SC30 - Auditing and inspection
06 Dec 2010



STFC Safety Code 30


SHE Auditing and Inspection

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Initial la​unchMay 2008
1.1Update to flow chart in Appendix 2 and Tour scoresJuly 2010
1.2Remove references to "housekeeping" in Appendix 4August 2011
1.3Amendments to audit checklist and training matrixMay 2013
1.4Changes to Appendix 2 and template Audit Report
June 2013
​Changes to 4.2.1 and 4.2.6 to extend audit cycle
March 2014​
Add Document retention policy Appendix
August 2014
Changes to Appendix 4 and minor update to reflect the launch of SHE Assure
August 2018

1. Purpose

This code establishes a framework of STFC Safety, Health and Environment (SHE) Management System audits and inspections in all areas where the STFC holds SHE responsibilities. It establishes the scope, frequency, method, competency, and responsibilities for SHE audits and inspections.

Audit and inspection are critical elements of the STFC SHE Management System providing essential feedback that STFC SHE Policy and Codes are being implemented and are fit for purpose. Audit and inspection:

  • Proactively maintain the profile of SHE management and STFC SHE policy within the Council;
  • Provide management assurance of the integrity and implementation of the SHE management system;
  • Improve the operational effectiveness and efficiency with which SHE codes are implemented; and
  • Ensure that improvements identified are acted upon in a proactive and timely manner.

Audit and inspection are key aspects of the STFC Corporate Governance framework providing assurance of the integrity of the SHE Management System. The findings of SHE audit and inspection provide an input to the STFC Corporate Risk Register and Stewardship Framework.

This audit and inspection programme is designed to be complementary to that provided by the Research Council Internal Audit Service (RCIAS) and will be reported to the STFC Audit Committee alongside those of the RCIAS.

Establishing and relying upon audit and inspection are consistent with the Health and Safety Executive (HSE) Guidance document HSG65 "Successful Health and Safety management".

2. Scope

This code applies to the inspection of STFC estates infrastructure, offices, laboratories and facilities, and audit of all relevant STFC SHE codes, at:

  • STFC owned and operated sites, for example: RAL; DL; UKATC; Chilbolton; the Cosener's House; JAC; and ING; and
  • sites where STFC UK staff occupy facilities/offices as tenants, for example: Boulby Mine Dark Matter Facility; Swindon Office; and the Cockcroft Institute.

Host site restrictions, where the STFC is a tenant, or non UK SHE legislative requirements may limit the use or application of STFC SHE codes as a basis for safety management and auditing. In such circumstances local SHE codes or their equivalents will form the basis for audits conducted by the STFC where these are not conducted by the host site for example fire management, building maintenance. See STFC SHE Policy Appendix 1.

Audit and inspection shall encompass the activities of STFC staff, contractors working on behalf of the STFC, tenants on STFC owned sites, visitors and facility users.

The code does not apply directly to institutions where the STFC has shareholder responsibilities, for example: DLS; CERN; ILL; ESRF; ESO; AAT; EISCAT. Through our representation at such institutions, and consistent with our shareholding influence, the STFC may undertake or assist in the audit and/or inspection of these institutions in collaboration with the institution.

Where STFC staff are required to work at the sites of collaborative partners in the UK or overseas, with the agreement of the host site, the STFC may undertake audit and/or inspection of the locations where STFC staff will work to give STFC management assurance of their health and safety.

3. Definitions

3.1 SHE System Audit

The documented, systematic and objective examination of the SHE management system, SHE Policy and Codes, with the aim of assessing whether the management system meets STFC needs and legal requirements - to identify opportunities for its improvement - "Are we doing what we should be doing, is the system working as a whole - delivering STFC expectations?".

System and Compliance auditing both rely upon the examination of representive samples and is not a process for identifying all discernable non-conformities. Auditing can not therefore be relied upon to provide absolute assurance. Audits are best conducted by those independent of the activity being audited.

3.2 SHE Compliance Audit

The documented, systematic and objective examination of the implementation of the SHE management system, SHE Codes, with the aim of improving their efficiency, and/or effectiveness in managing a particular SHE hazard - to identify opportunities for their improvement or non compliances with documented controls - "Are we following the codes, and can they be improved?".

3.3 SHE Inspection (including Safety Tours or Housekeeping Inspections

A SHE assessment that focuses primarily upon the adequacy of the physical working environment in which staff and others work.

3.4 SHE Non-conformance

An evidence based observation that processes and controls documented in SHE codes have not been applied in practise.

3.5 SHE Improvement Opportunity

A documented suggestion, identified through audit or inspection, through which the efficiency or effectiveness of the code or its implementation may be improved.

4 Responsibilities

4.1 STFC H&S Management Committee shall:
  • 4.1.1 Commission and approve a rolling SHE Code Compliance Audit programme and periodic STFC SHE System Audit ensuring that sufficient resource, including internal auditors, is made available for their efficient, effective and timely completion.
  • 4.1.2 Review at least annually delivery of the compliance audit programme and the effectiveness of SHE Code deployment across the STFC. Determine through the results of the audit programme whether additional or STFC wide action is required, see STFC SHE Policy Appendix 4.
4.2 SHE Group shall:
  • 4.2.1 Establish a prioritised and risk based SHE Code compliance audit programme based upon: the results of risk assessments of STFC activities; current SHE performance - incidents and near misses; planned changes to current work programmes; new legislation; and the results of previous audits.
  • The programme shall encompass all STFC sites or sites where STFC staff work in the UK and overseas and all SHE Codes relevant to those activities.
  • The programme should ensure that all STFC SHE Codes are compliance audited on a sample basis across the STFC on a 6 year cycle. As a risk based audit programme there may be instances where audits are conducted more frequently than that dictated by a 6 year cycle. This programme should, as appropriate, utilise the RC Audit and Assurance Services Group (AASG) and complement its external audit programme.
  • 4.2.2 Ensure that sufficient and suitably trained SHE compliance auditors are available to undertake the agreed programme, see Appendix 1, nominating a lead auditor where a team of auditors is required. Where possible auditors should be independent of the areas they audit. As appropriate specialist and external auditors may be employed to undertake SHE audits as part of this programme on behalf of the STFC.
  • 4.2.3 Monitor and ensure that the compliance audit programme is completed to plan; that the findings of audits are documented; and that non conformances/actions are assigned to relevant managers and staff and recorded in SHE Assure, see Appendix 2 for further guidance.
  • 4.2.4 Monitor and ensure the timely completion of non conformances/actions arising from SHE compliance audits reporting progress to the STFC H&S Management Committee and as appropriate Site and Departmental Safety Committees, see STFC SHE Policy Appendix 4.
  • 4.2.5 Ensure that a review of the compliance audit programme and its findings are reported to the STFC H&S Management Committee and Site Safety Committees annually and included in SHE Improvement plans at Council and Departmental levels (see SHE Code 7, SHE Improvement Planning).
  • 4.2.6 Establish 5 yearly SHE System Audits employing competent auditors who are independent of the STFC and report their findings to the STFC H&S Management​ Committee, see Appendix 3.
4.3 Department Directors/Safety Contacts shall:
  • 4.3.1 Establish an agreed programme of SHE Inspections (Tours) prioritised upon the results of risk assessments of Departmental locations/hazards; current SHE performance - incidents and near misses; planned changes to current work programmes; and the results of previous inspections/tours, see Appendix 4 for further guidance. As appropriate this programme should be approved by the Departmental Safety Committee or equivalent. All areas should be subject to at least one inspection every 2 years.
  • 4.3.2 Ensure that sufficient and suitably trained SHE inspection team members are available to undertake the programme, see Appendix 1, where possible inspectors team members should be independent of the areas visited. Good practice encourages: swapping inspection team members between Departments, sites/areas to provide 'fresh' perspectives and share good practices; and to include Trade Union (TU)/employee safety representatives, see Appendix 4 for further guidance.
  • 4.3.3 Ensure that the inspection programme is communicated in advance, completed to plan and that the findings of the inspections are documented and that remedial actions identified or non conformances are recorded in SHE Assure ​and assigned to relevant managers and staff, see Appendix 4 for further guidance.
  • 4.3.4 Ensure the timely completion of non conformances/actions arising from SHE inspections and report progress appropriately Departmental Safety Committees or other management meetings, and as appropriate Site Safety Committees or SHE Group, see STFC SHE Policy Appendix 4.
  • 4.3.5 Ensure that a review of the inspection programme and its findings is included in Departmental SHE Improvement plans (see SHE Code 7, SHE Improvement Planning).
4.4 SHE Auditors and SHE Inspection Tour Members shall:
  • 4.4.1 Undertake necessary training, see Appendix 1​, and conduct audits or inspections to plan, objectively documenting, reporting findings and non conformances, and making recommendations for action to local management, see appendices 2, 3 and 4 for guidance.
4.5 Managers responsible for areas/activities subject to audit or inspection shall:
  • 4.5.1 On receipt of the findings of SHE Compliance and System audits, and SHE Inspections, consider and as appropriate act on the non conformances and recommendations raised. Where such recommendations are accepted address the findings in a timely manner and if not accepted the basis for this decision should be recorded and the audit signed off.​

Contact: Baker, Gareth (STFC,DL,COO)