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					            Catholic Safety, Health & Welfare South Australia


                          SOCIAL SERVICES SECTOR
              AUDIT                      Policy Reference:               No. 7             Version No.: 5
Sector Approved: 27/4/2010               Review Date: 2013                                 Page 1 of 13


PURPOSE:

This procedure details the process used by the Catholic Church Endowment Society Inc. (CCES)
Self Insured Licence to ensure compliance with legislation and conformance with the Catholic
Church Safety Management system. The CCES Audit process identifies areas for improvement
and provides information for the continual improvement of the safety system.                              P
RESPONSIBILITIES:

ELGC will:
   approve the annual Audit Program
                                                                                                          R
   as executives be involved in an audit annually
   monitor and review audit outcomes

Sector Forums will:
   identify areas related to the industry sector for audit (based on identified trends, risk,
                                                                                                          O
    legislative change, previous audits/evaluations)
   develop an annual audit schedule
   determine scope and include targets and performance indicators for sector level audits


    monitor and review audit outcomes
    provide a report of all audits to ELGC
                                                                                                          C
CSHW SA:


    Develop an annual Audit Program
    Develop an audit schedule based on identified trends, risk, legislative changes, evaluations,         E
    programs, and incident, near miss and injury data
   Develop audit tools
   Follow the Action Flowchart in this procedure
                                                                                                          D
Manager CSHW SA:
   Resource the audit schedule with trained & competent personnel; internal & external
    including technical experts as required


    Select audit teams & assign roles & responsibilities
    Respond to any grievances & disputes related to OHS&W audits within 10 working days of
                                                                                                          U
    lodgment
   Review Audit Program annually & report to ELGC

Manager (site level):                                                                                     R
   Provide resources to ensure site level procedure verifications (site level audits) are
    conducted as per schedule
   Ensure corrective actions are implemented to rectify non-conformances and observations
   Review effectiveness of corrective actions
                                                                                                          E
Employees:
   Participate in the audit process as required
                   Catholic Safety, Health & Welfare South Australia

                                     AUDIT                                         Version No.: 5               Page 2 of 13




       ACTION FLOWCHART:

          LICENCE                                       SECTOR                                             SITE
      Conducted by CSHW                            Conducted by CSHW                             Conducted by worksite



Preparation:                                 Preparation:                                Follow Audit Schedule
-   Determine scope                          - Determine audit scope
-   Tool & associated documents              -   Tool & associated documents
    prepared                                     prepared                                Conduct Audit:
                                                                                         -       Complete Procedure
                                                                                                 Verification (CCSM Form
                                                                                                 No… (relevant procedure
Site Selection:                              Site Selection:
                                                                                                 No.)
-   Selected randomly                        -   Selected randomly
-   Selected sites advised in                -   Selected sites advised in
    writing 4 weeks before audit                 writing 4 weeks before audit            Report:
                                                                                         -       Report outcomes of
                                                                                                 Procedure Verification to
                                                                                                 Worksite Manager
Conduct Audit:                               Conduct Audit:                              -       Note areas for improvement
-   Opening meeting                          CSHW SA staff will conduct audit                    onto Hazard Register
-   Worksite inspection                                                                  -       Note Result/Score & Sign off
-   Gather information                                                                           on Site Level Audit Result
-   Documentation review                                                                         Log CCSM Form 7b.
-   Interview employees
                                             Report:
                                             -   Issue worksites with Corrective
-   Closing meeting
                                                 Action Reports (CAR’s) as
                                                 required
                                             -   Write Worksite Report & send            Follow Up
                                                 within 10 working days                  -       Worksite Manager to follow
Report:
                                             -   Lead Auditor to write Report                    up areas for improvement
-   Issue to worksites with
                                                 within 1 month of completion of         -       Document completed
    Corrective Action Reports
                                                                                                 actions on Hazard Register
    (CAR’s) as required                          Audit
                                             -   Forward Report to ELGC &                -       Review effectiveness of
-   Write Worksite Report & send
                                                 Sector Forums                                   actions
    within 10 working days
-   Lead Auditor to write Licence
    Level Report within 1 month of                                                           -    CSHW SA OHS
    completion of Audit                                                                           Consultants will review Site
-   Forward Licence Level Audit              Follow Up:
                                             -   Agree with worksite on close                     Level Audit Documents for
    Report to ELGC & Sector                                                                       verification
    Forums                                       out dates for CAR’s
                                             -   Add CAR’s to CCES CAR
                                                 Register
Follow Up:                                   -   Worksite respond to non-
-   Agree with worksite on close                 conformances
    out dates for CAR’s                      -   Visit worksites to verify
-   Add CAR’s to CCES CAR                        completion
    Register                                 -   Worksite to review
-   Worksite respond to non-                     effectiveness of actions
    conformances
-   Visit worksites to verify
    completion
-   Worksite to review
    effectiveness of actions
            Catholic Safety, Health & Welfare South Australia

                              AUDIT                                            Version No.: 5    Page 3 of 13



TRAINING:

Employees will be trained (where applicable) specific to their defined roles. Training will be
conducted annually (see OH&S Training Plan).

MONITOR & REVIEW:                                                                                      P
This procedure will be monitored for compliance and effectiveness in accordance with Audit
Procedure Document No 7. Or at any time pursuant to either legislative or CCES Policy change.

Review will be in consultation with Sector Forums at least 3 yearly.
                                                                                                       R
RELATED DOCUMENTS:
OHS & W Act 1986
                                                                                                       O
OHS & W Regulations 1995
Performance Standards for Self Insured Employers; Standard 4 – WorkCover Corporation 2008
AS/NZS 4804:2001 Occupational health and safety management systems – general guidelines,
systems and supporting techniques. Section 4.4.3
                                                                                                       C
APPENDICIES:

Appendix 1: Definitions
Appendix 2: Scope document
                                                                                                       E

FORMS:
                                                                                                       D
Form 7a:        Procedure Verification
Form 7b:        Site Level Audit Result Log
Form 7c:
Form 7d:
                CCES Audit Cover Sheet
                Audit Notification/Confirmation letter
                                                                                                       U
Form 7e:        Corrective Action Report (CAR)
Form 7f:        Corrective Action Report (CAR) Register
                Audit Report – Licence & Sector level
Form 7g:
Form 7h:        Worksite Report - Audit                                                                R

                                                                                                       E
             Catholic Safety, Health & Welfare South Australia


                         SOCIAL SERVICES SECTOR
                 AUDIT               Policy Reference:                No. 7             Version No. 5
Sector Approved: 27/4/2010           Review Date: 2013                                            Page 4 of 13

                                              APPENDIX 1
DEFINITIONS:

Audit                        A systematic examination against defined criteria to determine whether activities &
                             related results conform to planned arrangements. Also to examine whether these
                             arrangements are implemented effectively & are suitable to achieve the
                             organization’s policy & objectives.
Auditor                      Person with the competence to conduct an audit.
Audit Conclusion             Outcome of an audit, provided by the audit team after consideration of the audit
                             objectives and all audit findings.
Audit Criteria               Set of policies, procedures or requirements (used as a reference against which
                             audit evidence is compared).
Audit Evidence               Records, statements of fact or other information, which are relevant to the audit
                             criteria and verifiable.
Audit Findings               Results of the evaluation of the collected audit evidence against audit criteria.
Audit Plan                   Description of the activities and arrangements for an audit.
Audit Programme              A set of one or more audits planned for a specific timeframe and directed towards a
                             specific purpose.
Audit Scope                  Extent and boundaries of an audit, the audit scope includes a description of the
                             physical locations, organizational units, activities and processes, as well as the time
                             period covered.
CCES                         Catholic Church Endowment Society Inc.
Competence                   Demonstrated personal attributes and demonstrated ability to apply knowledge and
                             skills.
Conformance                  Where the worksite and/or group being audited has in place and actions the
                             requirements of the system or component of the system being examined in the
                             audit.
Corrective Action            An action, decided by the relevant Manager to rectify the non-conformance
CSHW SA                      Catholic Safety Health & Welfare SA
ELGC                         Exempt Licence Governing Council
Lead Auditor                 A CSHW SA OHS Consultant will be the Lead Auditor, supported if needed by
                             technical experts. The audit team may include auditors in training.
Non-Conformance              A non-conformance occurs when it is identified that a core business management
                             system is undocumented or missing and includes when any requirements of the
                             audit criteria are not met.
Observation                  Recommendations for system improvement to confirm or improve systems
                             requirements. Consistent observations of a similar nature will lead to recording of a
                             non-conformance.
Sampling                     Sampling is that part of statistical practice concerned with the selection of individual
                             observations intended to yield sufficient knowledge about a population of concern,
                             especially for the purposes of statistical inference.
Technical Expert/Advisor     A person who supplies specific knowledge or expertise to the audit team.
                             Note: the specific knowledge or expertise is that which relates to the organization,
                             the process or the activity to be audited, or language or culture. A technical expert
                             does not act as an auditor in the audit team.
             Catholic Safety, Health & Welfare South Australia


                             SOCIAL SERVICES SECTOR
                 AUDIT                       Policy Reference:                   No. 7              Version No. 5
Sector Approved: 27/4/2010                   Review Date: 2013                                                 Page 5 of 13


                                                       APPENDIX 2

                 Catholic Safety, Health & Welfare South Australia

                                            Licence Level Audit – Name of audit
                                                     Scope Document
Introduction
An audit of name of audit will be conducted across the four (4) sectors of the Catholic Church Endowment Society Inc (CCES)
Self Insured Licence during time span. The purpose of this audit is to determine the efficiency of and conformance with the
name of procedure and will assess and verify conformance with the Catholic Church Safety Manual Document No?
This audit will identify areas for improvement in documentation, process and practice, and provide a basis for improving the
management of what the procedure entails.
Non-conformances identified will have actions implemented to improve the process what the procedure entails at CCES
worksites
Scope
The audit will be conducted at XX worksites randomly selected from across all four (4) sectors.
The audit will involve a team of auditors (1-2 auditors) from either Catholic Safety Health and Welfare SA visiting each site for
approximately ½ -1 day, on occasions it may take longer.
The audit will be limited to XXXXXXXXXXXXXXX .
The audit process at each worksite will include:
 an opening and closing meeting with management and/or key personnel;
 desktop review of documentation, such as but not limited to, what the procedure entails documents, induction and training
    records and staff meeting minutes;
 formal and informal discussion from a cross-section of position roles at each location; approximately 10% of employees will
    be involved in the discussions or a smaller percentage sample size at large worksites;
 a site inspection;
 a verbal report and audit summary sheet will be provided at the closing meeting; to be signed by management and a copy
    retained by the auditor;
 a written report will be sent to the management within 14 working days;
 in the case of any non-conformances a Corrective Action Report (C.A.R.) (Form 7e) will be forwarded to the worksite. The
    Corrective Action will be added to the CAR Register (Form 7f) and followed up by the worksite’s OHS Consultant.
The licence level audit report will be written by the lead auditor in consultation with all auditors involved in the process. Areas
identified for improvement will be placed onto the Exempt Licence Hazard/Issue Register
Performance Measurement
The current efficiency of the procedure will be measured by:
        >85%.
        >85%.
        >85%.


NAME:                                                  SIGNATURE:                                              DATE:
            Catholic Safety, Health & Welfare South Australia


                           SOCIAL SERVICES SECTOR
              AUDIT                            Policy Reference:                      No. 7                 Form No: 7a
Sector Approved: 27/4/2010                     Review Date: 2013                                                          Page 1 of 1


                                          PROCEDURE VERIFICATION

                                                                                     RESULT
         TARGET                               MEASUREMENT                                                           ACTIONS
                                                                                     SCORE
Annual Audit Schedule will       Audit Schedule viewed
be developed
>85% of Audits will be           Completed audits viewed against
conducted as per schedule        schedule
>90% Corrective Action           Corrective Action Report Register
Reports will be registered       viewed
onto the CCES Corrective
Action Report Register
>75% of CAR’s will be            Corrective Action Report Register
completed by the                 viewed
negotiated date of
completion

                                                                           TOTAL


Each verification question is scored out of 1.

If the target is being met to indicate that the procedure is in place and being complied with then a
score of one (1) is obtained, if not the score is 0

Record completed procedure verification on Site Level Audit R (Form 7b).



Verification completed by:


Signature:         .....................................................


Name:              .....................................................      Date: ...................................




Manager:


Signature:         .....................................................


Name:              .....................................................      Date: ...................................
            Catholic Safety, Health & Welfare South Australia


                       SOCIAL SERVICES SECTOR
              AUDIT                Policy Reference:            No. 7    Form No.: 7b
  Sector Approved: 27/4/2010       Review Date: 2013                               Page 1 of 1


                               Site Level Audit Result Log
  Once an audit has been completed, please complete this page to track when it was completed,
  who did it and the score achieved. This template is to assist you with managing the completion
  of your internal audits and monitoring progress.
      Procedure                      Date        Score      By Who            Signature
                                     completed
1     OHS&W Policy
2     Incident Reporting
3     Smoking
4     Asbestos
5     Consultation
6     Contractor Management
7     Internal Audit
8     Vehicles
9     Electrical
10    Emergency Evacuation
11    First Aid
12    Skin Cancer
13    Induction & Training
14    Hazard Management
15    Management of Plant
16    Manual Handling
17    Remote or Isolated Work
17.1 Confined Space
18    Health & Wellbeing
18.1 Psychological Health
18.2 Occupational Violence
18.3 Fitness for Work
18.4 Conflict Resolution
18.5 Bullying & Harassment
18.6 Behaviour Management
19    Management of
      Substances
20    Purchasing
21    Voice
22    Volunteers
23    Rehabilitation
24    Document Control
25    Fall Prevention/Working at
      Heights
25.1 Slips, Trips & Falls
26    Environment
26.1 Infection Control
26.2 Waste Management
              Catholic Safety, Health & Welfare South Australia


                            SOCIAL SERVICES SECTOR
                   AUDIT               Policy Reference:                 No. 7       Form No: 7c
Sector Approved: 27/4/2010             Review Date: 2013                                    Page 1 of 1



                                   CCES AUDIT COVER SHEET
AUDIT:                                                              AUDIT REF No.:      2010-LL-XX
DOCUMENT:
                           Catholic Church Safety Manual Document No. XX
AUDITOR/S:

WORKSITE:                                         WORKSITE No:
                                                  (Licence + Sector Audits)

SECTOR:

WORKSITE                   Date:
INFORMED:
OPENING                    Date:
MEETING:
(Attendees sign)




CLOSING                    Date:
MEETING:
(Attendees sign)




CAR’s Issued:              No.2010-LL-XX-no.




   Site FTE

   No.    employees
    interviewed


AUDITOR: ………………………………………………………………….                                              DATE: ………………

MANAGER: (Parish Priest, Principal, Site Manager)……………………………………….                DATE: ………………
          Catholic Safety, Health & Welfare South Australia


           SOCIAL SERVICES SECTOR
        AUDIT                 Policy Reference:         Form
                                                        No. 7 No.: 7d
                                                                                               Catholic
Sector Approved:              Review Date: 2013
                                                                    Page 1 of 1              Safety Health
27/4/2010                                                                                     & Welfare
                                                                                          South Australia
                                                                                        General OHS&W Enquiries:
                                                                                             08 8210 9342

                                                                                                   Website:
                                                                                    http://www.adelaide.catholic.org.au/chsw




      [DATE]


      Name
      Position
      Organisation
      Address
      Address


      Dear name

                   Re: Licence Level Audit – name of audit (Audit No. 2010-LL-XX).

      Site name will be participating in the above audit during the coming weeks. As discussed
      per telephone I wish to confirm the date and time of the audit:

                      Date:

                      Time:

      The audit will take approximately XXXXX and will involve documentation review and
      interviews with key personnel including the Manager, OHS Coordinator and employees.

      The current Policy Document Doc No. is available on the website under the respective
      sectors.

      I am the auditor allocated to conduct this part of the audit at your worksite so should you
      have any queries with regard to the above, please do not hesitate to contact me on
      0438 396 062 or the CSH&W SA office – 08 8210 934.


      Yours sincerely

                                                                                         Correspondence:
                                                                                  Catholic Safety Health & Welfare SA
                                                                                          39 Wakefield Street
                                                                                           Adelaide SA 5000
      Name
      OHS Consultant, CSH&W SA


                                                                                       Responsible Entity:
                                                                                Catholic Church Endowment Society Inc.
                                                                                          ABN 29 608 297 012
         Catholic Safety, Health & Welfare South Australia


                     SOCIAL SERVICES SECTOR
             AUDIT               Policy Reference:           No. 7   Form No: 7e
Sector Approved: 27/4/2010       Review Date: 2013                             Page 1 of 1

             Catholic Safety, Health & Welfare South Australia

                             CORRECTIVE ACTION REPORT (CAR)

                                                        AUDIT NO.
WORKSITE:                                               DATE:

AUDITOR:                                                CAR NO:

Details of Non-Conformance:




Proposed Corrective Actions:




Follow up:




Agreed Completion Date:
Follow Up & Review Date:
WORKSITE MANAGER:                 Name:                                Date:

                                  Signature:

Date Closed Out:
Closed Out By:
Signature:
         Catholic Safety, Health & Welfare South Australia


                                            SOCIAL SERVICES SECTOR
          AUDIT               Policy Reference:          No. 7                                                      Form No: 7f
Sector Approved: 27/4/2010    Review Date: 2013                                                                             Page 1of 1


                                           CORRECTIVE ACTION REPORT (CAR) REGISTER
                                                             Register maintained by CSHW SA


   WORKSITE           AUDIT:          CAR NO.                    SUMMARY                      REFERENCE  ACTIONS        AUDITOR
                    Name & No.                                                                   NO.    COMPLETED      SIGNATURE
                                                                                                          (Date)
             Catholic Safety, Health & Welfare South Australia


                         SOCIAL SERVICES SECTOR
              AUDIT               Policy Reference:          No. 7     Form No: 7g
Sector Approved: 27/4/2010        Review Date: 2013                           Page 1 of 1




                             AUDIT REPORT – Licence Level
AUDIT NAME                                             AUDIT
                                                       LEVEL
AUDIT NO.                                              AUDIT
                                                       DATE
Previous Audit
Reference
Performance                      Performance Measure                 Result
Measures



INTRODUCTION



SCOPE OF AUDIT




METHODOLOGY



RESULTS




CONCLUSION




REPORT PREPARED BY:

Name:

Signature:                                               Date:
             Catholic Safety, Health & Welfare South Australia


                         SOCIAL SERVICES SECTOR
              AUDIT                 Policy Reference:            No. 7                 Form No: 7h
Sector Approved: 27/4/2010          Review Date: 2013                                      Page 1 of 1




                                  WORSITE REPORT (Audit)
AUDIT NAME                                               AUDIT LEVEL

AUDIT NO.                                                DATE

Previous Audit
Reference - site
Performance               Performance Measure                        Worksite Result
Measures




INTRODUCTION




FINDINGS




Non Conformances




REPORT PREPARED By:

Name:

Signature:                                                                      Date:

				
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