation and how
needs and expectations of interested parties are included in your Management System.

The SD showed the LA the Group Business Plan which contained strategic planning and
headline objectives for the Group including those related to the development of conference
facilities, he added “Over the past number of years we have ascertained that our clients want
more from our conference rooms, WiFi, and intelligent smart boards, we know this from our
customer feedback questionnaires, which we have continually monitored”.

“Furthermore” he said “The context of our organisation is we operate a hospitality service”.

The needs of our customers range from rooms, conferences, food and beverages and our
main objective this year is to upgrade our conference rooms as the profit margin in this area
of the business is large”.

“In respect of interested parties; they are customers, staff, and suppliers.”

“What do you see as the main risks in your service delivery?” asked the auditor.

“The risks in our business are not filling rooms or not satisfying our clients whether that be
food or accommodative, risks are dynamic and change dependent on client – having spent
20 years in this business, we have decided to accept these risks”. “Now that is not to say
that we do nothing at all, we have spent around £50,000 on a software system that removes
the diligence from our service – I am sure you will see aspects of this system on your audit”.
“In addition our training scheme is towards best in class. We are also certified to Investors in
People (IIP), and our rate of pay is competitive for this market. Thus these steps help
mitigate risk in our service”.

“We train our staff so they can do the job, treat them well so they stay. What are your
thoughts on that?” asked the SD of the auditor”.
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“What about health and safety aspects in the business then?” asked the auditor.

“Well, I think it would be best if you saw our register of hazards and risks”, said the SD. To
summarise very briefly, we have to consider a number of key aspects, such as: the layout
and disposition of furniture for both staff and visitors; electrical safety in communal and
bedroom areas; fire and signage; kitchen management and food safety; the swimming pool
and leisure centre equipment; the facilities management – aircon, lifts, etc; car parking; and
security.

“Ok”, said the LA, “We’ll look at that in detail later. Meanwhile, how do you communicate the
occupational health and safety policy and how do you know your employees have an
understanding of this document?”

“All our staff wear a lanyard with their name, this badge is connected to our security system
for access to certain parts of the facility, also attached to this lanyard is a copy of the OHS
policy, which we update every four years”

LA: “Are there objectives related to OHS set for the Hotel”?

Senior Director: “Yes, we have three main objectives: regular fire checks; zero lost time
accidents for staff and regular checks on signage arrangements for ensuring visitors / paying
guests are made aware of potential hazards such as steps, self-closing doors, very hot water
in rooms and toilets, polished / slippery floors, etc”.

LA: “Do you set objectives for members of staff”?

Hotel Manager: “Absolutely, all the Heads of Departments have objectives which are
developed and recorded in their appraisals. Objectives are reviewed at our monthly
management meeting. We have tried to anticipate the sort of records you may need so I
have the last three meeting minutes here”.

The LA looked at the Hotel Business plan and the meeting minutes. “Do you set objectives
for individual members of staff”?

Consultant: “We did consider objectives for staff and where appropriate they are set but
objectives are generally set at management level”.

The LA nodded and made a note on his checklist.

LA: “How do you monitor OHS performance overall?”

Hotel Manager: “Well, we have regular meetings with heads of department where we
discuss any incidents. These meetings are minuted. We also hold a quarterly meeting at
Group to discuss any issues that are identified. Naturally the Hotel Managers will respond
immediately to any issues that are represented verbally and require urgent attention.”

LA: “Could I see minutes from the meetings please?”

Hotel Manager: “They’re in the administration office; we’ll have to go there”.

LA: “OK, please could I see the records for the last Management Review meeting”?

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The Hotel Manager handed the LA a set of minutes. The record was comprehensive and
showed attendance by ‘Top Management.’ He noticed however, that there was no reference
to occupational health or a review of the risk and hazards register and pointed this out to the
Manager”. The LA made a note on her checklist.

Tour of Hotel and Maintenance

The tour of the premises was conducted by the Hotel Manager and the Housekeeping
Manager accompanied by the consultant. It was intended to complete the tour at the
maintenance manager’s office to review maintenance records. It was evident that the Hotel
was well appointed and that facilities such as the restaurant and swimming pool were of a
high quality. On their way around, they were introduced to several members of staff and
were able to view several bedrooms. The rooms were tastefully and luxuriously furnished;
however, there appeared to be no pattern or commonality to the way in which the rooms
were laid out.

LA “Is there a standard format used to check room safety aspects when servicing a room
and preparing it for occupation?”

Housekeeping Manager: “Yes we have what we call a guidance note which includes a
checklist of points to look out for”.

The LA was shown a copy of the guidance notes which were comprehensive and clearly
showed the layout of a bedroom. The guidance notes covered such items as: state of the
carpets; wall socket condition; visual checks on lighting and tea making facilities; bathroom
condition / leakage etc; damage to furniture edges etc.

LA: “Is an inspection completed following the servicing of rooms as per the signature space
on the guidance note. This part of the guidance note appears not to be completed on any
that you’ve shown me?”

Housekeeping Manager: “I had noticed that myself, there should be an inspection by the
team leader, I don’t know what is going on I will need to look into this”.

LA “Do you record any issues as a non-conformance if a room is not to standard?”

Housekeeping manager. “Not particularly since we’re trying to remove paperwork from the
system as many of the staff don’t have good English. They should report to the team leader
if they think anything is wrong.”

LA: “Have you got any copies of documented non-conformances from team leaders?”

Housekeeping Manager: “Not recently”.

LA: “Why do you say not recently”?

Housekeeping Manager: “I can’t think of any being reported to me in months. What tends to
happen is that maintenance are called and deal with any concerns as quickly as possible.”

LA: “Would maintenance have any copies of remedial work done?”

Housekeeping Manager: “I can’t say – you would have to ask them.”

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LA: “Moving on, what problems do you have, if any, with suppliers?”

Housekeeping Manager: “We had some problems with poor washing / cleaning from a local
laundry we used.”

LA: “What action did you take”?

Housekeeping Manager: “We had to look for another supplier. We couldn’t continue with
unclean laundry. However, we couldn’t just let the other company go as it would have had a
detrimental effect on our business; so in parallel to using this supplier we began to evaluate
another supplier, once they met our criteria I terminated the contract of the other”.

LA: “Is there a record of your actions regarding this supplier?”

Housekeeping Manager: “Oh no. I have been working here for a number of years and know
all the history with this vendor”

LA: “How did you select the new contractor”?

Housekeeping Manager: “I just phoned around; got a good price and they are on trial at the
moment. Our process for selection is not written down, but rule of thumb is a new supplier
will get some work, we visit the premises has a chat with the owners. Based on this sample
work, they get to be an approved vendor, simple as that. ”

LA: “OK let’s go onto the maintenance manager’s office I would like to review the
maintenance records now”.

The group arrived at the maintenance office. The Hotel Manager introduced the
maintenance manager who, it was explained, had been in post about six months having
previously been a ship’s engineer. There was a detailed preventive maintenance system in
place and all maintenance appeared to be up to date. The LA checked a comprehensive
sample of maintenance records which included samples from the water systems, kitchen
equipment maintenance, and air conditioning system maintenance.

LA: “I notice that there are four passenger lifts fitted in the Hotel”.

Maintenance Manager: “Yes that’s correct. One is used by staff and the other three are for
the exclusive use of guests”.

LA: “Could I see the servicing and inspection records for the lifts please?”

The maintenance manager went to his computer and opened a folder containing
maintenance records. He explained that that all maintenance records were held
electronically and where necessary were scanned so that they could be retained
electronically.

LA: “These records indicate that servicing has been completed but statutory inspections
have not been carried out. Regulations require that a formal inspection should be completed
every six months”.

The Hotel Manager and the engineer looked at one another.

Hotel Manager: “I am sure that the records are here somewhere it’s just that we cannot find
them at the moment”, said the Housekeeping Manager.

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LA: “Well it is important that those records are found, I would like to see them by the end of
the day along with any non-conformance reports that may have been produced as well”.

Hotel Manager: “I am sure we will find them, perhaps you like to see administration
processes now?”

Administration Office

The LA was taken to the Administration Office and introduced to the reservations team. One
of the team demonstrated how reservations were booked onto the Reservations
Management System (RMS) a bespoke computer application. It was explained that guests
usually booked by phone or via the Hotel’s website which also gave a good description of
the Hotel’s services, facilities and charges. There was detailed audit evidence of the review
of guest requirements and the allocation of rooms. Additionally the cancellation policy and
arrangements were discussed and which appeared to work well.

LA: “What if any comments do you give to guests on health and safety when they check in?”

Team Member: “We don’t do anything – we wouldn’t want to worry guest or pout them off.”

LA: “What if any briefing have you had in this department regarding health and safety?”

Team Member: “We have an induction meeting when we start in the hotel and that focuses
on what to do if there’s a fire. There’s not much else to worry about is there?”

LA: “Do you have an accident book?”

Team Member: “What’s that? I’ve never heard of one. Should we have one?”

LA: “I’ll discuss this with your managers, but thank you for explaining that. I would like to
move on to the food and beverage department now”.

Food and Beverage Department (Catering)

The LA was introduced to the Catering Manager who explained how the various
departments forwarded their food and beverage requirements to her so that she could place
orders with suppliers. She also explained that purchase orders were raised using a computer
application called the Purchase Order Program universally known as POPs. The Catering
Manager demonstrated the raising of purchase orders, purchasing information was clear and
comprehensive.

LA: “I noticed when reviewing your system documents that you have a Guidance Note for
purchasing Food and Beverages, do you have access to a copy?”

Catering Manager: “Yes I keep a copy in my desk draw, I don’t refer to it very much as I
know what I am doing”.

LA: “I’m sure you do. I want to focus on health and safety. What are your main
considerations in this respect in the kitchen?”

Catering Manager: “Well there’s a lot to think about. There’s food storage of course and we
have to check fridge and freezer temperatures regularly. Then there’s food temperature
checking. The use of knives and equipment by staff as well as handling is important too.”

LA: “OK, that’s great. What records do you have of staff training in these respects?”
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The Catering Manager replied: “Administration keep records of staff training. I don’t have
these records.”

LA: “How can you be sure that all the staff here, as there are many part timers too, have the
necessary food hygiene and food safety training?”

The Catering Manager replied: “I rely totally on Administration for this.”

The LA made a note on his checklist and then asked “Do you maintain a list or records of
your suppliers?”

Catering Manager: “Yes it’s a spreadsheet; it mostly shows who the suppliers are and what
they supply”.

LA: “How do you select your suppliers who provide ready to eat food such as cakes and
special meat products you don’t prepare yourselves?”

Catering Manager: “Either by reputation or we put them on trial for a month or so”.

LA: “But how do you assess their food safety and hygiene?”

Catering Manager: “Well, we don’t actually do that. I assume local Environmental Health
Officers visiting their premises”.

The LA made a note on her checklist.

LA: “I would like to see the kitchens now please”. The LA was taken on a tour of the kitchens
and food storage arrangements. He was introduced to the Head Chef, using a dedicated
checklist the LA took samples from aspects of the kitchen processes such as menus and
response to special dietary requirements and hygiene.

LA “Please could I see the food temperature probes and their calibration record?”

The Head Chef produced what was clearly a probe which showed some damage as if it had
been bent at some time.

LA: “Is this the only probe in use in the kitchen”?

Head Chef: “To be honest the other probe disappeared several weeks ago, I have placed an
order for the new one. However we are managing fine with this one at the minute”

The LA asked “How often do you calibrate this probe?”

“We don’t necessarily calibrate it. We verify it on a fortnightly basis with our ovens”, the
Head Chef said. “The ovens are maintained every six months and a certificate is issued from
manufacturer, would you like to see this”

“May I see the verification for this probe?” the LA asked

The Head Chef found a form with various temperature recordings on it, but the LA noticed
that the document did reference the probe in question.

“So how do you know this probe is fine to use, it looks quite damaged?” the LA said

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The Head Chef: “Quite simple really. You will notice two temperatures on that form, one is a
reference temperature from the oven, which we know is calibrated; the other is the
temperature from the probe. As long as it meets the same temperature after 30 seconds to
a tolerance of plus/minus 2 degrees it’s OK. As you can see they are all within range.”

“What about the refrigerator temperature?” the LA asked

“I am a bit behind in that area as we are quite busy, and short-staffed”, replied the Head
Chef, pulling out a form that was last filled in a week previously.

Head Chef: “You know we have been have been short-handed for the last two months”.
Turning to the LA, he said “We are out in the country here and there are no decent transport
arrangements; so staff don’t want to work here”.

The LA nodded and made some notes.

“There a spreadsheet onto which complaints are recorded, this links with an electronic
workflow process along which the complaint passes which is controlled by time scales for
answering and resolving complaints also it shows who should be responsible for particular
categories of complaint”.

LA: “The process sounds very comprehensive”. He then selected a sample of complaints
with which to verify the process.

LA: “I notice there are two complaints about food poisoning”.

Catering Manager: “Yes we never really got to the bottom of those two complaints, although
I think the Catering Manager thought it was to do with some under cooked chicken. They
were serious complaints and I believe the Group paid financial compensation to the
complainants to finalise and close those complaints”.

LA: “So were the complaints investigated?”

Catering Manager: “Yes. As I told you, we never really got to the bottom of the matter

The remainder of the process seemed to be compliant with procedures.

LA: “I think it’s time we took a break now”.

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