Assess the adequacy of service objectives and whether they ...

Audit: TMO Health and Safety

Subject: P3 Risk Analysis l T1 Testing document Audit Year: 2015/16

I Prepared by: A Patel Date: Jan 2016 I

I Reviewed by: John Barnett Date: Feb2016

1 - Service Objectives

Working Risk Control Processes Testing Findings and Recommendations

Papers

Satisfactory no issues or concerns 1.1. Service objectives strategies and procedures may not be clearly set out or communicated.

1.2 Strategy setting out development of service is not clear.

1.3 Lack of clarity on development of the service.

Health and Safety (H&S) is governed by a number of statutory pieces of legislation and roles responsibilities of employers and housing associations such as THO are clearly laid out in H&S Act.

All Housing Associations are required to comply with legislation and ensure that robust processes procedures and systems are in place to mitigate the risk of any H&S incidents occurring which may cause financial and reputation damage to the organisation.

Examine documented service objectives for the TMO.

Review SDP for TMO and in 3articular reference to H&S and how this function is carried out within the organisation.

Assess the adequacy of service objectives and whether they are subject to regular review and revision.

Service objectives are clearly defined within the People and Organisational Development Directorate Service Plan 2015/16

Document sets out objectives like "To undertake Fire Risk Assessments" and "Have up to date and accessible records on asbestos" and "To ensure H&S of our residents" and details who the responsible persons are for carwing out these roles

Service objectives are reviewed annually and the Health Safety and Facilities Manager has updated the most recent service objective document

Risk Analysis and Testing

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Audit: TMO Health and Safety Prepared by: A Patel Date: Jan 2016

Subject: P3 Risk Analysis / Tt Testing document Audit Year: 2015/16 Reviewed by: John Barnett Date: Feb2016

2 - Znternal Guidance and Procedure Documents

Risk Control Processes

I 2.1.Clear guidance procedures protocols for H&S checks processes procedures are not in place for the TMO

Service objectives defined within the People and Organisational Development Directorate Service Plan set out the key roles responsibilities of the TMO wrt H&S

Testing

Examine documentation and H&S regimes in place across each of the service areas

Findings and Recommendations

Internal procedure documents have recently been refreshed and updated by all officers and have been collated by the Health Safety and Facilities Manager (Janice Wray) and copies provided.

See

..\Reference\TMO Lone Workino Guidelines Nov 2014.doc..\Reference\Water Manaqement Policy - Version Two 22nd October 2015.docx ..\Reference\ReoorL Form - Accident, Incident, Occupational Stress.doc ..\Reference\TMO Lone Working Guidelines Nov 2014.doc

2.2. Inconsistent Local procedures and guidance Assess adequacy of As above approach to undertaking documents are maintained by arrangements and H&S inspections each of the different service whether procedures are

heads wrL of H&S and the up to date and relevant inspection regimes in place

Discussions with all officers showed clear understanding of the roles and responsibilities with regard to health and safety

2.3. Lack of clarity and or awareness on H&S requirements and legislation by officers responsible for H&S at TMO

TMO Internal Policies and Regulations and the Health and Safety ACt and various different legislations for this area provide framework for the service and roles responsibilities duties of the organisation

Assess whether officers are clear about their roles responsibiliLies duties for H&S

A recent reorganisation had also focused appropriate resources to areas where there were known issues

Working Papers

See OroaStrucLure Jan16.odf


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3 - Corporate Health and Safety

Working Risk Control Processes Testing Findings and Recommendations Papers

3.1 Up to date guidance on corporate health safety responsibilities are not documented for TMO

3.2 TMO may be in breach of Corporate Health Safety requirements where these are not followed

3.3 TMO and Council may be exposed to reputational damage and risk of Bnancial loss through failure to comply with legislation for H&S

TMO has specific officers in post with responsibility for Corporate Health and Safety including Health Safety and Facilities Manager and a Policy Compliance Manager

TMO is also governed by legislation including H&S Act and Housing Act which sets out number of key responsibilities for H&S and in particular with regard to employees of the organisation and tenants of council owned properties

Examine current arrangements for ensuring compliance with corporate health and safety requirements

Determine whether these are clearly set out and all officers have a good understanding of their responsibilities

A wide suite of policy documents have been developed and updated by the Health Safety and Facilities Manager (Janice Wray) which address all the key corporate areas that TMO have responsibility for

The policy guidance documents are detailed and provide a step by step guide on what is required from responsible officers in carrying out their role

They cover Asbestos / CDM / Lighting Electrical / Fire Protection Systems / Gas Safety / Gas Access for Inspections / Lift Breakdown / Water Quality

All policies have been or are shortly to be approved by Executive Team and H&S Committee prior to be being released for general circulation.

All documents are electronic and saved on shared network drive and hence accessible by all officers that require these.

However could benefit from storing these on a shared platform such as Sharepoint so that all officers have access to documents across the organisation

Recommendation: The use of Sharepoint to hold all procedure and guidance documents should be considered. This allows all TMO officers to easily access and share such documentation whilst being held in one central repository site.

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3 - Corporate Health and Safety

Working Risk Control Processes Testing Findings and Recommendations Papers

3.4 The well being of staff" and TMO service users may

be compromised in absence of appropriate robust Corporate H&S guidelines and procedures

3.5 All staff" receive appropriate training on health and safety

issues and matters

All caretakers at the various council estates are issued with a health and safety handbook which covers all the key areas and sets out what the individuals responsibilities are for these areas.

Training records were provided for staff, that are required to have specific training on H&S matters ie ]anice Wray + her team

All training records and information is maintained on a centralised HR database called HE Select. A specific module for Health & Safety is used as well as a Training module which records all training undertaken by staff,.

All staff, had received training within the past year where relevant for H&S matters

Structure of section see OrqaStructure Jan16.pdf

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I Audit: TMO Health and Safety Prepared by: A Patel Date: Jan 2016 I

I Subject: P3 Risk Analysis / Tt Testing document Audit Year: 2015/16 Reviewed by: John Barnett Date: Feb2016

4 - Gas and Electrical Installations

Risk Control Processes Testing Findings and Recommendations Working Papers

4.1. Inadequate or inappropriate arrangements in place for undertaking regular gas and electrical safety inspections.

4.2 Systems are not in place to identify where when inspections should take place.

Keystone Asset Management System is used to log and record all inspections

Reports are produced from system which inform officers of due inspection dates

Extract sample of inspections that have recently been undertaken from Keystone

Examine supporting document to veri~ that inspection has been carried out

Head of Contract Management (Alex Bosman) oversees two contract managers and two assistant contract managers who oversee inspections covering

Gas / Electric / Plant / Lifts / Water Quality / Boiler Rooms

Raymond Hylton (Contract Manager) oversees all domestic and communal area electrical testing in addition to estate lighting and water quality

4.3 Inspection regime has not been formally documented and implemented for gas and electrical inspections.

4.4 Reliance cannot be placed in accuracy of recorded inspections.

4.5 Council and TMO exposed to reputation damage and financial loss were an incident to occur with H&S implications involving gas electrical installation.

All inspections are governed by legislation and best practice in terms of frequency

Where appropriate advice also sought from fire safety teams and fire service on electrical and gas installation safety issues

Contractors used for inspections are as follows

Stewart Consultants Electrical testing and provide all electrical safety certificates which are uploaded on to Keystone

Clearwater - Water quality checks

Wilmott Dixon do compliance checks on contractors to ensure all inspections are up to date

See ..\Reference\From Ray Hvlton Electrics Water

Testing on sample of ten properties confirmed all had electrical safety inspection carried out within the past twelve month period and copy of certificate was available to view on Keystone


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4 - Gas and Electrical Znstallations


Papers

I Electrical safety compliance checks are similarly closely monitored using jeopardy reporLs generated from Keystone.

The December 2015 list showed ten properLies (6,800 total) where an inspection was due within the next thi~y days and 299 non compliant properLies. Of these 296 related to properLies where no entry or access could be gained.

See ..\Reference\From Ray Hvlton Electrics Water\Electrical Compliancy - 21-01-2016.xlsx

Contract Manager stated a programme of inspections will be in place from April 2016 to ensure all inspection are up to date especially where no entry could be gained to prope~y. Where needed appropriate steps will be takeb including seeking cou~ orders will be taken to ensure access is provided to all properLies.

Recommendation= Management should ensure all non complianL properLies where no enLry access is provided are closely moniLored and acLion Laken, including legal proceedings, to facilitate entry at the earliest oppo~unity


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Papers

Summaw:

I Communal & Domestic electrical: ConLracL Manager Raymond Hylton / Main contractor RMA & Capital works contracLors where works are included within capital works (Works included in current FM contracL procurement) / Technical advisor Silcock Dawson 5% certificate validation to 14/15 electrical program carried out by RMA prior to upload to Keystone. 5% certification validation of capital works Compliancy levels are calculated based on certificates held in Keystone.

Compliancy levels reporLed on live dashboard.

Lighting Protection: ContracL Manger Raymond Hylton Main contractor RMA (Works included in current FM contract procurement) CerLiBcation validated internally and uploaded to Keystone with reporting run manually.


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Papers

I Independently verify that inspection was completed in accordance with inspection regime in place

Determine whether level of detail disclosure for inspection is adequate

Determine whether information is updated onto Keystone on timey basis on completion of inspection

Charlie Saul (Assistant Contract Manager) oversees all gas safety inspecLions and cerLiBcation

K&T Heating Services undertake majority of gas appliance inspections including boiler rooms. Cofey also unde~ake inspections where required

GCS undertake compliance checks on gas certificates to ensure they are up to date and contractors undertake inspections on timely basis

For both gas and electrical checks a repo~ listing from Keystone (housing management system) which shows following -all compliant properties where inspections undertaken within agreed dates -non compliant prope~ies where inspection outstanding for whatever reason -inspections due within next 30 days. This listing is referred to as the jeopardy listing report

See ..\Reference\From Charlie Saul

Testing on sample often prope~ies confirmed all had gas safety inspecLion carried out within the past twelve month period and copy of certificate was available to view on Keystone


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Papers

I 4.6 Absence of system record log inspections underLaken for reference purposes resulting in inspection regime not being out dated

All inspections are underLaken by third party contractors

All inspections are documented and then passed onto TMO for Keystone record to be updated

All inspection records are signed off by the contractor

Keystone system can produced reporLs which shows where most recent inspecLions undertaken and where inspecLions haven’t taken place for over any given period i.e. one/two year

Verify that third party contractors conducting inspecLion have appropriate qualification and indemnity liability insurance cover

Verify whether any sample spot checks undertaken by TMO officers to check inspections have actually been carried out

(GCS and Wilmott Dixon underLaken compliance checks on behalf of TMO)

See above for inspections who carried them out and where recorded

Gas safety compliance checks are closely monitored to ensure these are undertaken on a timely basis using jeopardy reports generated from Keystone. This lists all properties where appliances are due for rechecking within the next thirty day period.

Checks on the most recently produced jeopardy list in January 2016 showed 12 properties (6,500 total) where an inspection was due within the next thirty days and one non compliant property where entry could not be gained

See ..\Reference\From Charlie Saul\Gas.xlsx

ContracLManager AnthonyCheney Main contractor Cofely / Technical advisor GCS 100% certification validation by GCS prior to upload to Keystone. Compliancy levels are calculated based on valid certificates held in Keystone. 100% works inspection valued over £1000 contractor liability. 10% servicing & repairs physical inspecLion. Compliancy levels reported on live dashboard.

Risk Analysis and Testing Page g

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Papers

I Domestic gas: Contract Manager - Charlie Saul / Main Contractor - K&T Heating / Technical advisor - GCS All certificates are validated by GCS prior to upload to Keystone. Compliancy levels are calculated based on valid cerLiBcates held in Keystone. 100% install physical inspection by GCS 10% servicing physical inspection by GCS 10% repair physical inspection by GCS Compliancy levels reporLed on live dashboard.

All health and safety related inspecLion data is displayed on the Keystone Compliancy Dashboard which refreshes each day and provides real time compliance data for

Compliance levels on two separate dates are shown below:

Compliance (%) at 10.12 015 and 21.01.2016

Water Quality 51.52 82.30 Gas Safety 100 100 Electric Domestic 95.22 95.64 Electrical Communal 100 100 Central Plant 100 100 LifLs 100 100


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5 - Asbestos Inspections

Working Risk Control Processes Findings and Recommendations

Papers

5.1. Inadequate or inappropriate arrangements in place for undertaking regular asbestos inspections.


5.3 Inspection regime has not been formally documented and implemented for presence of asbestos.

5.4 Reliance cannot be placed in accuracy of recorded inspections.

Keystone AsseL Management System is used to log and record all inspections and Capita Academy system used to record all asbestos related works carried out

TMO required to comply with Control of Asbestos Regulation 2006 in order to minimise asbestos risk for staff and contractors

Reports are produced from system which inform officers of due inspection dates

All inspections undertaken by appoinLed asbestos contracLor

All outcome of inspections are submitted to the TMO by contractor for update on Keystone

Any issues raised are addressed by Technical Team in terms of remedial repair or removal of asbestos work required

Testing

See above testing he. as per gas electrical inspection

List provided of all contractors that undertake H&S inspections on behalf of TMO by Janice Wray

All asbestos works carried out by one of two firms Express Environmental & European Asbestos Services (who were previously known as Slough Thermal Insulation Services)

Spend for each is Express Environment: £8,500 and European Asbestos: £60,000

Asbestos inspections are undertaken each time a property is refurbished, works are carried out or when there is a void.

A review of five recently refurbished properties confirmed appropriate surveys were undertaken for asbestos and details updated onto the Keystone system on a timely basis.

See ..\Reference\From Janice Wray re asbestos

Satisfactory procedures and processes in place for dealing with asbestos and its removal from TMO properties


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Audit: TMO Health and Safety

Subject: P3 Risk Analysis l T1 Testing document Audit Year: 2015/16

I Prepared by: A Patel Date: Jan 2016 I

I Reviewed by: John Barnett Date: Feb2016

5 - Asbestos Inspections


Papers

5.5 Council and TMO exposed to reputation damage and financial loss were an incident to occur with H&S implications involving asbestos

5.6 Absence of system record log inspections undertaken for reference purposes resulting in inspection regime not being out dated


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6 - Fire Safety and Water Quality inspections

Worki Risk Control Processes Testing Findings and Recommendations ng

Papers

6.1. Inadequate or inappropriate arrangements in place for undertaking regular fire safety and water quality including


6.3 Inspection regime has not been formally documented and implemented for fire safety water quality.

6.4 Reliance cannot be placed on accuracy of recorded inspections.

All inspections are logged on Keystone Asset Management database

All inspections are undertaken in accordance with the documented policies developed by John Bora setting out best practice frequencies for inspections for TMO

Examine sample of ten inspections undertaken

Verify against supporting evidence that inspection was carried out on timely basis and all aspects covered

Water quality: Contract Manager Raymond Hylton Main contractor Clearwater Certificates validated in house prior to upload to Keystone Compliancy levels are calculated based on certificates held in Keystone. Compliancy levels reported on live dashboard.

Fire Safety: Contract Manger AlexBosman

Main contractor - Allied Protection (Works included in current FM contract procurement) Asset verification and service scheduling currently held on independent spreadsheet (this will be uploaded to Keystone prior to the mobilisation of the FM contract) Compliancy levels calculated on spreadsheet (certification to be uploaded to keystone as part of FM contract once mobilised)


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6 - Fire Safety and Water Quality inspections

Worki Risk Control Processes Testing Findings and Recommendations ng

Papers

6.5 Council and TMO exposed to reputation damage and financial loss were an incident to occur with H&S implications involving fire safety and or water quality

6.6 Absence of system record log inspections undertaken for reference purposes resulting in inspection regime not being out dated

All fire safety inspections undertaken by specialist C S Stokes and Associates Limited

Fire risk assessments are undertaken annually and overseen by the Heath Safety Team (Adrian Bowman Janice Wray) All reports are held on local shared drive for reference purpose


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7 - Management Information and Budgetary Control

Risk Control Processes Testing Findings and Recommendations Working Papers

7.1. Appropriate and timely management information is not made available

7.2 Inadequate systems in place to enable provision of accurate timely and relevant budgetary information

7.3 Management information may not be circulated distributed to all relevant officers

7.4 Budgetary information and reports may be inadequate

Head of Health Safety oversee budget for asbestos inspections approx £200k

All otherinspections are incorporated within the corporate budget allocation

Specific budgets are not devolved down to operational managers for health safety

Reports from Keystone are produced as and when required or requested by senior managers

Determine what property management system is used

Assess how budgets are managed and expenditure monitored for all aspects of

health and safety spend

Keystone Asset Management system is used to record all data for property assets and inspections undertaken. Procured in 2010 and is now used as the prime record keeping system for asset management purposes

Capita Housing System Academy is also used but data from Keystone is back loaded periodically onto Academy and therefore the most up to date information regarding property management resides on Keystone

System is administered by the IS Team and approx 150 users set up with various degrees of access. In order to restrict data entry a limited number of officers have access and functionality to undertake this, mainly John Parsons and his team (Technical Systems Manager)

System cost £34k to procure and annual maintenance and licences costs are £13.5k (see ..\Reference\RE Keystone Asset Manaoement Svtsem Costs N Miah.htm

A number of standard and bespoke management reports are produced from the system which aid officers and managers in carrying out their roles in terms of health and safety


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Papers

7.5 Budget holders are unable to manage their budgets in absence of up to date accurate budget forecast information and spend to date budget statement reports

7.6 Risk of overspending allocated budget

7.8 Asset Management System may not be fit for purpose

7.9 Decisions are not minuted and presented to the appropriate committee and executive team for approval re important Health Safety issues and decisions

Budget reports are produced by Central Finance and Health Safety Manager is has responsibility for the asbestos budget appro× £200k which she monitors each quarter

System resides on the network so all back up and system recovery is overseen by the IS

Team (Nurul Miah) and servers are located within the Hub

The keystone is an access database system and therefore any interrogation reports are carried out using standard query language

A significant amount of development work has gone into Keystone to enable it to produce appropriate management reports that allow officers to monitor check compliance levels

The Technical Systems Manager John Parsons and in particular his officer Anthony Morris Technical System Co-ordinator have undertaken a significant amount of development work on Keystone in liaison with system users to enable it to generate appropriate management reports

A significant data cleanse exercise was also undertaken approx 24months ago to ensure all inspection data and property records on Keystone was correct and contained no errors or erroneous entries

This has made a notable difference in the functionality of Keystone which now provides the appropriate reports to manage~ to enable them to perform their duties in terms of compliance with agreed inspection regime.

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Papers

Monthly KPIs across a number of performance areas are produced and monitored to assess performance

SeeKPI Extract 1516.~df KPI Extract 1516 (2).pdf

Approximately 26 KPI’s are used to monitor performance across a range of areas for the TMO. These are produced on a monthly basis and enable management to track any areas where performance is not in line with expectations and take remedial action

Additionally budget reports are provided by Finance to the Head of Contracts Management who oversees most of the operational budgets relating to health safety

Examination of the KPI’s for October and November 2015 showed performance was in line with expectations and most showing 95% - 100% of target figure being achieved

Spend on repairs maintenance related to health safety is approximately £4. lm with expenditure on contractors that undertake health safety checks approx £400k See BudqetStatement 1516.pdf

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Working Control Processes Testing Findings and Recommendations Papers Risk

Property management System may not be fit for purpose

Keystone is the Asset Management System Capita Academy is the housing management system

Assess whether systems are fit for purpose

SigniBcanL development work undertaken on Keystone has meant that it is now fit for purpose and has the ability and functionality to produced appropriate management reports for health and safety matters

A significant amount of development work has gone into Keystone to enable it to produce appropriate management reports that allow officers to monitor check compliance levels

The Technical Systems Manager John Parsons and in particular his officer Anthony Morris Technical System Co-ordinator have undertaken a significant amount of development work on Keystone in liaison with system users to enable it to generate appropriate management reports

A significant data cleanse exercise was also undertaken approx 24months ago to ensure all inspection data and property records on Keystone was correct and contained no errors or erroneous entries

This has made a notable difference in the functionality of Keystone which now provides the appropriate reports to managers to enable them to perform their duties in terms of compliance with agreed inspection regime.

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8 - Bi-borough Developments / Value for Money

Risk Control Processes Testing Findings and Working Recommendations Papers

N/A N/A 8.1. Opportunities to achieve efficiency savings through merged services is not given due consideration

8.2 Spirit of joint working is not embraced

8.3 Working in silo can lead to inefficient and ineffective processes being embedded

8.4 Failure to explore joint working opportunities could result in savings being foregone and continuing with inefficient processes

8.5 Value for money is not achieved from current service provision arrangements


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Assess the adequacy of service objectives and whether they ...

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