rNational Health and Safety Function, WHWU, CERS, Human Resource Division.

/ Level 2 Health and Safety Audit Tool
REF:005:001 / Ref: Level 2 Audit Tool
Issue Date / July 2017 / Review Date: / July 2018
Author(s) / National Audit and Inspection team
Interviewee / Title

Introduction

This Level 2 Health and Safety Audit Tool is the second in a suite of five audit tools. The purpose of this audit tool is to provide assurance to senior managers of compliance with the HSE Safety Management System.

The audit tool should be used by General Managers/Service Manager or equivalent to evaluate their compliance.

The audit will systematically assess the systems in place and measure against HSE current policy and national legislation. It requires the co-operation of the GM/Manager of the service and all members of the Executive Management Team in order to be effective.

Questions are based on:

Non-compliance,

Compliance

Each question must be answered and evidence of verification is required for each question.

The audit tool is divided into the following parts:

Part A: Health and Safety Management (31 Questions)

Section 1: Roles and Responsibilities (7 questions)

Section 2: Policies (4 questions)

Section 3: Training (13 questions)

Section 4: Accident/Incident Reporting and Investigation (7 questions)

Part B: Hazard Identification/Risk Assessment /Risk Registers (3 questions)

Part C: Audit and Inspection (3 questions)

Part D:Consultation (4 questions)

Part E:Representation (4 questions)

Part F: Dangerous Goods (1 question)

Scoring the audit

This audit contains 45 questions which all carry equal marks – 100 marks each.

The auditor should calculate the audit score as a percentage.

This is explained by a worked example as follows:

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.

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 hospital management to implement a plan for improvement.

Traffic light system for audits.
90-100% / Compliant – Repeat self auditon annual basis as determined
60- 80% / Repeat self audit at 6/12.
30- 50 % / Immediate action by hospital/service –repeat self-auditat 3 months
0-20% / Critical – Immediate action by hospital/service - Repeat audit at 1 month.

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Part A: Health and Safety Management: Safety Health and Welfare at Work Act 2005 Part 3 Chapter 3 Section 20
Section 1: Safety Statements
Question / Evidence of Verification / Response / Compliant / Non-Compliant / Score
1. Does the hospital/service have an overarching documented site-specific safety statement dated within last 12 months? / Name of Service Area, Hospital signed and dated within last 12 months.
2. Is there a hospital /service organisational management chart dated within the previous 12 months? / An organisational management chart that clearly indicates the responsible persons in the hospital / service.Reviewed within the last 12 months and dated to reflect same.
3. Are reporting relationships clearly defined in the organisation? / Site Specific Safety Statement to define these reporting relationships.
4. Has the Site Specific Safety Statement been signed off by the Chief Executive / Service manager /G.M or his/her Designate? / Name of Service Area, Hospital Signed and Dated. Safety statement must bear signature of the chief executive /service manager/G.M. or designate.
5. Is safety and health effectively integrated into the hospital /service/organisations strategic
Plan? / Objective on service plan –documented on same.
6. Are managers, made aware of their responsibilities with regard to safety and health? / Responsibilities in Site Specific safety Statement (S.S.S.S). Health & Safety Training for managers within the service.
7. Are safety and health responsibilities detailed in the job descriptions of managers, / Duties of Senior Managers detailing this.
Total Section 1
Section 2: Policies
Question / Evidence of Verification / Response / Compliant / Non-Compliant / Score
1.Is there a named person responsible for coordination and dissemination of all current and new National Health & Safety Policies, Procedures and Guidelines within the hospital / service / Name & title to be provided.
2. Is there a system in place to ensure that all current national occupational health and safety policies are easily accessible to all staff? / Evidence of hard copies or access to IT system.
3. Explain the system of notification within the hospital/ service when a new policy, procedure or guideline has been launched / How does this happen? Who is the responsible person to disseminate this information? Meeting minutes, I.T system and /or hard copies for thosewho do not have I.T. access.
4. Have all employees access to the H.S.E.’s National Website, if no then how is this information disseminated to those that do not have access? / Evidence that all groups of employees are taken into account. Documented procedure for those who do not have access.
Total Section 2
Section 3: Training: Safety Health &Welfare at Work Act 2005 Part 2 Chapter 1 Section 10
Question / Evidence of Verification / Response / Compliant / Non-Compliant / Score
1. Has management identified the training needs of employees through a systematic training needs assessment? / Central Database/ PPARS/ Training Records (identifying statutory and mandatory training and other training
2. Has the health and safety training programme been communicated to all relevant staff? / Schedule of Training
Risk Assessment
Systems in place to communicate to staff What is the system e.g. email, notice boards, electronically
3. Is training provided within an appropriate reasonable timescale? / System in place to record and flag refresher training.
4. Is nonattendance at training programmes recorded and managed. / Disciplinary Procedure
Written correspondence to staff
5. Is there a central database for recording training / Either central database, PPARS, manual training record
6. Do local managers have access to this database? / Is there a common folder which managers can access
7. Is there a system in place to identify % of managers who have completed the HSElanD module: Managing Health and Safety in the Healthcare Setting / % from ward/departments collated in overall hospital/service percentage.
Stats from training department/training coordinator
8. Is there a system in place to identify % of staff who have received Manual Handling (MH) training in the last three years / % from ward/departments collated in overall hospital/service percentage.
Stats from training department/training coordinator
9. Is there a system in place to identify % of staff identifed as Display Screen Equipment (DSE) users who have undertaken the HSELand module / % from ward/departments collated in overall hospital/service percentage.
Stats from training department/training coordinator
10. Is there a system in place to identify % of staff who have undertaken HSElanD module: Health, Safety and Security / % from ward/departments collated in overall hospital/service percentage.
Stats from training department/training coordinator
11. Is there a system in place to identify % of staff who have received medical gas cylinder training as per TNA / % from ward/departments collated in overall hospital/service percentage.
Stats from training department/training coordinator
12. Is there a formal induction program for all new employees including health and safety? / Documented Induction programme
13. Is instruction, training and supervision provided to employees in the following situations;
Recruitment
Transfer
Change of task
On the introduction of new work equipment
Changes in work environment or systems of work
Introduction of new technology
Sensitive risk groups / Safety Statement
Training Records
Attendance sheets
Evaluation sheets
Post training assessment
Total Section 3
Section 4: Accident /Incident Reporting and Investigation- Safety, Health and Welfare at Work (Reporting of Accidents and Dangerous Occurrences) Regulations 2016 (S.I. No. 370 of 2016).
Question / Evidence of Verification / Response / Compliant / Non-Compliant / Score
1. Is there a policy and procedure in place for reporting accidents, incidents and near misses? / Detailed in Hospital Safety Statement. Internal written procedure. Managers have attended training. Access to forms. Safety Committee Key Performance Indicator
2. Is there a hospital database detailing all accidents/incidents/ near misses? / Electronic Spreadsheet that clearly indicates
Location
Category of person – e.g. Nurse, Doctor
Incident Classification
Sub Hazard
Work Days Lost
IR1, if applicable
IR3
Accidents to Contractors
Accidents to Members of the public – non clinical
3. Is there a hospital wide system in place so that all managers have access to relevant forms? / National Incident Management System access to forms. This can be in paper or electronic form.
4. Is there a nominated person for reporting Lost Time Accidents (IR1s) to the Health & Safety Authority? / Named person with access to HSA IR1 database for hospital
5. Is trend analysis completed on injuries/ill health absence? / Annual Reports. Minutes of Safety Committee and /or Quality & Risk Committee detailing trends.
6. Is there a system in place to ensure remedial measures identified on accident investigations are closed out? / System for accident investigation. System for escalating measures identified, as required, to senior manager(s). Evidence of review and implementation of measures and close out of same. Evidence that at a regular frequency department manager are required to provide evidence to senior managers of action and close out of remedial measures identified following accident investigation.
7. Does the hospital/Service ensure that the number of Accidents/ Incidents/ Near Misses & Dangerous Occurrence corresponds with investigations completed? / Record of accident investigations collates with number of Accidents/ Incidents/ Near Misses & Dangerous Occurrences.
Total Section 4
Part B: Hazard Identification / Risk Assessment / Risk Registers
Question / Evidence of verification / Response / Compliant / Non-Compliant / Score
1. Are there Safety Statements and risk assessments that cover each department, common areas, external satellite areas, contractors, leased premises etc / Safety Statements
Plan of where staff work,
Named department heads
Common areas, including grounds and car parks.
Areas where staff work outside main premises/away from base.
Names of contractors.
Leased premises.
2. Is there a process to escalate hazards to senior management for action? / Procedure to escalate hazards to senior management for action.
Named responsible manager
Risk Register
3. Is there a process to prioritise implementation of control measures? / Process
Risk Register
Allocated budget
Total Part B
Part C: Audit and Inspections
Question / Evidence of Verification / Response / Compliant / Non-Compliant / Score
1. Is there a system in place for recording all Health and Safety Authority (HSA) inspections. / Evidence of records
2. Is there a nominated person to upload HSA reports of inspection, improvement notices or other documentation to National Health and Safety website / Named person
3. Does the hospital/ service have a programme of auditing using the National Level 1 Health and Safety Audit Tool / Evidence of programme
Total Part C
Part D: Consultation
Question / Evidence of Verification / Response / Compliant / Non-Compliant / Score
1. Is there a mechanism in place for consultation on safety, health and welfare? / Safety Committee
Safety Rep
Agenda Item for departmental meetings.
2. Is there a committee in place to ensure effective consultation on safety and welfare matters? / Safety Committee in place
Minutes
3. Is there evidence that the committee operates in accordance with its terms of reference? / Annual Report
Follow up action lists
4. Is health and safety an agenda item at Management team meetings? / Agenda and Minutes
Total Part D
Part E: Representation
Question / Evidence of Verification / Response / Compliant / Non- Compliant / Score
1. Does the employer consider representations from employees on safety, health and welfare? / Health and safety committee meetings
Named person
Safety rep
Team meetings
Minutes
2. Is there a mechanism in place for the appointment of a safety representative? / Coordination of safety rep selection, election and training.
3. Is the safety representative provided with adequate time to perform and discharge his/her representative functions? / Interview Safety Rep
Accidents or Incident Reports
HSA inspection
Training records
Attendance safety committee meetings
Total Part E
Part F: Dangerous Goods
Question / Evidence of Verification / Response / Compliant / Non- Compliant / Score
1. Does the facility/service have access to an appointed Dangerous Goods Safety Advisor / Named person.
Total Part F

Score Table

Score / Overall percentage
Part A (Max 3100) / AAS/ MAA x 100/1 =
Part B (Max 300)
Part C (Max 300)
Part D (Max 400)
Part E (Max 300)
Part F (Max 100)
Total

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