Professional Documents
Culture Documents
to audit LCA Members. It is also available for Members to use as the questions for their internal audit and
Assessor auditing a Member and the Member responding to the LCA. The same steps and process shoul
LCA involvement.
Structure - This document is broken down into tabs for audit details, non-conformity tracker, Code of Cond
coloured yellow where an audit of that standard or code has been completed. Do NOT hide, delete or c
Audit Details - The audit details tab includes administrative details such as name, date etc and other item
record when the audit was done.
There is a status drop down for noting the stage at which the audit is at the time the record is saved. This
LCA), SoC signed off (end of the first stage of application to join the LCA), Audit actions (an audit has been
completed), audit follow up (a Member has responded to the identified actions but the Assessor cannot sig
the Assessor and confirmed as complete).
There is a short explanation of what is required as an action for non-conformances and for observations. T
At the bottom of the Audit Details tab there is a section on each of the different Service Delivery Standards
area of interest. If a service category is registered for the member this should be used for recording an ind
assessments, xxx members of staff work in that area, etc. Exact numbers are not critical but the record of
registered as an area of interest for a Member the Assessor will question if this service has been delivered
conformance and a recommendation made to register the service or stop providing it.
Non-conformity Tracker - this tab is the action plan for the member to see in one place what needs to be
taken to close them out with references to evidence. When a Member has been audited and sends their re
Non-Conformity Tracker tab to see what the Member has done to correct the non-conformance and the de
The LCA assessor should then note any further comments, date and complete or not the audit in the follow
this should be shown in the next set of blue columns with the assessor response following that. Any furthe
clear which lines have been completed or not.
The non-conformances are numbered with a prefix for Code, or specific Service Delivery Standard and rep
P&E-1.
Code - this tab contains structured questions that explore compliance with the LCA Code of Conduct and i
Column C contains structured questions, prompts and embedded explanatory notes to explore compliance
Column D is for recording answers to the questions in Column C, to describe process and reference evide
achieved and where this is detailed in procedure the answer should reflect the content of the Members Sta
actual practice, example records of actual practice are checked, a note is made of what was checked and
Column E is for recording non-conformances from answers in column D. The non-conformances are num
replicated on the non-conformance tracker.
The Service Delivery Standard tabs are numbered 1-8 and include the specific questions on the individu
At the top of this tab in cell D2 there is a space to record the work being audited. Use quote, job, etc. refer
the audit could be replicated.
Column B references the clause in the standard that underlies the audit question. If unsure of the meaning
Column D is for answers to the audit questions based on templates, procedures and master documents - t
system in place deliver work to the required standard. Answers in column D should be regarding the proce
Column E is for recording non-conformances from answers in column D. The non-conformances are num
replicated on the non-conformance tracker.
Column F is for answers to the audit questions based on the evidence from actual work being checked - th
performance, has the system in place delivered work to the required standard. Answers in column F shou
Column G is for recording non-conformances from answers in column F. Often if there is a column D/E no
because the management system flaw has led to an output flaw. A single corrective action common to bot
consecutively throughout the audit report and replicated on the non-conformance tracker.
Audit Date:
Audit issue Date:
Assessor response Date:
Audit status:
Auditor:
Signature:
Present/Assisted by:
Audit method
Audit Explanation
This audit is detailed under these sections (Please read carefully)
Code Audit - Statement of Compliance (SOC) and Management procedures/process audit
Checklists to evidence operational compliance with each applicable LCA Service Standard &
Service standard check lists -
utilisation of the member's procedures/processes.
Non-conformity tracker - Non-conformity tracker with corrective actions required, actions taken and closure.
Bold All non-conformances raised are highlighted in bold with red fill, issued a Non-conformity reference
and require a response on the Non-conformity tracker tab.
OBS
In addition to the non-conformances, the assessor has given a number of Recommendations for
Improvement, observations (OBS) these are optional suggestions for the member.
Please use the Non-conformity tracker tab to record your response to the non-conformities raised.
The company is to write to the assessor via the LCA secretariat admin@legionellacontrol.org.uk within 6 weeks indicating the steps which have
been taken to address these non-conformities providing, where applicable, evidence in the form of completed documents. Amendments to
procedures should be highlighted. All Non-conformities in the Non-conformity tracker must be completed satisfactorily within 3 months of the
date of the Report for existing members (the initial 6 week period allowing sufficient time for any negative assessor responses and still achieve
final completion within 3 months). Applicant members should aim for satisfactory completion of non-conformities within 12 months from date of
application acceptance. In the event of non-completion by this date, then the existing Member will be at risk of being suspended from the LCA
website and ultimately have membership withdrawn, and new applications will be cancelled.
Service standard Assessor's comments on relative activity, numbers staff operational, sub-contractors used
1 Legionella Risk Assessments
Hot & cold water
Evaporative cooling systems
Other systems
Healthcare
2 Water Treatment services
Hot and cold water
Evaporative cooling systems water
treatment
Process & Other systems water
treatment
Hot and cold water monitoring
3 and inspection
4 Cleaning and disinfection
Hot & cold water
Evaporative cooling systems
Other systems
Independent Consultancy
5 Services
6 Training services
7 Legionella monitoring services
Sampling
In field analysis
Laboratory analysis (In house)
Audit details
Interpretation of analysis
8 Plant and equipment services
Design and supply
Installation
Service and Maintenance
Refurbishment
Action plan
Non-Conformity Tracker
Please use the Non-conformity tracker tab to record your response to the non-conformities raised.
The company is to write to the assessor via the LCA secretariat admin@legionellacontrol.org.uk within 6 weeks indicating the steps which have been taken to address these non-conformities providing, where applicable, evidence in the form of
completed documents. Amendments to procedures should be highlighted. All Non-conformities in the Non-conformity tracker must be completed satisfactorily within 3 months of the date of the Report for existing members (the initial 6 week period
allowing sufficient time for any negative assessor responses and still achieve final completion within 3 months). Applicant members should aim for satisfactory completion of non-conformities within 12 months from date of application acceptance. In
the event of non-completion by this date, then the existing Member will be at risk of being suspended from the LCA website and ultimately have membership withdrawn, and new applications will be cancelled.
Target
Allocated Description of action taken to correct the Evidence of Date / (complete / Not
NC Ref Action required Response Assessor follow up comments
to non-conformity completion/reference complete)
Date
Page 5 of 74
LCA Management Process audit
Include sub-contractor activity in the Procedure referenced in SOC under 8.4 and briefly
8.4
evidence examined in their internal described.
audits under requirement 7 to ensure The procedure/process relevant to this requirement is
that all aspects (scoping, quotation and The Procedure/Process details the actions required
delivery) are compliant with the LCA and was found to be in-line with actual practice
Code of Conduct and Service Delivery Forms/Master documents used by process
standards.
Procedure may be defined in the SOC under 9.1 and
9.1
A copy of the LCA Code of Conduct and briefly described.
proof of Registration are made available Procedure/process relevant to this requirement if
to all Legionella control service users. separate
This can be achieved either by providing
The SOC/Process details the actions required and
them with hard copies, electronic copies
was found to be in-line with actual practice
or making them available as
downloadable files from their website or Forms/Master documents used by process
links to the LCA website.
Number of Actions 0
Number of Observations 0
Check list 01 - Legionella Risk Asses
Brief description of the work(s) being audited:
- Quote(s) & Dates
- Job/Works(s) Ref & Date:
Clause Question
The member should inform the client that it is the responsibility of the duty
holder/responsible person to:
a. Ensure there is a Legionella risk assessment record that includes all systems
where water is stored/used in any premises controlled by the duty holder, and that it
is reviewed regularly to ensure it is valid and reassessed when required.
b. Clearly define the scope of any required Legionella risk assessment.
c. Make reasonable enquiries of proof of competence of the Legionella risk
assessor.
d. Ensure any schematic diagrams and asset registers are available to inform and
help the risk assessor.
30 e. Ensure the findings of the legionella risk assessment including the required
corrective actions and control measures are implemented, or if not implemented
recorded as to why they were not.
f. Ensure a written scheme of control is produced and maintained and the output
from the scheme of control is recorded and used in any subsequent review of risk.
g. Ensure regular reviews of the effectiveness of Legionella control activities are
carried out to verify the written scheme of control remains adequate and if they are
not to carry out a review of the legionella risk assessment.
h. Have change management procedures and or regular review procedures to
determine if the existing risk assessment is still valid, suitable, and sufficient. If it is
not, then a reassessment of the risk is required.
heck list 01 - Legionella Risk Assessment
Non-Con
Ref
Check list 02 - Water Treatmen
Brief description of the work(s) being audited:
- Quote(s) & Dates
- Job/Works(s) Ref & Date:
Clause Question
Non-Con
Ref
Check list 03 - Hot & Cold Water Mo
Brief description of the work(s) being audited:
- Quote(s) & Dates
- Job/Works(s) Ref & Date:
Clause Question
Non-Con
Ref
Check list 04 - Cleaning & Disinfec
Brief description of the work(s) being audited:
- Quote(s) & Dates
- Job/Works(s) Ref & Date:
Clause Question
The member should tell their customer that it is the responsibility of the duty
holder/responsible person to:
a. Maintain the water system, and the water in it, in a clean condition and to
facilitate inspection to determine if the system is clean or not.
b. Make the systems available for the agreed work, with safe access, and adequate
notice to ourselves to schedule and execute the agreed work.
22 c. Provide us with any information on known risks and safety requirements in the
areas we will be working, and advise of any known deadlegs, redundant pipework
and the location of schematic diagrams.
d. Ensure any preparatory work you are responsible for is completed prior to
commencing cleaning and disinfection work.
e. Ensure any necessary trade effluent discharge consent is in place for effluent
generated from the cleaning and disinfection process.
Check list 04 - Cleaning & Disinfection
Non-Con
Ref
Check list 05 - Consultancy
Brief description of the work(s) being audited:
- Quote(s) & Dates
- Job/Works(s) Ref & Date:
Clause Question
The member should tell their customer that it is the responsibility of the duty
holder/responsible person to:
14 a. Provide us with any pertinent historic information relevant to the project.
b. Clearly define the work, its objectives, and outcomes.
c. Agree the expectations regarding the level of detail in and the report format.
Check list 05 - Consultancy
Non-Con
Ref
Check list 06 - Training as a serv
Brief description of the work(s) being audited:
- Quote(s) & Dates
- Job/Works(s) Ref & Date:
Clause Question
Non-Con
Ref
Check list 07 - Legionella Monitoring S
Brief description of the work(s) being audited:
- Quote(s) & Dates
- Job/Works(s) Ref & Date:
Clause Question
Does the member have a suitable process to describe and manage - Sample
transport & delivered to the laboratory?
- Transport of samples
14 - Temperature of transport/storage
15 & - Sample labelling and documentation (Member identification, sampler, sample points,
16 sample time, sample matrix, analysis required)- in appropriate condition
- as soon as is practical from the point of sampling.
(Samples should begin analysis, ideally within 24 hours but certainly within 48 hours
from sampling).
Does the member have a suitable process to describe and manage - Laboratory
Result Reporting?
19(a-c) - Confirming the laboratory have a sample reception process
- Confirming the laboratory report Interim result
- Confirming the laboratory issue of a final certificate
Does the member have a suitable process to describe and manage - Reporting
Analytical Results to the Client?
23 As a minimum, recommendations must be based on the guidance in HSG274, HTM
04-01, HSG282 or
other national guidance as applicable.
Avoiding transcription errors?
- the original laboratory certificate forwarded. or
22
- robust procedures in place to ensure that it is correctly transcribed and all data
transferred from the original certificate is included.
Verification and Quality Control?
- All required visits are done to schedule (missed visit control)
- Appropriate recommendations have been made for results
- Required samples are completed and any missing results are followed up
24(a-g)
- The correct control limits are employed
&
- Results are understood and interpreted correctly
25
- Appropriate corrective actions are advised to the agreed contacts
- Significant non-conformances are recorded and tracked to conclusion
- A representative proportion of output must be monitored to ensure compliance with
the above.
D) What you need to tell your customer
The member should inform the client that it is the responsibility of the duty
holder/responsible person to:
a. Have a legionella risk assessment, written scheme of control and schematic
diagram in place which includes a programme of treatment, monitoring, and
inspection (and may include legionella sampling) and make this available to us.
b. Provide sufficient information to allow us to design an appropriate treatment
programme, including a legionella sampling plan if appropriate.
26
c. Make the systems available for the agreed work, with safe access, and adequate
notice to ourselves to schedule and execute the agreed work.
d. Provide us with any information on known risks and safety requirements in the
areas we will be working.
e. Ensure the control scheme tasks you are responsible for are completed and
recorded.
f. Participate in the agreed review process.
eck list 07 - Legionella Monitoring Services
Non-Con
Ref
Check list 08 - Plant & Equipme
Brief description of the work(s) being audited:
- Quote(s) & Dates
- Job/Works(s) Ref & Date:
Clause Question
The member should inform the client that it is the responsibility of the duty
holder/responsible person to:
a. Consider that any changes to the system may alter the Legionella risk and
therefore require a review of risk assessment, associated control scheme and
records. This may result in:
• a reassessment of the legionella risk
• an update of the written scheme of control
• a revised schematic diagram
• a revision of the record keeping system
19
b. Make appropriate notification under the requirements of the Plumbing Notification
Laws.
c. Ensure the necessary trade effluent discharge consent is in place for any effluent
generated from any equipment installed.
d. Ensure any preparatory work you are responsible for is completed prior to
commencing plant and equipment work.
e. Ensure any equipment is installed, commissioned, operated, and maintained
correctly.
Check list 08 - Plant & Equipment
Non-Con
Ref