Introduction

In statutory guidance published by the HSC in September 2001 the requirement to carry out inter authority auditing at least every 5 years was introduced.

The attached audit report examines the health and safety enforcement service of the Isle of Wight Council. The assessment includes local arrangements in place for the enforcement of the Health and Safety at Work etc. Act 1974 (HSWA) in premises defined by the Health and Safety (Enforcing Authority) Regulations 1998.

Section 18 of the HSWA requires that LAs perform their duties in accordance with guidance from the HSC. This guidance is mandatory.

Section 18 (4) states it shall be the duty of every local authority to:

· make adequate arrangements for the enforcement within their area of relevant statutory provisions; and

· perform the duty imposed on them by the above paragraph and any other functions conferred on them by any of the relevant statutory provisions in accordance with such guidance as the HSC may give them.

The HSC issued revised Section 18 guidance to LAs in October 2002. This sets out the broad principles that the HSC wishes LAs to adopt in enforcing health and safety legislation. It sets out the framework in which LAs should operate.

The Hampshire and IOW Benchmarking Group audits assess LAs’ compliance with Section 18 guidance together with the opportunity to identify and disseminate good and best practice. Additionally scores against the Performance and Quality Matrix are verified.

Contents

1 Introduction Page 2

1.1 Purpose of the audit Page 4

1.2 Scope of the audit Page 4

1.4 Organisation and management Page 4

2 2.1.1 Executive summary Page 5

2.1.4 Best Practice Page 5

2.2 The authority’s strengths Page 6

2.3 Areas for improvement Page 6

3 Audit findings Page 7

3.1 Officers interviewed Page 7

3.2 Enforcement policy and procedures Page 7

3.2.9 Enforcement practices Page 8

3.3 Work Programme and Service Plans Page 9

3.3.7 Planned inspection programme Page 10

3.3.12 Priority Planning system Page 11

3.3.16 Database/IT systems Page 11

3.3.20 Education and promotional work Page 11

3.4 Training and competence Page 12

3.5 Investigations Page 13

3.6 Performance management and review Page 13

4 Conclusions Page 14

Annex 1 Diagram showing organisation of section

Annex 2 Hampshire and IOW protocol inter-authority auditing

Annex 3 Performance indicator for LAs’ compliance with

HSC’s Section 18 guidance

Purpose of the audit

1.1 The audit was carried out as part of the programme agreed by the Hampshire and the IOW Chief Environmental Health Officer’s Group and in compliance with HSC Sec18 Guidance.

Scope of the audit

1.2 The audit covered the Council’s health and safety enforcement service. It took place at the Council’s offices in Newport, Isle of Wight, PO30 1LT on 22^nd August 2003.

1.3 The audit assessed the Council’s compliance with the HSC’s Section 18 guidance using the HELA audit protocol for the management of LAs’ health and safety enforcement and verified Quality and Performance Matrix scores. A revised version of the protocol and supporting guidance (LAC 23/19) was issued to LAs on 24 January 2002.

Organisation and management

1.4 The Council comprised 48 elected members with the Island First Group (a cross party alliance) having overall control with 28 Councillors; the Conservatives had 13 seats and the Labour Party 3 and others 4. The Council had a cabinet structure with a leader, an executive board and a scrutiny process. The lead member for health and safety enforcement was the Executive Member for Fire, Emergency Planning and Consumer Protection – Mr David Knowles.

1.5 Health and safety enforcement was part of the Council’s Environmental Health Department, which is part of the Directorate of Environmental Services. The Department is divided into three sections, Food Safety, Licensing and Environmental Protection (which includes Health and Safety).

1.6 The Health and Safety Service Plan for 2002/2003 indicates that the Councils resources for health and safety were 2.85 (FTE). Comprising of the Principal Environmental Health Officer, who manages the team strategically and its day to day operations spending 0.45 FTE on health and safety and reports directly to the Chief Environmental Protection Officer who spends 0.12 FTE. Two Environmental Health Officers who spend 0.35 and 1 FTE on health and safety and one Environmental Health Technician who spends 0.93 FTE on health and safety work.

At the time of the audit due to staff changes these targets have not been met and there has actually only been 1.3 FTE since October 2002. The Principal Environmental Health Officer devoting his time between managing the health and safety and environmental protection functions activities.

This is likely to increase following recruitment this year.

2.1 Executive Summary

2.1.1 For 2002/2003 123 inspections were completed, and the files seen showed consistency between officers, the enforcement policy and general guidance. The files seen by the auditors’ demonstrated competency and quality.

2.1.2 It was agreed that the Council has excellent systems in place and a good approach to enforcement, however lack of resources allows them to implement them.

2.1.3 The Health and Safety enforcement team at the Isle of Wight Council are a close-knit and well motivated team. However for a number of years they have been under-resourced and consequently in a number of areas compliance with HSC, HELA and other guidance are unsatisfactory. If increased resources were available during 2003/2004 this situation should be remedied.

2.1.4 Best Practice

2.1.5 An assessment of the LA’s level of compliance with Section 18 guidance was made using the HELA audit protocol. Using the ‘compliance matrix’ attached at Annex A, the LA was adjudged to be demonstrating frequent compliance with the HSC’s Section 18 guidance. Overall, the authority was assessed to be of a level 2 standard.

2.1.6 The LA was adjudged to be scoring 23.5 (53%) against the Hampshire and IOW Management Matrix.

2.1.7 The LA will develop an Action Plan to implement the minor recommendations made in the audit report.

2.2 The Authority’s Strengths

2.2.1 Enforcement Policy and practices - the authority had developed a comprehensive and very well written enforcement policy. The policy was consistent with the Cabinet Office’s Enforcement Concordat and HSC’s Enforcement Policy Statement. The Policy referred to the use of informal and formal (prosecutions, formal cautions, notices, etc.) enforcement action and outlined the circumstances when such action would be considered. It specifically referred to the principles of good enforcement - targeting, consistency, proportionality and transparency. Elected Members had agreed the policy in December 2001. The policy was available in leaflet form and is contained on the Councils website. The What to expect when a health and safety inspector calls leaflet was routinely handed out during visits. Checks on officers work, by the auditors, showed that they were acting in accordance with the policy.

2.2.2 The section had developed a detailed health and safety Service Plan for 2002/03. The Plan outlined what activity the LA would carry out in 2002/03 and how it would deliver its statutory duties. It included details of: the aims and objectives of the section; its links with corporate strategic objectives and the Community Plan; the structure of the organisation; the demands on the health and safety service; the delivery of the service, the resources required; and quality assessments and review. The Service Plan for 2003/2004 was not seen and has not yet been agreed by members, it is hoped that this will be rectified shortly.

2.2.3 The Council was operating a risk-based priority planning system, its aim to inspect all due and outstanding category ‘A’ premises by end of March 2004. All accidents were investigated. Files checked showed that the level of investigation was in accordance with the enforcement policy.

2.2.4 Database/computerised software system - Sampling revealed that the authority had an accurate premises database (FLARE). It provided easily accessible information on health and safety activity and monitoring of performance. It gave clear and precise information regarding derivation of costs.

2.2.5 Standards of competency - The authority had developed a competency matrix to identify the core skills required by officers. There was some evidence of shadowing and officer monitoring. At present there are only two officers dealing with health and safety. They work closely together and have a good working relationship. They are enthusiastic and dedicated.

2.2.6 Monitoring and measurement of health and safety activity. There was some evidence that Principal Environmental Health Officer carried out a bi-monthly review of inspection and enforcement activity. However this has been unachievable for some time due to lack of resources.

2.2.7 Health and safety promotion – The council are currently working on adding more health and safety information to the Councils website.

2.2.8 Quality systems – The authority has a basic quality system, and is working towards an application for the Investors in People award.

2.3 Key areas for improvement

2.3.1 The service plan identifies a planned programme of work that is risk based, targets key-risk areas and reflects both the HSC Strategic Plan and the HELA Strategy. However due to lack of resources these targets are not being met. Consideration should be given as to how this situation will be resolved as and when the team is fully staffed.

2.3.2 There is no evidence that consultation with local stakeholders is carried out. The authority should consider how stakeholders could be consulted in the future.

2.3.3 It was seen from the files checked that inspections, accidents investigations and similar activities are carried out consistently and in accordance with the enforcement policy, however the housekeeping of the files was poor making it difficult to work through a case from beginning to end. Although a minor detail officers and administrative staff should ensure files are kept tidy so that cases can be easily read and important information is not lost.

2.3.4 A number of the statutory notices that were reviewed were found to contain minor flaws. These flaws included open-ended requirements, implying that British Standards were enforceable standards and language that suggested requirements beyond legal compliance were mandatory.

2.3.5 Although the inspection audit form considers the main HELA strategies, i.e. slips, trips and falls, workplace transport, manual handling etc., it is not actually clear what was discussed during the inspections. Consideration should be made to make the section of the form bigger so that inspecting officers can make more detailed notes.

3. Audit Findings

3.1 Officers interviewed: Warren Haynes and Garry Warren

3.1.1 At present there are only two officers carrying out health and safety activities. Only Garry is carrying out inspections. On interviewing he showed competency and consistency in dealing with accident investigations, service requests and carrying out inspections. All actions were in accordance with the enforcement policy. This was clarified when looking through the files audited.

3.1.2 A diagram showing the organisation and management of the Unit is shown at Annex 1.

3.2 Enforcement policy and procedures

3.2.1 The authority had developed a comprehensive enforcement policy for health and safety. It outlined the Council’s overall approach to enforcement including the adoption of the principles of good enforcement (targeting, consistency, proportionality and transparency) in accordance with the Enforcement Concordat and the HSC’s Enforcement Policy Statement. It outlined the occasions and circumstances when informal and formal enforcement action would be considered by the Council and its policy on the authorisation and competence of officers. The authority had also developed a corporate prosecution policy. This referred to the Crown Prosecution Service’s Code for Crown Prosecutions

3.2.2 The policy had been agreed by Members in December 2001. It is reviewed annually. It had been published on the Council’s website and publicised via a summary leaflet. No stakeholder consultation had been carried out when developing the policy, the authority recognises this as a weakness.

3.2.3 The policy did not mention liaison with lead authorities. The policy did refer to liaison with other regulatory authorities such as other LAs and the HSE.

3.2.4 Officers routinely handed out the What to expect when a health and safety inspector calls leaflet during inspections. In addition, a copy of the enforcement policy was offered to all duty holders when they were visited. It was considered that the authority was making adequate arrangements to ensure that its enforcement action was transparent.

3.2.5 The authority had produced a short and informative leaflet. The leaflet briefly explained what the Council does to help people comply with the law and the action the Council would take when people did not comply. It included details of the authority’s complaints policy and procedure.

3.2.6 Recommendations

3.2.7 More effort should be made to develop and consult local stakeholders, including employers and employee representatives.

3.2.8 The enforcement policy should be revised to make clear the procedure for liaising with lead authorities and other regulatory bodies.

Enforcement practices

3.2.9 During an inspection, officers completed an inspection report form. This included: details and description of the premises; a list of documentation available and observed; and findings noted. A copy of this visit report was handed to the duty holder. The report was countersigned by the duty holder to confirm that they had received it. A number of files of recent visits were observed. Records had been completed for all the visits. All visits were carried out by officers of appropriate competence and authorisation.

3.2.10 Examination of the premise files revealed that inspection letters were well drafted, very thorough and comprehensive, included reference to relevant legislation, outlined what the duty holder needed to do and the time scales in which he needed to do them in, and distinguished between legal requirements and advice.

3.2.11 Examination of the inspection files indicated that the risk-ratings for premises were consistent with officers’ documented findings. The files indicated that officers had taken proportionate action. The authority’s policy on re-visits was to schedule these if serious contraventions were identified. Otherwise, they were carried out at the next planned visit. This was found to be the case.

3.2.12 A number of the statutory notices that were reviewed were found to contain minor flaws. These flaws included open-ended requirements, implying that British Standards were enforceable standards and language that suggested requirements beyond legal compliance were mandatory. These were mainly due to the style of the language used in the notices and this should be reviewed. It was noted that there was an improvement notice that should not have been in the public register.

3.2.13 There was some evidence that the authority had systems in place to help promote the consistency of enforcement. These included: reviews of officers’ letters and Notices; accompanied inspections; review by the Principal Environmental Health Officer of paperwork; and team meetings. At present there is a lack of this actually happening due to lack of resources. The authority extensively benchmarked its health and safety activity with other Local Authorities as part of the Hampshire and IOW scheme. The authority had carried out limited peer review activity due to lack of resources.

3.2.14 The authority is an active member of the Hampshire and IOW Chief Environmental Health Officers Group.

3.2.15 Recommendations

3.2.16 The drafting of statutory notices should be reviewed.

3.2.17The local authority is recommended to undertake more active peer review to promote the consistency of enforcement. (Paragraphs 5 and 4.3, HSC’s Section 18 guidance)

3.2.18 The inspection report form should be altered to allow for more detailed noted concerning the HELA priority areas.

3.2.19 The authorities arrangements for enforcement policies and practices were assessed to be at level 2 (using the HELA ‘compliance score’ outlined in LAC 23/19 copy attached at Annex A)

3.3 Work Programme and Service Plans

Service Plan

3.3.1 The authority had produced a detailed health and safety Service Plan for 2002/2003. This was agreed by the portfolio holder. The Plan included details of: the aims and objectives of the section; its links with the Council’s corporate strategic objectives and the Community Plan; the structure of the organisation; the demands on the health and safety service; the delivery of the service; the resources required; the competency of staff; and quality assessments and review. It also detailed how the authority would ensure that the activity it carried out was consistent, transparent, targeted, proportionate and accountable.

3.3.2 The Service Plan clearly outlined the link between health and safety regulatory activity and the delivery of its Community Plan.

3.3.3 The service plan was also developed in response to national and local enforcement issues and the HSC/HELA strategic priority programmes of slips and trips, workplace transport, musculo-skeletal disorders, work-related stress and falls from a height. Other key priorities outlined by the authority included: work to prioritise inspections and effectively target resources in line with national guidance; maintaining the computer database to identify those premises presenting the highest risk.

3.3.4 The service plan for 2003/2004 was not seen and has not as yet been agreed by members.

3.3.5 Recommendations

3.3.6 The authority should ensure that the service plan for 2003/2004 is taken before committee.

Planned inspection programme

3.3.7 The annual (LAE1) return to HELA for 2002/2003 indicated that the Council had carried out approximately 70% of category A premises inspections due. 76 category B premises inspections had been carried out, although none of these were due and 6 category C premises had been inspected. Given the resources, this indicates that the authority is, correctly prioritising its scarce resources towards high-risk activity.

3.3.8 The annual (LAE1) return to HELA for 2002/2003 indicated that the Council had carried out 123 health and safety inspections.

3.3.9 The Service Plan for 2002/03 stated that the authority would carry out 54 programmed inspections fort category A premises in 2002/03. The plan indicated it would send out 1265 self assessment questionnaires and analyse approximately 1088 returned questionnaires, and that it would carry out approximately 177 inspections of non-returnee’s of self assessment questionnaires. The Plan indicated that the authority enforced health and safety law in 2625 premises. Health and safety inspections were carried out separately from those for food safety.

3.3.10 Recommendation

3.3.11 The authority may wish to consider reviewing the frequency of inspections in accordance with the HELA cir67/1 to help achieve its target for inspections.

Priority planning system

3.3.12 The authority are carrying out desk top assessments to risk rate all the known premises where it enforced health and safety law. The breakdown of risk ratings from the 2002/2003 service plan were as follows: category A premises (54); category B1 (96); B2 (109), B3 (149); B4 (318); and C (627). The authority has 2625 premises in which they enforce health and safety, although only 1353 have been updated.

3.3.13 The authority planned to achieve all its due inspections for category A premises by March 2004.

3.3.14 The authority planned to carry out inspections at the following frequencies: category A – every 12 months; category B1 – every 24 months; B2 – every 24 months; B3 – every 36 months; B4 – 36 months and category C – every 5 years.

3.3.15 At present the team is under resourced and there is evidence to suggest that decisions regarding inspections are being affected.

Database systems

3.3.16 The health and safety section used a common Environmental Health Services premises database. The database used the FLARE software system. Fairly regular checks of premises were carried out through other related information (e.g. planning applications, Yellow Pages). This has recently been difficult due to lack of resources. Sampling showed the database to be accurate. A number of reports were requested from the database, such as inspections due, these were produced without any difficulty and produced appropriate data.

3.3.17 A number of premises records were cross-checked with files. These were found to be accurate.

3.3.18 Recommendation

3.3.19 That FLARE is used to produce information concerning accidents trends so that target areas can be identified.

Educational and promotion work

3.3.20 The Service Plan stated that the authority planned to carry out promotional and educational activity in 2002/03. This included further development of the Council’s website to provide a source of health and safety information for businesses and seminars in partnership with the Chamber of Commerce targeted at small businesses. Considering the lack of resources in the team at present the authority has does well to keep these targets.

3.3.21 The authority’s arrangements for the delivery of risk-based programme of activity was adjudged to be of the level 2 compliance standard.

3.4 Training and competence

3.4.1 The Service Plan stated that the authority would train officers to: be consistent; operate transparently; target their work; and take proportionate action. This would normally be done by discussion and coaching, using team meetings, etc. The Council’s health and safety enforcement policy referred to the competence of officers and that officers would be authorised according to their competence. Officers were accompanied on inspection annually. The authority had documented records of officers’ accompanied inspections and a subsequent assessment of their performance. These were examined.

3.4.2 New officers to the authority were supervised as part of a structured training programme to assess that they were competent. This would include accompanied inspections. 10% of the case records and files are reviewed to assess the enforcement activity taken The authority at present carry out formal peer review when resources allow. The health and safety section is a small close-knit team.

3.4.3 The authority are working towards the Investors in People Award.

3.4.4 The authority had developed a competency matrix to determine officers’ training requirements. As part of their annual appraisal, officers were encouraged to identify their training and development needs

3.4.5 Copies of HSE and HELA guidance are readily available to officers, both in hard form and electronically. Officers have Internet access. EHCNet messages and copies of the LAU Newsletter were sent electronically to officers as appropriate.

3.4.6 Recommendation

3.4.7 The authority needs to have a procedure in place to review and evaluate the effectiveness of officers actions.

3.4.8 The authority’s arrangements for ensuring the competency of officers were assessed to be of a level 2 standard, had resources been available to carry out sufficient peer review the authority would certainly gained level 3. The authority was complying with Section 18 guidance.

3.5 Investigations

3.5.1 The authority had procedures in place to respond to the investigation of reported accidents, incidents and dangerous occurrences. The procedures included: a description of the processes for receiving RIDDOR forms (e.g. From the ICC); accident investigation criteria; an aide memoire on carrying out an investigation. The authority would consider the investigation of any incidents relating to the HSC’s priority programme, e.g. slips and trips and manual handling.

3.5.2 All complaints and requests for service were responded to in 2002/2003.

3.5.3 The authority’s LAE1 for 2002/2003 highlighted that they investigated all the accidents reported to it. The degree of investigation was in accordance with the enforcement policy.

3.5.4 The authority had set response times for complaints and requests for service. The adopted response time for these was within 3 days. It planned to respond to 91% of all complaints/requests within the target. These targets were met.

3.5.5 Procedures for making a complaint against the authority were available upon request.

3.5.6 There is a policy for responding to requests for disclosure from injured parties, following accident investigations.

3.5.7 The authority’s arrangements for carrying out investigations effectively were assessed as level 3 standard.

3.6 Performance management and reviews

3.6.1 The authority had developed a quality system for its management of health and safety enforcement.

3.6.2 The Health and Safety Service Plan for 2002/03 outlined the authority’s commitment to assessing its work and reviewing performance and policies. It stated that its weaknesses were in the areas of planned inspections due to lack of resources.

3.6.3 The authority had carried out an inter-authority audit exercise in 1999. Some of the recommendations have been actioned and implemented. The authority also measured itself against the Best Value Performance Indicator 166 for environmental health.

3.6.4 The Division has a comprehensive time recording system, which allows analysis of cost for all elements of the service.

3.6.5 The council is a member of the Hampshire and IOW Chief Environmental Health Officers’ Group, Benchmarking Group and CIEH Branch Health and Safety Advisory Group. The council recognise that it needs to develop improved links with other Council Departments and organisations such as the Primary Care Trust with employer and employee organisations.

3.6.5 The authority are putting in an application for the Investors in People award this year.

3.6.6 The Principal Environmental Health Officer carries out bi-monthly checks on work to ensure nothing is outstanding.

3.6.7 Overall, the authority was developing very effective arrangements for measuring and monitoring activity. It was assessed to be compliant with Section 18 guidance and at a level 3 standard.

4 Conclusions

The authority’s health and safety function is well managed and the work is undertaken in a very professional manner, generally in accordance with section 18 guidance. Some minor improvements are required which have mainly been recognised already by the authority and are due to the lack of resources available.

4.1 Recommendations

4.1.1 The Health and Safety enforcement team at the Isle of Wight Council are a close-knit and well motivated team. However for a number of years they have been under-resourced and consequently in a number of areas compliance with HSC, HELA and other guidance are unsatisfactory. If increased resources were available during 2003/2004 this situation should be remedied.

4.1.2 By developing an action plan and implementing the recommendations of this report in conjunction with providing adequate resources, the authority will provide a health and safety service complying with the HSC S18 guidance and ensure that it achieves continuous improvement.

The HELA audit protocol has been developed to provide a framework to be used to measure the extent of LA’s compliance with Section 18 guidance using the following matrix:

Level	Compliance with statutory requirements (HSC’s Section 18 guidance)	Best Practice
0	No compliance with HSC’s mandatory Section 18 guidance.
1	Statutory requirements infrequently met (less than 50% compliance with HSC’s Section18 guidance).
2	Statutory requirements frequently met (50-99% compliance with HSC’s Section 18 guidance).
3	Requirements under HSC’s Section 18 guidance met fully.
4	Requirements under HSC’s Section 18 guidance met fully.	Full commitment to, and achievement of, best practice and continuous improvement

The matrix does not assume that LAs who do not fully comply with Section 18 will be developing no elements of best practice. However, the best practice section of levels 0-2 have been shaded out to emphasise that those scores will be based solely on achievement of LAs’ statutory obligations.

LAs should measure each element of their health and safety service to calculate a ‘score’ for each. The overall LA score will be the lowest score for any individual element of the LA’s service.

For example: An LA measures that its enforcement policy, managed work programme and investigation procedures fully comply with Section 18 guidance and display some elements of best practice. It achieves level 3 for these elements. Arrangements for ensuring the competency of staff and performance management and review do not fully comply with the standards outlined in Section 18, although they display some elements of best practice. They meet the criteria of level 2. The LA therefore achieves a level 2 service.

Hampshire and IOW CEHOG Benchmarking Group

Quality and Performance Matrix

OCCUPATIONAL HEALTH AND SAFETY

Element	Score
Enforcement Policy	4
QA and Management Systems	1.6
Staff Competency	3.6
Communication with Stakeholders	0.2
Derivation of Costs	4
A& B Inspection	0.7
C Risk/vacant	0
RIDDOR	4
Service Requests	4
Education	1.0
Promotion	0.4