Management System Certification

Hesp

Issue 10

Management System Certification

Audit Summary Report

Organisation: / City of Edinburgh Council City Development Department
Address: / Planning & Building Standards
Waverley Court, 4 East Market Street
Edinburgh
EH8 8BG
Standard(s): / ISO 9001:2008 - Quality Management System Certification / Accreditation Body(s): / UKAS
Representative: / xxxxx
Site(s) audited: / 4 East Market Street / Dates(s) of audit(s): / 5/3/2012 9:00:00 AM
EAC Code / 35,36 / NACE Code: / 74,75
No of Employees: / 230 / No of Shifts: / 1
Lead Auditor / xxxx / Additional team member(s)
This report is confidential and distribution is limited to the audit team, client representative and the SGS office

1. Audit objectives

The objectives of this audit were:

• To confirm that the management system conforms with all the requirements of the audit standard;
• To confirm that the organisation has effectively implemented the planned management system;
• To confirm that the management system is capable of achieving the organisation’s policy objectives.

2. Scope of certification

ISO 9001:2008 - Quality Management System Certification / The Development Quality process:
Planning registration, validation, processing and reporting of applications to committee, decision letters, appeals, enforcement, street naming, listed buildings and tree preservation orders.
Building Standards:
Processing applications or other submissions, in accordance with the Building (Scotland) Act 2003 and associated legislation in relation to:
a)Building Warrants, Completion Certificates, together with associated site inspections
b)Property Inspections and Confirmation of Completions, and
c)Structural evaluations, enforcement of dangerous buildings and site inspections in relation to the above
Emergency Planning:
Fulfilling the Council’s emergency planning responsibilities as stipulated by Stature, including:
a)Co-ordinating the Council’s advance preparations for responding to serious emergencies,
b)Liaising with all internal and external partner agencies and appropriate stakeholders as required,
c)Preparing, maintaining and developing corporate emergency plans and arrangements including the maintenance of emergency co-ordination facilities and equipment, and
d)Planning an delivering, or contributing to the delivery of, training and exercise initiatives at local, regional and national level
Public Safety and Events:
a)Processing and inspecting temporary licence applications in relation to the Civic Government (Scotland) Act 1982, Theatre Act 1968 and the Cinema Act 1985,
b)Appraising safety plans and risk assessments for medium to large scale public assemblies and events, as facilitated through the Event Planning Operations Group (EPOG) System. This includes the creation of the Safety Plan and the inspection and monitoring of the event.

Has this scope been amended as a result of this audit? Yes No

This is a multi-site audit and an Appendix listing all relevant sites and/or remote locations has been established (attached) and agreed with the client.

Yes No

3. Current audit findings and conclusions

The audit team conducted a process-based audit, focusing on significant aspects/risks/objectives required by the standard(s). The audit methods used were interviews, observation of activities and review of documentation and records.

The structure of the audit was in accordance with the audit plan and audit planning matrix included as annexes to this summary report.

The audit team concludes that the organisation has has not established and maintained its management system in line with the requirements of the standard and demonstrated the ability of the system to systematically achieve agreed requirements for products and services within the scope and the organisations’ policy and objectives.

Number of non conformities identified: __0___ Major ___0__ Minor

Therefore the audit team recommends that, based on the results of this audit and the systems’ demonstrated state of development and maturity, management system certification be:

Granted / Continued / Withheld / Suspended until satisfactory corrective action is completed.

4. Previous audit results

The results of the last audit of this system have been reviewed, in particular to assure appropriate correction and corrective action has been implemented to address any nonconformity identified. This review has concluded that:

Any nonconformity identified during previous audits has been corrected and the corrective action continues to be effective. (Refer to Section 6 for details)

The management system has not adequately addressed nonconformity identified during previous audit activities and the specific issue has been redefined in the nonconformity section of this report.

5. Audit findings

The audit team conducted a process based audit, focusing on significant aspects/risks/objectives. The audit methods used were interviews,
observations of activities and review of documentation and records. / Yes / No
The management system documentation demonstrated conformity with the requirements of the audit standard and provided sufficient structure to support implementation and maintenance of the management system. / Yes / No
The organisation has demonstrated effective implementation and maintenance/improvement of its management system. / Yes / No
The organisation has demonstrated the establishment and tracking of appropriate key performance objectives and targets and monitored progress towards their achievement. / Yes / No
The internal audit program has been fully implemented and demonstrates effectiveness as a tool for maintaining and improving the management system. / Yes / No
The management review process demonstrated capability to ensure the continuing suitability, adequacy, effectiveness of the management system. / Yes / No
Throughout the audit process, the management system demonstrated overall conformance with the requirements of the audit standard. / Yes / No
Certification claims are accurate and in accordance with SGS guidance. / Yes / No / N/A

6. Significant audit trails followed

The specific processes, activities and functions reviewed are detailed in the Audit Planning Matrix and the Audit Plan. In performing the audit, various audit trails and linkages were developed, including the following primary audit trails, followed throughout:

• Relating to Previous Audit Results:

• Relating to this Audit

Management Review: The Management Review for the City Development Department took place on the 26th September 2011, it was seen that the review included a review of the Quality aspects for the section, all items on the agenda were discussed at length, where actions were raised, an owner and deadline / target date were set. Items discussed, included: Internal audits, the previous external audit was discussed and commented upon, objectives/targets, Communications, training and continuous improvements.

Planning The Modernising Planning Mid Year Report on Service Improvement Plan 2011-2012 were seen and verified, this requires Planning Authorities to produce an Annual Service Improvement Plan. It was seen that the Council have adopted the Edinburgh Improvement Model (EIM) to drive quality and as a way of delivering continuous improvements. The EIM is reported quarterly the last was October 2011. The Service Improvement Plan has 36 indicators split into the EIM themes 75% of the targets were seen to have exceeded their targets and had been achieved. . The Building Standards Balance Scorecard is required to be submitted annually to the Scottish Government it was seen from the acknowledgement letter dated 31.08.2011 that the annual submission for 2010/2011 had been made.

Internal Audits: The internal audit schedule for 1st Sep 2011 to 30th June 2012 was seen and verified, all audits are currently to schedule. Hardcopies of audit report checklists CD01/11 and CD02/11 were seen to have been completed. The audits are then recorded and retained electronically on the City Development’s “G” drive. It was noted that no cars have been raised in the audits carried out to date. The Audit Feedback form was seen for CD01/11. This allows both the auditor and the auditee to make comments regarding the audits, these are reviewed and where applicable acted upon. . The frequency of audits is based on an annual rolling programme.

Complaints and Customer Feedback: there is a comprehensive and robust system in place for dealing with complaints. It was seen that customer complaints (originating in a variety of ways) are recorded on the “CAPTURE” database. Since May 2011, 127 complaints have been recorded on CAPTURE. Each complaint is assigned a unique identifier (Service Request) and progressed through to completion. A number of service requests were viewed these included 350661, 318442, 336301 and 333795. Two working weeks are assigned to deal with complaints, complaints are reviewed at the Customer Care Working Group (CCWG) and the Department Management Team (DMT) Meetings. Minutes for CCWG (date 16.11.2011) and DMT (date 03.10.2011) were seen and verified. Complaints relating to Planning are updated weekly and sent tpo the Plannning Leadership Team. The minutes for 27.02.2012 were seen and verified.

Complaints are assigned a descriptor such as (but not limited to) Process, Staff, No (Failure of) Service, Slow Service, Request for Service or Insurance or other claim.

Compliments currently there are only two (346637 & 326195) recorded on CAPTURE, the move to the integrated system includes the encouragement for compliments to be added to CAPTURE. Observations raised see section 8.

Building Warrants including structures: Building Warrant Applications, applications can be received either manually or by electronic means. Application submissions must include three plans, fee and the application form to be completed in full. Of the three plans submitted, one is sent to the regional assessor, one to Structural Engineers and one retained by Building Standards Group of Surveyors. Each application is logged on “Uni-Form” (an electronic database) each application is assigned a unique identifier, number were sampled 12/00773/ALTEX, 12/00772/ALT, 12/00771/ALT, 12/00692/ALT and 08/00497/ALT were seen and verified as being complete, new submissions or extensions to warrant.

The objectives/targets for processing applications is set at 80% for all applications to be completed within 15 working days. Four targets have been assigned these are: -

• Respond to Warrant, currently 4% over target
• Issue Warrant, currently 14% over target
• Respond to certificate of Completion, 19% over target
• Issue/verify Certificate of Completion, currently 16% over target.

Applications files are retained onsite for a period of two years; they are then transferred to Coburn St for a period. The retention period for applications is the lifetime of the building.

Building Inspection Process: the frequency of building warrant inspections is currently under review and subject to change in accordance with Scottish Government’s review. It was seen that the surveyor records all inspections on Uni-Form (seen and verified warrant application 08/00497/ALT, inspection carried out by Building Control Officer DMcC.

Complaints are handled through the CAPTURE system.

Structures Process: one copy of the site plan is submitted to the Structural Engineering Department, this is reviewed and commented upon, and where clarification (contained within Part A and Part B of the report) is required a letter is sent to the applicant or their agent to resolve the issue. A number of samples were seen and verified during this audit, these included, 12/00220/ALT (an open project), 12/00527/ERECT (Project now Discharged), and 11/00322/ERECT. The Report is completed (Part A – Design Aspects, and Part B – Details).

The process for checking that the applicants’ have provided all necessary information is taken from, the Scottish Governments “Procedural Guidance on Certification including information to be submitted with a Building Warrant Application”.

Planning Applications: The process where applicants submit planning applications was fully explained and demonstrated. Local applications can be submitted electronically (onto uni-Form), or manually, it was seen that six applications had been received at the time of the audit on the 7th March 2012., it was noted that electronic applications are proportionally higher. All applications and the subsequent paperwork (e.g. site plans) are logged onto i-dox. From the samples viewed 12/00633/ADV/1, DQ/12/00632/FUL/1, 11/04052/FUL, DQ/12/00702/FUL/1 and 11/04052/FUL (Completed application) all associated paperwork was seen and controlled. This included the Application Form, a Planning Application Workcard, Site plans. It was noted that many checks are carried out through the process involving a number of stakeholders, responses were seen from various stakeholders e.g. checking if the property is within a Conservation area, checking the Gazetteer Management System, checks with the Archaeological Officer.

Department objectives were discussed, it was that for household developments 90% of applications are to be dealt with within two months (a statutory period) it was seen that the target has been exceeded over the past year.

Department training was reviewed, it was seen that all officers are required to complete 35hrs training within the PRD year. It was seen that training had been rolled out for statutory Instrument 357 (Town and Country Planning).

Tree Protection: it was seen that the process for handling Tree Preservation Orders in accordance with sect 160 of the Town and Country Planning Act were carried out in accordance with the Statutory Instrument, internal communications are carried out in accordance with the Tree Correspondence Flowchart. All enquiries are recorded on the Register which is updated on a monthly basis.

It was noted that objectives and targets are set within the department and reported quarterly, it was noted that Tree Preservation Orders must be completed within eight weeks (Statutory Compliance) and for Conservation areas within six weeks. One observation raised see section 8.

Enforcements: The process for enforcements was described and followed through for a number of jobs selected for review – 12/00001/EOPDEV, 12/00050/EOPDEV, 11/00048/EOPDEV and 12/00102/ECOND. The uniform and IDOX systems were demonstrated and records checked within each. Training, including the PRD process, was discussed and recent training completed was verified. Reference documents in the form of the procedures manual and legislation were available on the intranet to ensure current versions are in use. Targets are in place for enforcement and performance is monitored on a regular basis through access reports.

Training: Training records are maintained on an annual basis for all employees, examples of which were sighted. Recent householder permitted development training was noted to have been conducted and was logged on the related individual training records. Training course request sheets were viewed which had been signed by the employee and authorised as required. Mandatory training was discussed and included health & safety and customer service. The staff development group have regular meetings as a form of internal communication and minutes dated 02/02/12 were provided, with good identification of actions and responsibility allocated. Information relating to team away days was also made available in the form of a proposal and related feedback (local development plan team away day, 28/10/11).

Listed Buildings: Processing of applications relating to listed buildings was described with reference to applications 11/03488/LBC and 12/00176/LBC. A checklist is in use to ensure all required steps are followed and questions considered in processing applications. This is also used when training students in the process. Training is provided for any changes to legislation and updates to procedures are notified by email, with access through the intranet to ensure current. One observation raised see section 8.

• Relating to Client Proposed Action to Address Minor Non-Conformances Raised at this Audit

7. Nonconformities

Nonconformity No: ___of ___ / Major / Minor
Department/Function: / Standard Ref:
Document Ref: / Issue/Rev Status
Details of Non-Conformity:
Nonconformities detailed here shall be addressed through the organisation’s corrective action process, in accordance with the relevant corrective action requirements of the audit standard, including actions to analyse the cause of the nonconformity prevent recurrence, and complete records maintained.
Corrective actions to address identified major nonconformities shall be carried out immediately and SGS notified of the actions taken within 30 days. An SGS auditor will perform a follow up visit within 90 days to confirm the actions taken, evaluate their effectiveness, and determine whether certification can be granted or continued.
Corrective actions to address identified major nonconformities shall be carried out immediately and records with supporting evidence sent to the SGS auditor for close-out within 90 days.
Corrective Actions to address identified minor non conformities shall be documented on an action plan and sent by the client to the auditor within 90 days for review. If the actions are deemed to be satisfactory they will be followed up at the next scheduled visit.
Corrective Actions to address identified minor non-conformities have been detailed on an action plan and the intended action reviewed by the Auditor, deemed to be satisfactory and will be followed up at the next scheduled visit.
Appropriate immediate action taken in response to each non-conformance as required
Note:- Initial, Re-certification and Extension audits – recommendation for certification cannot be made unless check box 4 is completed. For re-certification audits the time scales indicated may need to be reduced in order to ensure re-certification prior to expiry of current certification.
Note: At the next scheduled audit visit, the SGS audit team will follow up on all identified nonconformities to confirm the effectiveness of the corrective actions taken.

1. General Observations and Opportunities for Improvement

• Observation: The system for dealing with Customer complaints is comprehensive and well managed. Feedback to the party making the complaints was readily available and logged on the CAPTURE system. This provides a very good audit trail.
• Observation: It was noted that the Capture system is extensively used for recording complaints, (with only two compliments recorded), it was seen during the audit that a many compliments are received by the departments, it has been discussed that compliments are added to CAPTURE, this would be of benefit in providing evidence of customer satisfaction.
• Observation: it was noted that Tree Protection group have a project to “switch over” to Uni-Form and iDOX. This will be of benefit to the department and Council in their efforts to streamline the electronic management systems.
• Observation: Listed Buildings – the checklist in use was noted to be a useful document; however, this was not a controlled document. It would be beneficial to control this document to ensure any changes to this are controlled, especially if in use for training new staff.

Job N˚ / 208121 / Report Date: / 07/03/2012 / Visit Type: / Surveillance Audit / Visit N˚: / 2
CONFIDENTIAL / Doc Name: / GS304 Stage 2 Audit Report / Issue N˚ / 10 / Page N˚: / 1