The previous H&S audit was in 2017. Four recommendations were made. Two were implemented, one was obsolete, and the final recommendation has been carried forward.
The last Lone Working audit was in 2020. Twelve recommendations were made, six have been implemented, four are now obsolete and two have been carried forward.
The field work for the latest audit was conducted in 2022.
Assurance rating: Limited
There were eighteen recommendations made.
Although both H&S vacancies are now filled following the resignation of previous advisors (circa March 2023), and whilst acknowledging the interim resource since June 2023, all audit recommendation findings remain open.
This report provides updates on the observations and associated recommendations made by the audit team, and summarises other activities.
Both H&S positions have recently been fulfilled through the appointment of Andy Huckstep as Senior H&S Advisor, and Louise Doughty as H&S Advisor through internal transfer from Environmental Health, both effective from 11th Dec 2023.
All service areas are encouraged to ensure contact is made during Q4.
It is the recommendation of the H&S team to review and revise the entire H&S management system, in full agreement with the existing audit recommendations, utilising the existing H&S management system so far as practicable.
As the H&S team embed within the Councils, a number of topics are currently under review including but not limited to
· H&S training content within LEAH with a proposal for an alternative provider (content only)
· H&S training strategy to include training matrix and ‘in person’ training delivered in house by H&S
· Full policy / procedure program review
· Lone Worker (LoneAlert) program review and re-deployment
· H&S Incident reporting platform, investigation and summary report (inc SMT reports)
· Staff engagement to include management training & H&S Champions
The overall H&S program re-development and deployment shall be undertaken with consultation, and periodic update to both Joint Audit & Governance Committee and Internal Audit and Risk.
The risks have also been assigned RAG (red, amber, green) depending on the level of risk:
Colour Code
Red = High Risk
Amber= Medium Risk
Green = Low Risk
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Objective area |
Recommendations |
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Ref |
Description |
Risk score |
Update |
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Obj1: Policies and procedures |
1 |
Review H&S policies, procedures, and guidance (restated) |
8 |
A revised H&S policy was implemented in 2022. Due for review 2025. The following policies are available on LEAH (which is the councils’ online learning and training platform): · Display Screen Equipment · Eye Tests Procedure · First Aid Policy · H&S Policy · Hybrid and remote working policy · Lone Working Policy · Stress Management Policy
A full list of policies and the date last updated is in Appendix A.
The following policies are currently under review which have a health and safety element. · Volunteering Policy · Working from Abroad Policy |
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2 |
Review and update recommendations from the 2019 strategic health and safety review. |
5 |
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3 |
Implement the health and safety champions forum. |
2 |
H&S Champion role established and volunteers in place. Regular monthly meetings with H&S Unison reps. |
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Obj2: Training and guidance |
4 |
Maintain suitable H&S training on LEAH, establish training requirements for contractors and agency staff and develop H&S refresher training. |
7 |
The following courses are available on LEAH, there are no formal requirements to refresh training- this is being reviewed as part of the Workforce Strategy- consideration being given to implementing three yearly refreshers and reminders when training is due to be refreshed.
Those highlighted in yellow are mandatory for all staff and form part of the induction checklist process which is covered in the induction manual for new starters, those highlighted in green are mandatory for lone workers and safety critical roles, managers must do the course in blue too:
· COSHH Awareness · DSE Awareness Training · Fire Safety Awareness Training · Introduction to Health and Safety · Legionella Awareness Training · Lone Alert Worker Training · Lone Alert Responsible Officer Training · Manual Handling Awareness Training · Personal Resilience Training · Personal Safety Awareness Training · Remote Working · Remote Working for Managers · Safeguarding Adults · Safeguarding and Child Protection · Working at Height · Working from Home 1 & 2
All new starters as part of induction must complete a DSE assessment for home and office working if they are a DSE user.
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5 |
Continue to develop a centralised H&S training matrix, defining the requirements, and monitoring the completion of specialist training across individual roles and services. |
9 |
As part of the proposed workforce strategy a training needs analysis will be carried out and any skills gaps identified.
Reports are provided to Head of Service on the completion of H&S training, the latest report was Sept 2023.
Training planned for autumn 2023: Emergency First Aid at Work, Manual Handling, Fire Warden Training, DSE Assessors.
Members training was conducted in May 2023 and a members’ area has been created on LEAH.
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Obj3: Incident reporting |
6 |
Review and update the incident reporting policy, relaunch the revised incident reporting procedures and remind managers to notify H&S of RIDDOR reportable incidents in a timely manner. |
5 |
The incident reporting form was reviewed in June 2023. The policy needs review. Regular reports of incidents are received by H&S and logged. Any RIDDOR reports are conducted in a timely manner. Incident reports are reviewed, and advice and guidance provided, as necessary.
Quarterly H&S reports are submitted to SMT, and the data is used to analyse training needs and trends. Further consideration to be given regarding an online reporting system for first aid and incidents.
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7 |
Continue to explore options for an online incident management reporting system. |
2 |
To be reviewed once permanent staff in role. |
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Obj4: Risk management and compliance |
8 |
Implement a system for H&S inspections/ monitoring. |
9 |
Further training planned for heads of service and service managers in relation to their H&S responsibilities.
Need to ensure there are clear parameters as to who should complete inspections and risk assessments- these should be carried out by services and teams with H&S maintaining an oversight and support role with additional guidance as required. |
|
9 |
Review and update the risk assessment management system, including policy, procedures, training, and guidance. |
7 |
A centralised system for recording and reviewing risk assessments and inspections and reminders would support services with continuous monitoring and review.
Moving the H&S roles to sit within the D&CL service where the most risk assessments and requirements are, will hopefully improve consistency and enable a centralised repository to be created.
A cycle of audit and review to be put in place once the permanent roles are appointed to. |
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Obj5: Contractor management |
10 |
Review, update and republish the H&S contractor policy and procedural guidance. |
2 |
Policy needs to be reviewed. |
|
11 |
Remind service teams of the requirement per the procurement procedure rules to obtain H&S documentation as part of the contract tender/award. |
7 |
H&S to work with procurement/legal to devise checklist for services to use when completing procurement to assess whether H&S documentation is required and if so, what is needed.
There is joint responsibility here between Procurement and H&S to ensure requirements are considered. |
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12 |
Formalise and document the requirements for a permit to work process. |
3 |
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Obj6: Lone working (operational duties) |
13 |
Remind LoneAlert system users to complete training and read the revised lone working policy. |
4 |
HOS, Service Managers and Line Managers should ensure that where teams are likely to carry out lone working, staff are added to the system and access the training and guidance available. This should form part of the service specific induction and regular Let’s Talk/121 process conducted between line mangers and their team members. |
|
14 |
Remind service teams to ensure LoneAlert registered users and escalation hierarchy reflect the organisational structure. Conduct a full review of the senior management team escalation hierarchy. |
5 |
Lone Alert contract has been renewed for a further three years. H&S working with IT and teams to carry out audit of existing users and to move to a new platform with enhanced functionality and reporting.
Training and guidance to be given to staff when new platform launched which will provide an opportunity to remind users to read policies and training resources,
Looking to move to single sign on and to use existing IT hierarchy data to maintain system going forward. |
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15 |
Establish a regular LoneAlert user access review, where service teams are required to formally notify the health and safety team of user access changes. (restated) |
5 |
See above- audit currently underway. Teams need to notify H&S of new users and leavers, and the relevant info to add them. Teams must notify H&S of line management changes, staff on long term sick. Going forward IT hierarchy data is to be used to keep info up to date. |
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16 |
Issue LoneAlert system reports to service teams on a regular basis, for monitoring activities. (restated) |
2 |
In place- teams however are slow to respond to requests for updates. |
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Obj7: Hybrid working |
17 |
Establish an agreed approach to conduct regular portable electrical appliance safety checks/inspections, per the requirements of the Hybrid and Remote Working Policy. |
6 |
This action requires staff to report issues and regularly review equipment for signs of wear and tear. Report to IT for replacements
DSE assessment required for home and office, and they are reviewed by trained assessors who provide advice.
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Obj8: KPI reporting |
18 |
H&S to attend SMT meetings to present major papers, including policy and procedural changes, answer queries, and raise awareness of legislative requirements as the councils’ qualified, appointed officer. H&S to be added as a standard item on the SMT agenda. |
3 |
H&S is a standing item on all SMT meetings, with quarterly reports considered covering latest incidents reports, policy work and other relevant H&S information. There are monthly meetings with Unison H&S reps to discuss any issues, Data on incidents analysed and reports reviewed. H&S liaise with teams to consider any steps or training. For example, a regular visitor to AH who has been aggressive towards staff has received a letter advising they cannot enter AH and to liaise with their housing advisor by phone. H&S have reviewed risk assessments and control measures with team and are currently discussing refresher training re: handling difficult customers.
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Recommendation |
Update |
Risk Rating
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Continue to review and update H&S related policies procedures and guidance |
Stress, Driving at Work and Legionellosis policy under review currently. Schedule for review of overdue policy reviews in place (Appendix B) |
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Review and update all recommendations detailed within the strategic health and safety review, and implement controls where risks remain relevant to current operations.
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Review of the 2019 strategic H&S review ongoing. |
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Implement the H&S champions forum to ensure that the corporate H&S team are formally consulted on all individual service policy and procedures that may contain H&S matters and/or practices |
H&S Champions identified, and overview of role drafted. Training to be arranged. Regular meetings to be set up once appointments made to permanent roles. Monthly meetings with Unison H&S reps continue. |
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a) Verify all H&S training on LEAH is fit for purpose and remains relevant to current legislation.
b) Remind line managers of the requirement for new starters to complete the mandatory H&S training on LEAH within their probation period.
c) Remind all officers to complete the required mandatory training within LEAH.
d) Develop a report to assist managers in monitoring training compliance and issue at agreed intervals.
e) Establish requirements for contractors and agency staff to complete mandatory H&S training.
f) Develop a regular schedule for H&S refresher training for all officers (inc. contractors and agency staff if applicable). |
a) Interim H&S advisor to review training.
b) People & Culture Manager has provided article for comms bulletin and will do an update on Induction at next Operational Management Group comprising managers from across the councils.
c) Article in all staff comms will remind staff.
d) Report provided to all heads of service provided Sept 2023 for them to review and monitor compliance- reports to be provided quarterly in July/Oct/Jan and April.
e) Contractor and agency training requirements to be picked up once permanent staff in post.
f) Refresher training to be picked up as part of workforce strategy learning & development stream. |
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a) Identify and define specialist officer roles, responsibilities, and health and safety training requirements across all services.
b) Continue to develop the centralised H&S training matrix.
c) Embed refresher training arrangements for mandatory and specialist modules. |
Workforce strategy learning and development strand will pick up training needs analysis and work with H&S team to create a programme of training to meet the regular and specialist training required. |
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a) Following review and update of the Incident Reporting Policy, relaunch the revised incident reporting procedures, including the new incident reporting email address.
b) Remind managers to notify H&S of all RIDDOR reportable incidents in a timely manner following incidents being reported/notified.
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Incident report form has been updated. RIDDOR reports are coming into H&S within 48 hours. Policy reviews to be picked up as part of schedule and once complete a re-launch will be implemented. H&S training for managers is currently being scoped out. |
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Continue to explore options for an online incident management reporting system.
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Project for when permanent roles appointed to. |
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a) Implement a system for H&S inspections/monitoring, in line with HSE guidance and the councils’ Health and Safety Policy.
b) Property Assets team to consult and agree compliance inspection routines with Health and Safety to ensure any safety elements adhere to relevant H&S legislation and are fit for purpose.
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Project for when permanent roles appointed to. |
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a) Review and update the councils H&S risk assessment management system (i.e., policy, procedures, training, and guidance).
b) Establish a centralised records library for health and safety risk assessments.
c) H&S Business Partner to remind all service teams of the need to complete and regularly review all service area’s risk assessments.
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Project for when permanent roles appointed to. |
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Review and update the health and safety contractor policy and guidance published on Jarvis to ensure relevance to current legislation.
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See policy review schedule Appendix B |
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a) Procurement to liaise with Health and Safety on the revised procurement process, guidance, and template documentation to ensure there is suitable consideration of health and safety requirements and controls to comply with relevant legislation.
b) Remind service teams of the requirement per the procurement procedure rules to obtain H&S documentation as part of the tender/award of contracts etc.
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Project for when permanent roles appointed to. |
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a) Formalise and document the process used by the facilities team for issuing permits to work to the contractors under their management.
b) Consult Health and Safety to ensure the permit to work process is fit for purpose. |
Project for when permanent roles appointed to. |
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|
Policy |
Last Updated |
Comment |
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Hybrid and Remote Working |
Aug 2022 |
Review due Aug 2025 |
|
First Aid Policy |
Aug 2022 |
Review due Aug 2025 |
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Display Screen Equipment Policy |
Sept 2022 |
Review due Aug 2025 |
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Health and Safety Policy |
Jan 2022 |
Review due Jan 2025 |
|
Lone Working Policy |
Aug 2022 |
Review due Aug 2025 |
|
Fire Policy and Procedure |
2019 |
Overdue for review |
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Driving at Work Policy |
Nov 2017 |
Currently under review |
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Dangerous Substances Policy |
April 2017 |
Overdue for review |
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Electrical Safety Policy |
May 2018 |
Overdue for review |
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Hazardous Substances Policy |
Jan 2017 |
Overdue for review |
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Incident Reporting and Investigation Policy |
April 2018 |
Overdue for review- incident form has been updated July 2023 |
|
Legionellosis Policy |
Aug 2017 |
Currently under review |
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Lifts and hoists policy |
June 2016 |
Overdue for review- query whether this can be covered in manual handling policy |
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Managing violence and aggression policy |
July 2012 |
Overdue for review |
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Manual Handling Policy |
Sept 2016 |
Overdue for review |
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Personal Protective Equipment |
May 2018 |
Overdue for review |
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Risk Assessment and Control Policy |
May 2018 |
Overdue for review |
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Shared Premises Policy |
May 2018 |
Overdue for review |
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Working at Height Policy |
May 2018 |
Overdue for review |
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Work Equipment Policy |
May 2018 |
Overdue for review |
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Workplace Policy |
May 2018 |
Overdue for review |
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Control of Noise Policy |
May 2018 |
Overdue for review |
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Stress Management Policy |
Sept 2013 |
Currently under review |
|
Policy |
Review by |
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Stress Management Policy |
In progress |
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Legionellosis Policy |
In progress |
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Driving at Work Policy |
In progress |
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Managing violence and aggression policy |
End of Jan 2024 |
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Lifts and hoists policy |
End of Jan 2024 |
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Manual Handling Policy |
End of Jan 2024 |
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Hazardous Substances Policy |
End of Jan 2024 |
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Dangerous Substances Policy |
End of March 2024 |
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Electrical Safety Policy |
End of June 2024 |
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Incident Reporting and Investigation Policy |
End of June 2024 |
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Personal Protective Equipment |
End of June 2024 |
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Risk Assessment and Control Policy |
End of June 2024 |
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Shared Premises Policy |
End of Oct 2024 |
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Working at Height Policy |
End of Oct 2024 |
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Work Equipment Policy |
End of Oct 2024 |
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Workplace Policy |
End of Dec 2024 |
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Control of Noise Policy |
End of Dec 2024 |
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Fire Policy and Procedure |
End of Dec 2024 |
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Health and Safety Policy |
Jan 2025 |
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First Aid Policy |
Aug 2025 |
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Lone Working Policy |
Aug 2025 |
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Hybrid and Remote Working |
Aug 2025 |
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Display Screen Equipment Policy |
Sept 2025 |