Environmental Health Audit Number 0707 by fxw33739



Environmental Health
Audit Number: 07/07

     Date:           27 September 06     Auditor:            xxxxxxxx

     Service         Principal           Auditor Contact     X 4228
     Contact         Environmental
                     Health Officer
     Opening         28 June 06          Closing Meeting     06 October 06
     Meeting Date                        Date and
     and attendees                       attendees


This audit was undertaken as part of the 06/07 audit plan and concentrated on
the commercial side of Environmental Health in particular Food Hygiene


    Policies and Procedures
    Control and use of forms
    Business continuity
    Value for Money (KLOE to be used)
    Risk Management
    Staff Training / Competencies
    Control and assessment of contractors
    Production and use of inspection programme
    Records of inspections
    Improvement notices
    Budget review
    Best Value and Local Performance Indicators
    Progress against Service Plans
    Calibration

Final Version – Issue date 29 November12006


CONTROL                       CONCLUSION                                   Risk
To ensure that all food       The premises database is a statutory            High
inspections are carried       register that is held to detail business
out in compliance with        premises. A paper ‘registration form’
the food safety act 1990      should also be held. Some records (both
and     are     prioritised   paper and electronic) were found to be
according to risk.            out of date. Updates are reliant on
                              businesses      supplying    information
                              however a more pro-active approach
                              could be considered.

                              Officer authorisations were found to be
                              an area of weakness. The list of
                              authorisations and records held were
                              not up to date and authorisations were
                              not being issued in accordance with
                              documented procedures.

                              Contractors are being used to complete
                              the majority of food inspections,
                              however it was felt that the control over
                              these contractors was not at an
                              acceptable level in operational, financial
                              and contractual terms. It should be
                              noted that audit requested contractor
                              costs on several occasions, no
                              information was ever received.

                              Training records are not easily
                              accessible and I was unable to review
                              any training plans for future training. I
                              would have expected to see some plans
                              in place to expedite training of existing
                              officers to complete food hygiene
                              inspections as this is an area where
                              contractors are presently being used
                              and recruitment of qualified staff is

                              Food safety inspections are being
                              completed by the principal EHO and two
                              contractors, although as of August

Final Version – Issue date 29 November22006

                         targets were not being achieved. The
                         inspection which was observed as part
                         of this audit, was found to be
                         comprehensive and undertaken in
                         compliance with procedures. However
                         follow up inspections are not being
                         undertaken and there appears to be no
                         monitoring of outstanding enforcement
                         notices and recommendations. This
                         means that prosecutions are not
                         pursued and contravenes our statutory

                         Officers are currently being monitored
                         using customer feedback surveys.
                         However there was no evidence of
                         monthly checks on officer/ contractors

                         The sample of complaints reviewed
                         were found to be dealt with in a timely
                         manner, however August statistics show
                         that in regulatory services as a whole,
                         written complaints are not meeting
                         corporate response time targets.

                         Safety incident notices were found to be
                         dealt with as per written procedures and
                         are actioned appropriately.

                         There was no evidence of any ‘appeals’
                         in the last 2 years.

                         Calibration records and controls of
                         equipment was found to be inadequate.

To ensure that adequate Procedures were available in both hard      Medium
working procedures are copy and electronically. The paper
in place.                copies varied in revision status, some
                         reviewed and updated, others awaiting
                         review. Electronic copies held on the
                         network were found to be out of date.
Demonstration that value I was unable to ascertain the costs of     Medium
for money is being contractors used to complete Food
achieved.                Inspections.
                         There were some areas where control

Final Version – Issue date 29 November32006

                             over value for money was being
                             demonstrated, however it was still felt
                             there were areas where assurance
                             could not be given.


Job descriptions the JD for the principal environmental health officer was last
updated in January 2005. The current JD does not reflect the recent changes
made in regulatory services.

The risk register was reviewed however there was found to be unidentified risks
not documented (see recommendation 10), this should be addressed in the 07/08
service plan.


Management information and documents were difficult to obtain during the audit
and it came across that the service was not running effectively.

The mix of officers currently employed make it difficult for the food safety
inspections to be carried out in line with statutory requirements and the control
and management of contractors is weak.

Management statistics up to the end of August 2006 indicates that only 80% of
the ‘high risk’ premises have been inspected, the target is 100%, whilst 100% of
Low risk properties have been inspected.

The lack of risk identification, control and delivery of follow ups is a concern and
again does not fulfil our statutory duty.

Chief Executive
Corporate Directors
Interim Environmental Health Manager
Principal Environmental Health Officer

Final Version – Issue date 29 November42006

Recommendation                          Risk       Responsible     Officer Comments                  Agreed Date for
                                        Analysis   Officer                                           Implementation
1. Review the ways on which             Medium     Environmental   SG/ RH/ LS to co-ordinate         February 07
    internal resources could be used               Health and
    to share information in updating               Licensing       New uniform system to start
    the premises database (subject                 Manager         1st January 2007. Officers to
    to data protection issues) i.e.                                get up to date listings from
    planning revenues.                                             Council Tax
Risk: Premises may not be included
or amended on the database.
2. Ensure that all commercial           Medium     Environmental   Officers to ensure food           Immediate &
    properties requiring a data                    Health and      registration form is up to date   continuous
    registration form have a current               Licensing       and issue new forms as
    form and paper files correspond                Manager         necessary.
    with uniform.
Risk: Audit trail incomplete.                                      Double check uniform for
                                                                   duplication- ALL ADMIN
3. Undertake a review of the            High       Environmental   All calibrated from               Immediate
calibration procedure and ensure                   Health and      11/11/2006. LS to review
that items are calibrated in a timely              Licensing       calibration.
manner in line with the                            Manager
manufacturers recommendations,
and that any personal equipment
used is monitored and controlled.
Risk: Inconsistent and inaccurate
temperature readings.

Final Version – Issue date 29 November 2006             5
4. Ensure that the commercial             Best       Environmental   RH to investigate                 Ongoing
register is up to date and available      Practise   Health and
to the public. A fee also needs to be                Licensing       PEHO to run monthly reports
set for reproduction of this                         Manager         to check accuracy of
document.                                                            database
Risk: Poor customer service
5. Ensure that all authorisations and     High       Environmental   LS & PM                           February 2007
supporting records (including                        Health and
authorisations list) are accurate and                Licensing       Collect CPD certificates & file
kept up to date for both officers and                Manager         on professional personnel file
Risk: Unauthorised officers /
contractors completing inspections
6.Review training programme to            Medium     Environmental   RH to investigate. Training       Ongoing
expedite the training of existing                    Health and      and competency matrix to be
Technical Officers to Food Safety                    Licensing       produced to ensure that
Officers and look at ways in which                   Manager         officers receive 10 hours of
they can be retained.                                                CPD per annum.
Risk: Continued use of contractors
and related costs
7. Ensure that all legislative training   High       Environmental   LS/ RH to co-ordinate             February 2007
(in particular recent changes Jan                    Health and      gathering of evidence to
06) has taken place and a training                   Licensing       show that training has been
plan is available to ensure that all                 Manager         received.
recurrent training needs are met.
Risk: Training is not kept up to date
as per statutory requirements.

Final Version – Issue date 29 November 2006               6
8. Ensure that training records for all   Medium   Environmental   Evidence to be kept on file      February 2007
officers and contractors are kept up               Health and      and reviewed in line with
to date and are accessible for                     Licensing       training and competency
inspection.                                        Manager         matrix.
Risk: No assurance of competent
9. When employing the services of a       High     Environmental   Standard contract obtained       February 2007
contractor ensure that contracts                   Health and      from HR and ensure all new
and/ or letters of engagement are in               Licensing       contracts meet corporate
place detailing the terms and                      Manager         requirements.
conditions of employment.
Risk: Inconsistent and uncontrolled
10. A process should be put in to         High     Environmental   Monthly re-visits to be listed   Immediate
place in order to capture follow ups               Health and      and passed to relevant
following an inspection to ensure                  Licensing       officers and followed up by
that any further actions are                       Manager         PEHO. Admin to co-ordinate
completed in a timely manner. This                                 lists to officers.
items should also be identified on
the Risk Register.
Risk: Non Compliance with
Legislation and no assurance of
public health
11.The Job Description for the            Low      Environmental   RH to discuss and amend          February 2007
principal environmental health                     Health and      with Viv Evans
officer needs updating to reflect                  Licensing
current working practice.                          Manager
Risk: Responsibilities not defined.

Final Version – Issue date 29 November 2006             7
12. Electronically held, ‘out of date’   Medium   Environmental   All- procedures to be            February 2007
procedures are removed and                        Health and      reviewed and stored in
replaced with the current updated                 Licensing       separate electronic file, old
versions.                                         Manager         procedures to be deleted
Risk; Inconsistent working
13. Ensure that documents and            Medium   Environmental   File to be created relating to   February 2007
appropriate evidence is retained                  Health and      BV166 and updated
when reporting BV166 performance                  Licensing       accordingly
indicators.                                       Manager
Risk: Lack of audit trail
14. Reviews should be made to            Medium   Environmental   Corporate framework to be        February 2007
ensure that Value For Money is                    Health and      adopted and implemented.
quantified and achieved.                          Licensing
Risk: VFM not achieved                            Manager

Recommendations Agreed……………………………………………….                                                 Date:………………………

Recommendations Agreed………………………………………………..Audit Manager                                   Date:……………………….

Final Version – Issue date 29 November 2006            8
Final Version – Issue date 29 November92006

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