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Derry City & Strabane District CouncilSurveillance - OHSAS 18001:2007, Migration - ISO45001:2018 Assessment ReportOHSAS 18001:2007, ISO 45001:2018Assessment Dates: 25th - 27th November 2019

Confidence, Assurance and Certainty

Prepared for: Derry City & Strabane District

Council

Prepared by: Mary Coyle

Derry City & Strabane District Council - Surveillance - OHSAS 18001:2007, Migration - ISO 45001:2018 - OHSAS 18001:2007, ISO 45001:2018

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ASSESSMENT DETAILS

Client Details

Company Name Derry City & Strabane District Council

ManagementRepresentative

Oonagh O'Doherty

Company Address 98 Strand Road, Derry, Northern Ireland, BT48 7NN,

Date of Assessment 25th - 27th November 2019

Location ofAssessment

98 Strand Road, Derry, Northern Ireland, BT48 7NN

Templemore Sports Complex, Derry, Northern Ireland

Objective ofAssessment

To confirm the extent of conformity of the system to the ManagementSystems OHSAS 18001:2007, ISO 45001:2018, to evaluate the capability ofthe management systems, to ensure conformity to statutory, regulatory andcontractual requirements, to identify potential OFI and to evaluate theeffectiveness of the system to achieve organisational objectives.

Assessment Details

Type of Assessment Surveillance - OHSAS 18001:2007, Migration - ISO 45001:2018

Standard(s) used inassessment

OHSAS 18001:2007, ISO 45001:2018

Scheme specificrequirements

N/A

Scope of certificationEnvironment & Regeneration, Business & Culture, Health & Community andSupporting Services.

EA CodeOHSAS 18001 - (35) OtherServices

NACE Code N/a

Current Exclusions N/A

No. of Employees inScope

932

Assessment Team Mary Coyle

Distribution list forAssessment Report

Oonagh O’Doherty – Corporate Health and safety officer -Oonagh.O'[email protected]


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Assessment Summary

Opening meetingThe assessment commenced with a review and confirmation of the assessment plan, the objectives,criteria, and scope of the assessment. The assessor provided an overview of Certification Europe’scomplaints and appeals procedures, acceptable use of certification documents and marks andconfirmed the basis of Certification Europe's confidentiality policy. The audit methodology andcategorisation of non-conformities was summarised, and the assessor checked relevant procedures forworking on site.

FindingsThe assessment is based upon a sample of the company’s activities, as they were observed by theassessor, and therefore the findings detailed in this report do not purport to include, nor do theyinclude, all possible non-conformances which may exist within the system, either during or at any timeprior to, or subsequent to, the assessment. The use of certification marks was reviewed throughout theassessment and the organisation is using these in accordance with the guidance issued by CertificationEuropeThe findings of the assessment are detailed in the Tables below.

Limitations to completing assessment including deviations from audit planNone

Review of scopeThe scope of certification was reviewed and is deemed appropriate for the organisation.

Assessment ObjectivesThe objectives of the assessment were fulfilled.

Auditees


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The following staff acted as assessment guides, attended meetings or were interviewed during theassessment:

Attendees at opening meeting:John Kelpie – Chief ExecutiveKaren McFarland – Director of Health and CommunityStephen Gillespie – Director of Business and CultureKaren Philips – Director of Environment and RegenerationDenise McDonnell – Lead Assurance OfficerConor Canning – Head of EnvironmentOonagh O’Doherty – Corporate Health and safety OfficerAuditees:Adrian Kelly (Duty officer)Paddy Curtis (Union rep/leisure attendant)John Paul Glenn (Dry site service manager)Colleen Brown (GP referral co-ordinator)Dessie Thompson (Property Maintenance Manager)Keith Ferguson (Property Inspector)Cathy Farren (Leisure Area Manager)James Moore (Leisure Area Manager)Sean Doherty (H&S Service Manager)Karen McFarland (Director of Health and Community)Barry O’Hagan (Head of Community and Leisure)Barney Robinson (M&S Supervisor)Mary McLaughlin HR AssistantJason Flood – Health and Safety OfficerOonagh O’Doherty – Corporate Health and Safety OfficerConor Canning – Head of EnvironmentAttendees at closing meeting:Oonagh O’Doherty – Corporate Health and safety officerKaren McFarland – Director of Health and CommunityDenise McDonnell – Lead Assurance OfficerBarry O’Hagan (Head of Community and Leisure

Accompanying Persons


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EXECUTIVE SUMMARY

Summary of NonconformitiesNo instances of nonconformity were detected during the Assessment.

Summary of Opportunities for Improvement

Clause/Control OFI No.

9.3 - ISO 45001:2018 - Management Review OFI37138

8.1 - ISO 45001:2018 - Operational Planning and Control OFI37140

7.2 - ISO 45001:2018 - Competence OFI37141

7.5 - ISO 45001:2018 - Documented Information OFI37142

Assessment ConclusionOn the basis of the evidence identified above, the assessor has determined that the client’s managementsystem continues to meet the needs of the organisation and conforms to the requirements of OHSAS18001:2007, ISO 45001:2018.

It is the recommendation of the Lead Assessor to the Certification Manager of Certification Europe thatDerry City & Strabane District Council be approved for Migration.

Next Assessment Details

Next Assessment Type Surveillance

Next Assessment Date 29th and 30th April 2020

No. of Days of NextAssessment

2

Location(s) of NextAssessment


Guild Hall / Alley Theatre, Derry, Northern Ireland

Signed on behalf ofCertification Europe


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BUSINESS UPDATE & REVIEW OF PREVIOUS FINDINGS

Activity Assessed: Business Update & Review of Previous Findings

An opening meeting was conducted with senior management, in which the assessor outlined thepurpose of the assessment and reviewed the assessment plan with the management team. Theassessment process and potential outcomes and subsequent actions, if required, were also discussed.

The assessor was given a general overview of the organisation and detailed changes that havehappened since the last assessment. The assessor met with senior management who discussed the changes within the organisation sincethe last assessment, noting the recent changes within the council since the last assessment. Theassessor noted all management representatives spoke very highly and positively with regards to thechanges made to migrate to ISO 45001:2018. The assessor noted that the organisation took on a huge task for asset management with regardscompliance both from a legislative point and corporate systems, this has now been successfully put inplace and is dealt with in the main body of the report.

The assessor confirmed the scope as being “Environment & Regeneration, Business & Culture, Health &Community and Supporting Services”, which remains unchanged since the last assessment. Whilesections of the organisation work outside of normal working hours there is no shift work involvedwithin the organisation. Previous Findings

TT3259The organisation has failed to meet all of the requirements of the standard. Evidence: It is not evidentthat changing circumstances e.g. amalgamation of services has been discussed as part of themanagement review. The organisation has quarterly management review meetings, this has been dealtwith and is dealt with in the body of the report. The assessor deems this as closed. TT3260Note TT2714 raised at the previous assessment is carried forward from previous report. Theorganisation has failed to control documents in accordance with the requirements of the standard. Evidence: Asbestos register not updated as per advice given in 2003. The organisation has done afull survey of all property with regards to this finding, and is dealt within the body of the report. Assetmanagement system now in place, with approximately 152 assets noted on this system. This is dealtwith in the body of the report and the assessor deems this closed. OFI27330 Suggest including positive observations as part of the internal audit process. This has beenimplemented. OFI27331The assessment team suggest that the organisation would benefit by reviewing minutes in particularheadings and issue number in line with SP 03 Document Control and Records. This has beenimplemented. OFI27332The assessment team suggests that the organisation would benefit by reviewing the local held trainingmatrix to ensure same is kept up to date with the general training matrix held by head office. This hasbeen implemented with completed training needs analysis, this has been organised through HR onquarterly basis. Then localised training outside of this is fed back to central HR.


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SUMMARY OF CONFORMITY

Activity Assessed: Context of the Organisation, Interested Parties, Scope of the Management System

Clause: 4 - ISO 45001:2018 - Context of the Organisation, 4.1 - ISO 45001:2018 - Understanding theOrganisation and its Contents, 4.2 - ISO 45001:2018 - Understanding the needs and expectations ofworkers and other interested parties, 4.4 - ISO 45001:2018 - OH&S Management System

Narrative: As part of the context of the organisation the organisation has developed a register of InterestedParties IMS 2017 Version 1 July 2019. The Interested Parties are listed as;

All employeesSenior Management TeamCouncil CommitteesUnionsExternalPublic/ Services UsersSubcontractorsSuppliersHSENIOther Local AuthoritiesGovernment DepartmentsPartner Agencies e.g. TNIEmergency ServicesCertification BodyMediaGovernment Policy MakersBanks Industry / Trade Associations e.g. Lasan, Gas Safe, TAG, WISHNIProfessional BodiesCommunity GroupsSAGInsurance

These interested parties are dealt with under the following headings;

Interested PartyNeeds / requirements/expectationsCommunication methodCompliance ObligationDetails

The organisation has also carried out a SWOT analysisStrengths

Improve H&S management within DCSDCImproved reputation and opportunity to grow H&S within the organisationHelp minimise risk of lost time through incidentsPossible cost savings of public liability insurance

Weakness

Adherence to certification on an ongoing basisPressure on organisation to maintain accreditationPressure on organisation in relation to roles, responsibility and financial pressures

Opportunity

Set clear management system / policy / proceduresBuild better safety cultureFocus attention of senior managementImproved reporting processes (internal and external)


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Streamline H&S within the organisation

Threats

Lack of compliance to set standardLack of senior commitment to the systemFailure of employees to follow system procedures

The organisation has also carried out a breakdown of potential impacts which deals with internal andexternal factors, these impacts include amongst others the following:Internal

Management commitmentResourcesITOrganisational ChangesFundingCultureCouncillorsUnionsEmployee Engagement

External Factors

Changes in legislationLASAN requirementsHSE Focus CampaignsAccident / Incident TrendsTAGFundingTransfer of functionsGovernment PolicyBrexit

The assessor reviewed this without issue. The assessor confirmed the scope as being “Environment & Regeneration, Business & Culture, Health &Community and Supporting Services”, which remains unchanged since the last assessment


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Activity Assessed: Leadership and Support, Organisational roles, responsibilities and authority,Consultation and participation of workers

Clause: 5.1 - ISO 45001:2018 - Leadership and Commitment, 5.2 - ISO 45001:2018 - OH&S Policy, 5.3 -ISO 45001:2018 - Organisational Roles Responsibilities and Authorities, 5.4 - ISO 45001:2018 -Consultation and Participation of Workers

Narrative: The assessor noted that the CE J Kelpie, and senior management team, attended the opening meeting,and openly discussed the processes, and how the organisation deal with Occupational Health andSafety. The continued involvement of senior management was noted for the duration of theassessment with senior management attending the site visit and being available at all times throughoutthe assessment. The assessor noted that the organisation has maintained and updated the organisational chart, allchanges within Management system have been driven by senior management with a commitment tothe process being evident throughout the entire assessment process. The organisation carried out a gap analysis which included leadership, this analysis report went to theSenior Leadership Team, who meet fortnightly. The gap analysis identified resources, and supporting,from this resource were included within all agendas, within support all directors and CE have agreed togo to 1 internal audit per year, and then each director will participate in half a day of internal audit asper their responsibility. The assessor noted that the organisation carried out a presentation in June 2019 which showed”Differences the standards 45001 and 18001”. This presentation was rolled out within the organisation,firstly through committee to all council members, once approval was received this presentation wentout to all monthly meetings attended by managers of the section who communicated same to theremainder of their team, this presentation is still being run out, and is now going to front line managersin December. This presentation came from senior management and refers to the commitment of seniormanagement for migration to ISO 45001:2018.

Under the organisations Health, Safety and wellbeing policy, (corp 40/17) dated 1/8/19. This detailsunder section 2.1 Roles and responsibilities, the policy set out general overarching responsibilities onmanaging health safety and wellbeing and gives details of more specific actions that directorsmanagers, and other employees are required to take to meet their responsibilities The following seniormanagers and elected members have strategic responsibilities which the assessor sampled thefollowing without issue:

CouncilChief ExecutiveDirectorsManagement team (heads of services and lead officers)Audit and assurance committee.

As part of the gap analysis carried out the by organisation in preparation for ISO 45001:2018 theorganisation reviewed its communications procedure. This now deals with consultation, participationand communications of all staff in particular non managerial staff, this was evident and is dealt with infacility tour whereby all staff were consulted and involved in changes within the facility. This wasreviewed without issue and complies with the requirements of the standard.


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Activity Assessed: Legal and other requirements

Clause: 6.1.3 - ISO 45001:2018 - Determination of Legal Requirements and other Requirements, 9.1.2 -ISO 45001:2018 - Evaluation of Compliance

Narrative: The assessor noted that since the last assessment the organisation has done a huge amount of workwith regards to asset management, compliance of same both legally and procedurally. Theorganisation has developed an asset management section within its intranet system whereby all assetsare listed under each of the directives, and area of responsibility. Under each asset is a folder structurewith an individual file per asset. The assessor sampled this both for compliance and in detail during thesite / facility tour. The assessor sampled the Foyle arena, noting that there were currently open jobswhich include items such as door handle, blocked toilets along statutory 6 monthly inspections both forsystem and legal. The assessor noted that this is a forward prompting system 6 – 8 weeks out, so thatcontractor can be scheduled for recertification. This was reviewed without issue. The organisation has maintained a register of relevant health and safety legislation and otherrequirements under the headings of:

Relevant Legislation / other requirementsSummary of LegislationAssociated AOP / Guidance NoteMethod of Demonstrating complianceEvidence of complianceAction Plan Required

Of note the organisation has the benefit of in-house legal team, which are available for consultation andadvise as required. The assessor reviewed the following legislation without issue;

Health and safety-First aid amendment regulations 2017 SR 2017 no 156 The Control of asbestos regs, (Northern Ireland) 2012The health and safety at work (NI) order 1978 (as amended 2000)

The organisation has maintained a procedure on legislation and other requirements which deals withintroduction procedure this states that legal compliance audit will be carried out annually, new andrevised legislation will be monitored for applicability via CEDREC, Croner, HSENI, and internally legaldept. The assessor also noted that the organisation maintains a flow chart which depicts guidance andwhere same can be sought from which includes amongst others the following:

CEDRECHSENIHSEACOP’s

This was reviewed without issue.

Activity Assessed: Management Review, Internal Audit, Nonconformity and corrective action,Objectives

Clause: 6.2 - ISO 45001:2018 - OH&S Objectives and Planning to Achieve them, 9.2 - ISO 45001:2018 -Internal Audit, 9.3 - ISO 45001:2018 - Management Review, 10 - ISO 45001:2018 - Improvement, 10.2 -ISO 45001:2018 - Incident Nonconformity and Corrective Action

Narrative: The assessor reviewed Procedure SP02 Management Review. This procedure deals with introduction,procedure, related documents, and agenda. The assessor noted that the agenda does not mirror theactual agenda used. The assessor suggests that the organisation would benefit by reviewing both theprocedure for management review and the agenda so that both mirror each other. Please refer to OFI. The assessor reviewed the agenda for management review without issue noting that the outputs andinputs comply with the standard. The agenda includes amongst others the following:


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ApologiesMinutes and actions from previousImplementation project ISOObjectives and targetsRisk assessment SSOWPolicyTrainingE learning zone reportsSafety Audit, Inspections corrective actions NCAccident incidents & Corrective ActionsChange ManagementCommunications/ Consultation HSENI updatesLegal UpdatesDoc ControlGap analysisWell beingProgramme of worksProcurement reactive change changing rolesAOB Next meeting

The assessor went on to review the organisations internal audit, and noted on discussion with themanagement representatives that the organisation h ad carried out a GAP analysis of the Managementsystem dated 14th June 2019 using all clauses of ISO 45001:2018. On discussion with management thetemplate that was used for the GAP analysis will be used going forward for internal audit purposes. The assessor reviewed this without issue, noting that any issues raised within this GAP analysis weredealt with and closed out. The organisation also maintains Checklist Questionnaire around organisational compliance. Title CHS41, this is available on safety drive for appropriate users. Other audits included26/9/19 which audited the following:

SWOTActions to address R&OCompliance CheckCommunicationsProcedure – procurement

The assessor reviewed the nonconformance register which deals with entries under the followingheadings under Non-conformance register;

AreaIssueAction TakenResponsibilityDue dateComplete yes / noCompleted date.

The organisation has the ability to run reports from this noncompliance register and can be run samevia, employee, area, type of Nonconformance or Internal audit, per facility and per dates. The assessorreviewed this register noting complete or outstanding entries. The organisation is operating thissystem for the last 4 years, at the time of the assessment there are 53 open items on the register. Ofwhich there are 21 still open, the assessor noted that none have reached their current to be closed date,however, several have had their dates extended on more than one occasion. The assessor sampled the following without issue

27/11/18 Lone worker controls at end of shift not controlled, the assessor that this has had 5extended dates. This was picked up on internal audit, civic amenity site.3/7/19 internal audit – environmental health, Legionella within public conveniences.


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7/11/19 Fleet – RA for welding require review and update re carcinogenic. Dated to be closed on18/12/19

The assessor noted that all Incidents are recorded and included within audit reports module of theorganisations system. The assessor noted that the organisation has had 2 RIDDOR with 59 days lost atthe time, and includes a costing to the organisation. The 2 incidents were recorded as a manualhandling issue, the second was a member of public Slip Trip and Fall in Car park. On discussion withmanagement representative the assessor noted that the organisation encourages all incidents to berecorded. The assessor noted that the incidents register includes near misses. At the time of theassessment there were 418 incidents reported on system, these will include very minor to RIDDORreports, this figure includes members of the public and employees. The assessor noted that there are59 employee incidents included within this register. The assessor reviewed without issue the 2 RIDDOR incidents, noting that full reports have beenrecorded along with copies of RIDDOR report. The assessor noted that the organisations objectives are agreed at Management review which tookplace at the beginning of the year and are set around the following:

Set around Risk assessment/ safe systems of workCompliance trainingAsset management systemCommunicationsAccident reporting and internal audit.

Objectives set for this year corporate objectives

Corporate plan – strategic direction of the organisationService area plan – these feeds into the corporate plan

Once a month the organisation gets a formal review of where KPI’s for each dept (50% have beenaddressed – which is on target. The assessor was informed during discussion that this is the first yearthat 50% has been reached so early within the year, and that objectives are either closed out oractively within their time frame. The full review of compliance within asset management is attributedto the success of objective KPI. This is managed on a traffic light system and all objectives are green. The assessor noted that all covalent objectives and targets are dealt with under the following headings

Parent Action TitleParent Action CodeTitleCodeDescriptionPlanned start dateActual Start dateDue DateAssigned toManaged by

All of the above information is fed into a tracker which is monitored and reported on a formal monthlybasis. This complies with standard and was reviewed without issue. The assessor noted that theorganisation carries out the following meetings

Quarterly Management Review meetingQuarterly H&S review Meetings (business and culture / community services)Monthly environment / leisure meetingsLocalised meetingsFortnightly frontline servicesWeekly localised meetings (daily refuse teams)

This follows the agenda health and safety agenda. The assessor was informed that if an item on theagenda cannot be resolved for whatever reason at a local level its escalated to monthly meeting andfurther if required.


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The assessor sampled the following Occupational Health and Safety review meetings for the followingdates without issue 9/9/19, 19/6/19, 3/3/19. These were reviewed without issue.

Activity Assessed: Operational Control - Facility Tour & Review of Associated Documentedinformation, Emergency Preparedness and Response, Legal Compliance, Support, Competence,Training and Awareness, Consultation and Participation, Hazard Identification and Assessment of

Clause: 5.4 - ISO 45001:2018 - Consultation and Participation of Workers, 6.1.2 - ISO 45001:2018 -Hazard Identification and Assessment of Risks and Opportunities, 7.1 - ISO 45001:2018 - Resources, 7.2- ISO 45001:2018 - Competence, 7.3 - ISO 45001:2018 - Awareness, 7.4 - ISO 45001:2018 -Communication, 7.5 - ISO 45001:2018 - Documented Information, 7.5.3 - ISO 45001:2018 - Control ofDocumented Information, 8 - ISO 45001:2018 - Operation, 8.1.2 - ISO 45001:2018 - Eliminating Hazardsand Reducing OH&S Risks, 8.2 - ISO 45001:2018 - Emergency Preparedness and Response, 9.1.2 - ISO45001:2018 - Evaluation of Compliance

Narrative: The assessor was given an extensive tour of one of the organisations leisure facilities in Templemore. During this tour the assessor met with several senior members of staff, along with personnel involved inthe daily running of the facility The assessor was given a tour of the facility which included the pool area, and noted on discussion withsenior management that this was developed in consultation with all staff within the complex, wherebyfencing was put in place to segregate the underage / children’s paddling pool from the main pool to comply with local legislation. The assessor noted on talking to staff within the facility the attitude of allstaff was welcoming the ISO 45001;2018 and the consultation of staff and involvement of staff from anoccupational health and safety point of view, and were proud of their achievements, involvement andinclusion in changes that have taken place. During the site tour a Code 1 happened, this is a part of the facilities emergency procedures. Theassessor noted that all complex staff excused themselves from the assessment and as noted withintheir procedures attended the area where the Code 1 (possibly drowning) was happening. Theassessor noted during the review of documentation during the facility tour the emergency action plan,titled TSC EAP dated October 2019, that the notification of the code 1 and response was appropriate asset out within this document. This was reviewed without issue. The assessor noted that the last fire drill took place on the 12/11/19 at approx. 1.50 and finished at 1.55. This was a practice fire drill. The assessor noted that all sections were completed and this wasreviewed without issue. The assessor was given an extensive tour of the plant room area for the leisure facility and noted thefollowing without issue;

Plant room daily log completedDaily duties checklistSafe handling and storage of pool chemicalsBoiler TMC serviced on 3/9/19 due again on 3/3/20

The assessor suggests that the organisation would benefit by reviewing the identification of PPErequired when entering / working in the plant room, with possible use of visual indicators for staff andor contractors. Please refer to OFI.

The assessor was also given an extensive tour of the gym facilities, pool area and indoor pitch area. The assessor noted the following without issue during the tour of same.

Fire extinguishers dated May 2019Specifically, designed posters which identify

Individual responsibility of all customerCompulsory inductions


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Key ServicesInductionFree one to one sessionsPersonal fitness programmesAdmissions policyFitness Suite EtiquetteGeneral Information

Well maintained fire exits and signage on sameWell maintained welfare facilities for both staff and customers

The assessor was given an extensive overview of how the new asset management system works andhow the forward prompting system has proven effective in the continued maintenance of bothlegislative and local compliance and certification. The assessor was shown on the asset managementthe overview of all certifications issued to the facility

Fire alarm inspection dates and certificationLegionella managementAsbestos registered area, removal of same along with documentation saved to same confirmingremoval and reoccupation certification

The assessor noted that this asset management system allows inspections to be logged, along with anyissues arising from same, responsibility for works needed assigned along with contractor and jobreference number. The assessor noted that this system allows the organisation not only to track theissue but it allows them to track all aspects of the issue or job raised to conclusion along with savingcopies of reports/ certificates it also forward prompts the system with a reminder of service intervalsor certification renewal dates allowing the organisation to appoint and organise same to be done. Itwas obvious from reviewing this with Barney Robinson (M&S Supervisor) the amount of work that hasgone into this system to get it up and running, and it was also obvious from discussion with all presentduring the tour facility that this was working very well and the willingness of staff to be involved insame was palpable during discussions. The assessor did at the time of the assessment compliment allinvolved in getting this system up and running and acknowledged the resources, support and workinvolved in setting this system up, and that the continuous support up to the assessment was obvious,and that given its forward prompting system should with management of same prove to be a veryvaluable asset to their management system.

The assessor noted during the tour that the facility has documented within its staff area’s items forconsultation and participation including notice boards, organisational chart, wellbeing programmes,courses available and recommendations including a recently published newspaper article whereby thestaff of the facility were published as local hero’s in the rescue of a gentleman within the pool facility.

The assessor reviewed the facilities Risk Assessment which is titled Premises General Risk assessmentdated 17/1/20, noting same as 5 x 5 criteria with risk rating as;

1 – 2 review as required8 – 3 monitoring required14 – 9 Action required asap19 – 15 Urgent action required25 – 20 Immediate action

The assessor noted the following risk assessment

Exercise reference rated as 12 with controls reduced to 4Changing rooms rated as 15 with controls reduced to 5Lifesaving rated as 16 with controls reduced to 8Chemical leak rated as 15 with controls reduced to 8Fire Extinguishers rated at 15 with controls reduced to 5Bouncy Castle rated as 20 with controls reduced to 8

All of the above were reviewed without issue. The assessor reviewed the training matrix for the facility noting all training was in date, however, theassessor suggests that the organisation would benefit by reviewing the matrix to include review datesand include within the matrix N/A as appropriate where training is not required. Please refer to OFI.


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The assessor noted that the organisation has maintained updated and reviewed their existingprocedures to comply with ISO 45001;2018. The assessor sampled during the assessment the following

Accident/Incident reportingCommunicationDocument controlEmergency ResponseFire safetyFirst AidLegal and other requirementsManagement ReviewNon conformanceObjectives and targetsPremises Risk AssessmentRisk AssessmentStatutory InspectionTrainingCorrective and preventive actionMonitoring and measurement matrixAudits and InspectionsContractor Appointment and ControlPermit to Work

The assessor reviewed all of the above without issue. The assessor noted that the organisationmaintains a suite of forms which include amongst others the following;

Contractors code of conductCommunication LogConstruction site inspection recordContractor assessment formCHS update templateCOSHH registerCOSHH assessment formDriver declaration formNew and Expectant Mothers Risk Assessment TemplatePermit to workPoint of Work Risk Assessment FormPPE issue record

The assessor suggests that the organisation would benefit by reviewing forms that are issued on alocalised basis to confirm that all old / obsolete forms are being removed completely from the system. Please refer to OFI. The assessor met with Mary McLaughlin – HR Assistant and reviewed the organisations Online learningsystem which includes amongst others the following:

Manual handlingFire awarenessDisplay screen equipmentH&S awareness.

Alongside E learning session, if safety group receive any additional relevant information i.e. in pdfformat this can be uploaded onto same. Because the organisation is aware that all staff do not go oneLearning system the organisation have launched “Bewell” programme, which is available on theintranet. On discussion approx. 90% of office staff use this system. HR are currently going through aprogramme for those without email to access eLearning with the addition of computers within theseareas. In terms of Health and wellbeing and Bewell it does sit within all the agendas, within theorganisation. In the last 12 months there has been a significant increase with non office staff in theparticipation of Bewell. Template from meeting is communicated to all staff, with details of courses,times, requests for items to be included within programme, including a survey monkey. The assessor was informed that the following courses form part of BeWell programme:


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Introduction to mindfulness followed by 6-week programmeLink and learn – changes to GCSE gradingCancer awareness – breast, prostate and reducing risk via endocrine system12 weeks choose to lose programmeNutrition for health workshopFinancial wellbeingIn house exercise programmeChoirGive it a grow – veggiesChristmas wreath workshopNatter – knit, crochetWellbeing for managers – stress awarenessKnow your numbers (Health checks)

Another programme being run through HR is Sustrans, this is a charity, staff not direct employees oforganisation to promote programmes throughout district and work along with public health – purposeis to promote sustainable active travel ( strand road, Strabane office looking at staff location V’s worklocation – encouraging staff to use alternatives to car transport) annual active travel challenge withinthe regional area.Other occupational activities/ benefits within the organisation include the following;

C25KWorkplace alcohol and drug training – referring to organisation policiesHosted mental health first aidOn site Yoga – Guild HallStaff engagement event – annually (health and wellbeing fair – physio)Health care cash play which staff can chose to make VC and family members can be added to. Inspire – telephone counselling and 6 free sessions.250 staff attended staff engagement – meet and greetMENOSPAUSE awareness sessionOccupational health nurse and doctor available to staff by appointment.

The organisation carried out a Monkey survey January 2019 through HR and noted that 63% saidBewell activities have impacted on their lives in a positive way, this survey also asked

What to be includedReasons for not getting involvedHow do you wish to be communicated with

All of the above was reviewed without issue.


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OPPORTUNITIES FOR IMPROVEMENT

OFI No.: OFI37138

Clause/Control: 9.3 - ISO 45001:2018 - Management Review

Observations:

The assessor suggests that the organisation would benefit by reviewing both the procedure formanagement review and the agenda so that both mirror each other.

Category: OFI

OFI No.: OFI37140

Clause/Control: 8.1 - ISO 45001:2018 - Operational Planning and Control

Observations:

The assessor suggests that the organisation would benefit by reviewing the identification of PPErequired when entering / working in the plant room, with possible use of visual indicators for staff andor contractors.

Category: OFI

OFI No.: OFI37141

Clause/Control: 7.2 - ISO 45001:2018 - Competence

Observations:

the assessor suggests that the organisation would benefit by reviewing the matrix to include reviewdates and include within the matrix N/A as appropriate where training is not required.

Category: OFI


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OFI No.: OFI37142

Clause/Control: 7.5 - ISO 45001:2018 - Documented Information

Observations:

The assessor suggests that the organisation would benefit by reviewing forms that are issued on alocalised basis to confirm that all old / obsolete forms are being removed completely from the system.

Category: OFI


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SUMMARY

Conclusion

On the basis of the evidence identified above, the assessor has determined that the client’s

management system continues to meet the needs of the organisation and conforms to the

requirements of OHSAS 18001:2007, ISO 45001:2018.

It is the recommendation of the Lead Assessor to the Certification Manager of Certification Europe that

Derry City & Strabane District Council be approved for Migration.

Confidentiality

Certification Europe maintains strict confidentiality with regard to client technical and commercial

information and all details relating to the assessment and certification process, including all Assessment

Reports. Please ask for our confidentiality policy statement should you require further details.

Signed on behalf of Certification Europe

Mary Coyle

Lead Assessor

Date: 1st January 2020


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ASSESSMENT PLAN

Client Details

Organisation Name Derry City & Strabane District Council

Management Representative Oonagh O'Doherty

Assessment Plan (V1.0)

Type of Assessment Surveillance

Standards (Criteria) ISO 45001:2018

Objective

To confirm the extent of conformity of the system to the Management

Systems ISO 45001:2018, to evaluate the capability of the management

systems, to ensure conformity to statutory, regulatory and contractual

requirements, to identify potential OFI and to evaluate the effectiveness of

the system to achieve organisational objectives.

Location(s)


Guild Hall / Alley Theatre, Derry, Northern Ireland

Date of Assessment 29th and 30th April 2020

Number of Days of

Next Assessment2

Assessor Mary Coyle

Technical Expert None


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Day

Clause

Activity

Time

Auditee

1

Opening Meeting Audit Process Findings Appeals and Complaints Audit Plan

9.30

Management Team

1

4.1, 4.3,5.2, 5.4

Context of the organisation, Leadership &Worker Participation and consultation,

10.00

1

6.1.1,6.1.2,6.1.3,6.2

Planning, Risks and Opportunities,Objectives

11.30

1

9.1, 9.2,9.3

Management Review, Internal Audit andPerformance Evaluation

12.00

Assessor Review

12.45

Lunch

13.00

1

7.1, 7.2,7.4

Support, Competence, Awareness andCommunications

14.00

1

8.1.1,8.1.4.8.2

Operation Control, EmergencyPreparedness

15.00

1

Summary Meeting

16.30

Management Team

Day 2

2

Opening Meeting and Recap on Previous day

9.30

2

8, 7,

Site Tour – Guild Hall / Alley Theatre

10.00

2

Lunch

13.00

2

Review of Documents from Site Tour

14.00


of 22

2

10.1,10.2

Improvement, Incident, Nonconformanceand corrective action.

15.30

2

Assessor Review

16.30

2

Summary Meeting

16.45

Management Team