Policy Redesign Project

All policies and procedures are being reviewed as part of this project. This document is pending review, but remains in effect until the review is carried out.

Work Health and Safety Auditing Procedures

Establishment:
Council, 27 August 2013
Last Amended: Council, 9 March and 25 May 2017
Nature of Amendment: Consequential to the repeal of statutes
Date Last Reviewed: May 2017
Responsible Officer: Director, People and Culture

Table of Contents

1. Purpose

2. Scope

3. Definitions

4. Responsibilities

5. Types of WHS audits

5.1 Internal Audit

5.2 Legislative Compliance Audit

5.3 WorkCover Evaluation

6. WHS Auditor Competency

7. WHS Audit Plan

8. Audit Procedures

9. Legal & Policy Framework

10. Review

 

1. Purpose

1.1  This document sets out the processes for planning and conducting health and safety and injury management audits at the University.

 

2. Scope

2.1  These procedures apply to all health and safety and injury management audits conducted at workplaces owned, managed or controlled by Flinders University and any place where work is performed by a worker on behalf of the University.

 

3. Definitions

3.1  For the purpose of these procedures the following definitions apply:

Work Health and Safety (WHS) Includes injury management
Worker A person who carries out work in any capacity for the University including staff, contractors and sub-contractors and their employees, labour hire company employees, trainees, persons gaining work experience and volunteers.
Student A person who has an active enrolment status in a course of study at the university in accordance with the University's policies on enrolment.
Workplace A place where work, study or research is carried out for the University and includes any place where a worker goes, or is likely to be, while working, teaching, studying or undertaking research.
Conformance A conformance is an activity, item or process that conforms to legislative requirements, or University policies, procedures, or other requirements of the University's WHS management system.
Non-Conformance A non-conformance is an activity, item or process that does not conform to legislative requirements, or University policies, procedures or other requirements of the University's WHS management system.
Observation An observation is an activity, item or process where there are opportunities for improvement, and which may become a non-conformance in the future.
Auditor A person appropriately trained or qualified to conduct audits. Auditors may act in teams if required.
Senior executives Vice-Chancellor, Deputy Vice-Chancellors, Pro Vice-Chancellors, Vice-President, Executive Deans

 

4. Responsibilities

Vice-Chancellor  Responsible for
  • submitting the rolling WHS Audit Plan to University Council annually for approval;
  • submitting any proposed amendments to the Audit Plan to University Council throughout the year;
  • reporting to University Council
    • progress against the WHS Audit Plan (at each meeting of Council)
    • ReturntoWorkSA or other Regulator audit reports
    • WHS Audit Agreed Actions Report (submitted to Council twice yearly)
Senior executives  Responsible for ensuring that
  • workers, and where relevant, students in their Faculty/Portfolio cooperate with the audit process;
  • there are adequate resources to remedy any non-conformances identified during any audits in their Faculty/Portfolio; and
  • corrective actions are implemented within the specified timeframes to remedy any non-conformances or to improve general workplace safety.
Managers/Supervisors of areas Responsible for
  • providing the auditor(s) with evidence of current system and procedural practices in response to audit questions;
  • identifying and implementing corrective actions to improve WHS systems and general workplace safety, where deficiencies are detected;
  • monitoring that corrective actions are implemented within the established timeframes; and
  • communicating the result of the audits with workers.
Associate Director, WHS  Responsible for
  • preparing the WHS Audit Plan annually for approval by University Council, with any proposed amendments submitted throughout the year;
  • implementing the University's WHS Audit Plan;
  • maintaining records of audit programmes;
  • entering any non conformance(s) and observation(s) onto the University Corrective Actions Register;
  • assisting Faculties/Portfolios to implement corrective actions and controls to system, procedural or item deficiencies and non-conformances;
  • monitoring the University's Corrective Action Register and preparing reports to senior executives on the progress of Corrective Actions; and
  • preparing reports for University Council.
 Auditors   Responsible for
  • conducting the audit(s) according to this procedure;
  • ensuring that the auditing process is transparent to the auditees;
  • maintaining effective communication throughout the audit; and
  • providing audit reports using the approved report format within the agreed timeframe.

 

5. Types of WHS audits

5.1 Internal Audit

5.1.1  An internal audit is a systematic, and wherever possible, independent examination, carried out by a competent person, appointed by the University, to determine whether

  • an activity or activities and related results conform to planned arrangements;
  • these arrangements are implemented effectively; and
  • whether they are suitable to achieve the University's policy and objectives.

5.2.2  The results of the internal audits must be documented and staff consulted about them. Preventative/corrective action plans must be subsequently developed and implemented.

5.2 Legislative Compliance Audit

5.2.1  A legislative compliance audit is a systematic and documented verification process to obtain and evaluate evidence to determine that the University's WHS policies, procedures and practices comply with legislative requirements.

5.3 ReturntoWorkSA Evaluation

5.3.1  A ReturntoWorkSA evaluation is a review undertaken by ReturntoWorkSA to evaluate the University's overall compliance with the requirements of the ReturntoWorkSA Performance standards for self-insured employers or in relation to a particular matter of compliance.

 

6. WHS Auditor Competency

6.1  All auditors must be suitably qualified and experienced and must be approved by the Associate Director, WHS. The minimum qualification required is RABQSA certified OHS auditor.

 

7. WHS Audit Plan

7.1 The Associate Director, WHS will prepare and maintain a rolling Audit Plan for WHS and Injury Management for approval by University Council.

7.2 The Vice-Chancellor submits the rolling WHS Audit Plan to University Council annually for approval and any proposed amendments to the rolling WHS Audit Plan to University Council throughout the year.

7.3 The frequency of internal audits will be determined taking into account:

  • the level of risk associated with the activity, policy or procedure;
  • the results of previous audits;
  • accident and incident statistics; and
  • the significance of problems encountered in the areas to be audited.

7.4 Unscheduled or follow-up audits may be conducted at any time based on:

  • audit results;
  • regulatory inspections;
  • operational changes;
  • management reviews;
  • incidents and accidents; or
  • identified non-conformances.

7.5 The ReturntoWorkSA self-insurance evaluations are conducted by ReturntoWorkSA. The timing of the evaluation is determined by the self-insurance registration period granted by ReturntoWorkSA and is based on the findings of the previous evaluation. ReturntoWorkSA may also conduct additional reviews during the self insurance registration period. These may be reflected in the ReturntoWorkSA Partnership Plan as negotiated between the University and ReturntoWorkSA.

 

8. Audit Procedures

 Steps  Actions  Who is responsible
8.1 Prepare the rolling WHS Audit Plan
  • Prepare an Audit Plan for all University sites (including rural, regional and interstate sites).
  • Forward the proposed Audit Plan through the University Health & Safety Committee to the Vice-Chancellor annually, for approval by University Council.
  • Submit any proposed amendments to the rolling Audit Plan through the University Health & Safety Committee to the Vice-Chancellor throughout the year, for approval by University Council.
  • Determine and document the objective, the scope and criteria for each of the audits.
  • Ensure master audit checklists are prepared as required.
Associate Director, WHS
8.2 Notification of audits
  • Prior to an audit, contact head of the unit/area to be audited notifying reasons and time of audit and confirming that the scheduled time is convenient.
  • Prior to an audit advise the Health and Safety Representative(s) for the area of the audit and its scheduled time;
Associate Director, WHS or delegate
8.3 Preparation for audit
  • Confirm the objective, scope and criteria of audit with the Associate Director, WHS.
  • Send an audit plan to the head of the unit/area to be audited.
  • Collate relevant information for review.
Auditor(s)
8.4 Conducting the audit  The auditor(s) will conduct the audit using the auditing protocol. Auditor(s)
8.5 Audit Report 

Finalise the audit report, using the Internal Audit Report Form and where necessary, the non-conformance report form, which includes audit findings, any non conformances and observations, and any corrective actions, which must be based on risk assessment and have a timeframe for implementation negotiated with the head of the unit/area being audited.


Copy of the report to be sent to

  • Associate Director, WHS;
  • the relevant Faculty/Portfolio Head;
  • Chair of the relevant Faculty/Portfolios Health and Safety Committee;
  • the relevant Faculty General Manager;
  • head of the unit/area audited; and
  • Health & Safety Representative(s) for the area.

If required, arrange a follow-up meeting with

  • head of the unit/area audited;
  • safety officer (where applicable);
  • Health & Safety Representative(s) for the area; and
  • WHS Consultant for the area

Auditor(s)

 

 

 

 

Associate Director, WHS

 

 

 


Auditor(s)/Associate Director, WHS

8.6 Corrective actions

 Ensure corrective actions are completed within the required timeframes, including

  • identification of the person responsible for performing the corrective action; and
  • tracking the progress and effectiveness of the corrective actions.

  • ensuring the corrective action is logged onto the Corrective Actions Register
  • closing out corrective actions;
  • closing out non-conformances;
  • reporting status of corrective actions to management and to the Faculty/Portfolios Health and Safety Committee; and
  • where required, providing advice and assistance to staff in the area audited.

Senior executives, or delegate

 

 

WHS Consultant for the area audited

8.7 Reporting

Report results of audits to:

  • Director, People and Culture;
  • Senior executives; and
  • University Health and Safety Committee.

Report to University Council

  • Progress against the WHS Audit Plan (at each meeting of Council)
  • ReturntoWorkSA or other Regulator audit reports
  • WHS Audit Agreed Actions Report (submitted to Council twice yearly)

Associate Director,WHS

 

 

 

 

Vice-Chancellor



9. Legal & Policy Framework

South Australian legislation:

Work Health and Safety Act 2012
Work Health and Safety Regulations 2012
Return to Work Act 2014
Return to Work Regulations 2015

Where University workers and students are working in University premises in other States or Territories, the following legislation applies:

Victoria

Occupational Health and Safety Act 2004
Occupational Health and Safety Regulations 2007
Accident Compensation Act 1985
Workers Compensation Act 1958
Accident Compensation Regulations 2012

Northern Territory

Work Health and Safety (National Uniform Legislation) 2011
Work Health and Safety (National Uniform Legislation) Regulations 2011
Return to Work Act
Return to Work Regulations

Flinders University WHS policies and procedures apply at all University premises regardless of location.

 

10 Review

10.1  These procedures will be reviewed at least every 4 years to ensure they remain effective, relevant and appropriate to the University, and reflect current legislative requirements.