OHST 88-2023-A5 UNIAC Audit Report UoM - Health and Safety 2022-23 Final IA Report 10.07.14

OHST 88-2023-A5
Internal Audit Report of Health and Safety

October 2023
1. Executive Summary
Overall Conclusions* Summary of Findings by Risk Rating*
Risk Assurance Limited Total Number of Findings: 6
High Moderate Low Advisory

Efficiency & Economy Limited
2 3 1 -
Benchmark Assessment Behind Norm
* See Appendix C for Conclusion and Risk Rating Descriptions
1.1 Audit Context

The University has seen a return to pre-covid levels of health and safety related events. During August 2019 – February 2020 there were 365
reported events and for the same period in 2022/23 there were 368 reported events. During the last two academic years, the numbers have
continued to go in an upwards direction and incidents are becoming more significant in terms of accidents and near misses. There could be a
number of reasons for this for example, with more shared spaces (including labs), there may be confusion around health and safety
responsibilities, and there are less staff on campus (since pre-covid) meaning less oversight. The first line of defence is provided by local
operational arrangements by the faculties and directorates, and the second line of defence is provided by Central Safety Services. The local leads
have a slightly different focus and the faculties have different risk profiles meaning that there is some variation required across the University in
terms of health and safety management. It is important that there is clarity for health and safety, consistency in policy and process where
possible, and a joined-up approach across the University to ensure the future reduction of events.
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1.2 Conclusion
Whilst the return to pre-Covid levels of health and safety related events was the underpinning rationale for this audit, it is clear that it is a multi-factorial issue.
In the process of analysing the possible contributory factors, we have reviewed health and safety structures and governance arrangements to identify gaps and
control weaknesses that may be contributing to increased levels of health and safety related events. In addition to our review of documentary evidence and audit
sample testing, we have considered qualitative feedback from staff. During the audit fieldwork we met with a total of 39 staff from across the University in a
variety of roles, including dedicated Health and Safety staff, technical staff, academics and PIs. We have triangulated all of the information gathered to identify
common themes which we have incorporated into the audit findings.
We conclude with limited assurance on the overall management of health and safety related risks. We have raised high risk findings in relation to the clarity of
roles and responsibilities for health and safety management and in relation to the management, recording and monitoring of mandatory health and safety
training to ensure that the University is meeting its statutory requirements. As the University operates a devolved structure for health and safety management,
there is a high degree of variation across faculties and departments. We have identified areas of good practice where controls are well designed, however there
are also some areas where improvements to the control framework are required. Specifically, level one lines of defence could be strengthened by ensuring that;
where possible, local arrangements are aligned with the organisational health and safety arrangements, that roles, responsibilities and accountability for health
and safety management are clear and well understood, that there is appropriate representation at local Health and Safety Committees and that there are
adequate controls in place to measure and report on health and safety staff training and competencies. Level two lines of defence could be strengthened by
enhancing the schedule of Central Safety Services inspections and more robust action tracking in relation to the follow-up of inspection recommendations.
There are opportunities to improve process efficiency and reduce duplication of effort for example, by implementing mechanisms to support cross-faculty
collaboration and joint-working. The University should also consider strengthening the third line of defence by considering where further external assurances
can be sought.
The University Health and Safety Policy and organisational arrangements set the framework for health and safety management across the University. We have
observed elements of deviation from the organisational arrangements in terms of job titles, job descriptions and line management for health and safety staff.
With the devolved arrangements for health and safety management, there is a risk that local health and safety arrangements may deviate further from the
organisational arrangements. The advent of Covid and hybrid working have also amplified the weaknesses in the health and safety management control
environment in terms of roles and responsibility and ownership. Furthermore, this audit has been conducted at a time when the University has experienced
significant organisational change. Continuity is an issue, with an unprecedented level of senior management changes across the University, voluntary
redundancy resulting in the loss of experienced staff and restructures of faculties, health and safety teams and technical staff. In the FSE, the moves connected
to MECD have also brought about significant changes in processes and ways of working. These changes have impacted on staff capacity, specialist knowledge
and the clarity of roles and responsibilities for health and safety.
There is an established governance framework in place to ensure health and safety management across faculties, schools and departments. The University
HSWC is supported and represented by a number of specialist Advisory Groups; Occupational Health, Safety and Training Advisory Group (OHSTAG), Radiation
Safety Advisory Group, Rose Safety, Environment and Security Committee, Fire Safety Advisory Group, Genetic Modification and Biohazards Safety Advisory Group,
Safeguarding Advisory Group, Resilience Advisory Group and Mental Health and Well-Being Advisory Group.
We raise the following High Risk findings:
1. Roles, Responsibilities and Accountability. There is a need to improve the clarity of roles and responsibilities for health and safety management and
for improved accountability for academic staff. In some areas there has been a slight deviation from the University Health and Safety arrangements and
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a historical lack of two-way dialogue between the Compliance and Risk Directorate and faculties with regards to restructures, job descriptions and job
titles for health and safety staff. Staff feedback suggests that recent internal reviews of health and safety staff and technical staff have led to a lack of
clarity of roles and responsibilities. Staff feedback indicates that it is a challenge to ensure ownership and accountability of staff in health and safety
management roles. See finding 2.
2. Health and Safety Training. There is a need to clarify where health and safety training sits in terms of management and co-ordination, and to improve
the recording and reporting of mandatory and statutory health and safety training to ensure that the University is meeting its statutory requirements.
There is a gap in terms of the provision of specific line manager training in health and safety management and for a formal approach to identifying
training needs. See finding 6.
We also raise moderate findings in relation to health and safety governance and data recording and reporting, and one further low risk finding in relation to
Communication, Collaboration and Sharing Best Practice and Lessons Learned.
During fieldwork, concerns were raised regarding specialist RSU support, however, we did not meet with anyone from the Unit. Management advised that the
University is currently recruiting to two posts in RSU to increase the capacity and competence of the team. In order to provide a greater level of assurance around
radiation safety, the Director of Compliance and Risk requested UKHSA to do a third line audit of radiation safety compliance, which concluded that appropriate
arrangements were in place. The UKHSA action plan is being monitored through the Radiation Safety Advisory Group and reported to the University Health, Safety
and Wellbeing Committee (HSW). Assurance has also been sought for Uniac to review this more widely with an audit of the Carriage of Dangerous Goods
included in the 23-24 audit plan.
During the review, we identified the follow areas of good practice:
+ Monitoring Reports - School monitoring reports are reported quarterly to the Faculty Health and Safety Committees. Faculty Monitoring Reports are produced
annually and contain the Faculty Health & Safety Risk Profile and Risk Control Strategies. These annual Health and Safety Monitoring Reports are reported to the
Occupational Health, Safety and Training Advisory Group (OHSTAG) which reports to the University Health, Safety and Wellbeing Committee.
+ Reporting to Leadership Team Meetings – There is reporting of issues from School Health and Safety Committees into School Leadership Team Meetings.
+ Oversight of Risk Assessments – In the FSE and FoH, they are currently developing an online risk assessment approval process in SharePoint. The Risk
Assessment is uploaded and the supervisor approves and it thereafter goes to the safety team for verification. Whilst it is recognised that there will be a need for
some risk assessments to be more dynamic in nature, this is good practice in terms of consistency of review, oversight and for generating a central repository of
risk assessments.
Appendix A provides the risks and controls assessed within the scope of the review and Appendix C highlights findings by key assurance areas. During the
course of this audit, some health and safety related concerns have arisen that sit slightly outwith the audit scope. As we deem these issues to be potential risks
to the University, we have collated them into a separate appendix (Appendix E) for management. To help inform this audit, we contacted five Russel Group
universities to participate in benchmarking in relation to health and safety. Where relevant have weaved the benchmarking information into this report.
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2. Key Findings The findings from our review are below, see Appendix C for our Finding Grading Definitions.
# Finding Risk Proposed Management Action Management Response

Rating (including Action Owner and Date)
1 Contributory Factors Moderate

From our analysis of health and safety event data and 1.1 Management should take action to
discussions with staff (See analysis at Appendix B), we have minimise the impact of hybrid
Central Faculty
identified that the following factors are likely to be contributing working on supervision in Professional Level
to the increase in health and safety related events: laboratories/technical areas. This Services
could include: Having in place formal
arrangements for hybrid working for  
1. Reduced supervision in labs/technical spaces due to
supervisors to ensure appropriate
hybrid working. See proposed action 1.1.
coverage on-site when required. Owner: Head of Planning
2. Reduced practical experience of students due to Covid Ensuring the appropriate delegation Compliance and Governance
lockdown. See proposed action 1.1 of supervisory duties when (FMBH), Head of Planning,
3. Increased use of Shared Labs/Technical Areas. See supervisors are not on site. For Compliance and Special Projects
Proposed action 1.3. example, if delegating supervisory (FSE), Head of Planning,
4. Organisational restructures and Voluntary Redundancy duties to PHD students and PDRA’s,
Compliance and Governance (FoH),
have left gaps in knowledge and experience. See proposed supervisors should ensure that they
with support from the Head of
actions 2,4 and 2.5. are fully competent to supervise.
This should include; training on Safety Services.
5. It is possible that an increase in reporting has
experiments, amending Date: April 2024
contributed to the increased levels of reported events,
experimental complexity where
however it is difficult to quantify this. We looked at levels
required, equipment, risk
of near miss reports and these are relatively low in
assessments, awareness of SOPs,
comparison to total numbers of events, which could
observations to assess knowledge
indicate that near misses are not being fully reported,
and competency, and formal sign-off.
therefore opportunities to prevent future accidents may
be missed. Feedback from staff suggests that there is a
known issue with under reporting in relation to the
student community. (see action point 4.1)
Reduced supervision due to hybrid working was the most

frequently stated contributory factor for the increase in health
and safety related events. This is not the case across all
faculties, for example in the FoH, labs are managed by technical
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staff who are on site five days per week. Feedback also suggests
that prior to Covid, many academic supervisors were often off-
site due to work related travel and meetings. Academic
supervisors delegate supervisory duties to PHD students and
PDRA’s. During Covid there was reduced exposure to practical lab
work, meaning that the PHD students who are
training/supervising undergraduate students, are now less
experienced than they would have been pre-Covid. There are
pockets where the risk is higher and there is no formal
consistent approach for the delegation of supervisory duties to
ensure those being delegated to are clear on their roles and
responsibilities and are suitably competent. See proposed action
1.1.
1.2 For supporting roles, for example fire Central Faculty

We contacted five Russell Group Universities to ascertain if they marshals and first aiders, the Professional Level
had experienced an increase in incidents post-Covid. Of the three University should consider Services
institutions that responded, one stated that they had developing local registers to record
experienced a notable increase in incidents post-covid, and that  
the days that they work on-site. This
they assessed that it was due to the impact of lockdown on work would help identify gaps and areas
and learning and the change in terms of hybrid where additional coverage is Owner: Head of Planning
working/presence on campus. required. Compliance and Governance
(FMBH), Head of Planning,
Hybrid working is also impacting on the availability and 1.2a Consideration should also be given Compliance and Special Projects
coverage of supporting health and safety roles such as first to incentives to attract staff into (FSE), Head of Planning,
aiders and fire evacuation marshals. Post-Covid it has been these voluntary roles. Compliance and Governance (FoH),
difficult to recruit into these voluntary roles, and where people with support from the Head of
are already in the roles, it is not always known when they are on- Safety Services.
campus due to hybrid working. See proposed actions 1.2 and 1.2a.
Date: April 2024
The University is recruiting more international students and
staff advised us that in particular, within Chemistry there are
challenges in terms of monocultural labs. These students have
been trained in a culture that is not UK centric in terms of health
and safety and there are challenges in terms of language barriers
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therefore it is crucial that appropriate support is provided to 1.3 The FSE should consider providing Central Faculty
ensure that health and safety requirements are clear and additional health and safety training Professional Level
understood. We were also advised that there are more students for students in monocultural labs Services
with non-chemistry first degrees doing PHDs in Chemistry and and for Chemistry students with
 
these students may not have had the same level of practical lab non-chemistry degrees and test their
exposure as students who have first degrees in Chemistry. See understanding of health and safety
proposed action 1.3. requirements. Owner: Chemistry Head of
Department
There has been a long term shift in practice towards the use of Date: April 2024
multi-disciplinary shared laboratories and workspaces. This has
been a gradual evolution which has led to a dilution and
deterioration of supervision in these environments which has
been amplified by the recent round of voluntary redundancy,
restructures and hybrid working. From our discussions with
staff, in some areas there appears to be a perception that
technical staff should take responsibility for shared lab areas. In
Engineering where there are the most shared labs, they have
been revising Health and Safety guidance and looking at
additional responsibilities such as lab manager responsibilities
to co-ordinate the shared labs. The Safety Compliance and Risk
Manager was involved in a number of conversations on the final
design of MECD and how the different spaces would work
operationally. It was specifically requested that there should be
policies around shared labs and ensuring supervision of spaces
in moving to smaller footprint had greater utilisation.
Management advised that they didn’t want to be too directive
and wanted to empower colleagues, however in some areas this
worked and in others it didn’t. In Engineering this is now being
looked at as part of the review of health and safety guidance.
In recent years, the Head of Safety Services proposed that a

‘champion’ be identified in shared areas to help co-ordinate
communication. This was put into guidance however wasn’t
mandated and hasn’t been adopted in practice.
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We were advised that for one multi-disciplinary shared area (the 1.4 The University should take a formal Central Faculty
dry lab within FSE), a community of practice was formed, approach to the management of Professional Level
involving academic leads and technical leads to work out health and safety in shared multi- Services
ownership and responsibilities. See proposed action 1.4. disciplinary laboratories and  
technical spaces. This should
The University has lost a number of experienced staff through include forming Communities of
voluntary redundancy and new staff have joined the organisation Practice so that there is a formal Owner: Head of Planning
during and post-Covid. Staff advised that there has been a loss collective agreement on roles and Compliance and Governance
of organisational memory with previous arrangements not responsibilities for health and safety (FMBH), Head of Planning,
always being clear and documented. This has created gaps, management including supervisory Compliance and Special Projects
impacted on staff capacity and on the clarity of roles and duties and responsibility for (FSE), Head of Planning,
responsibilities. See proposed actions 2.4 and 2.5.Feedback from equipment. Compliance and Governance (FoH),
management provides that some areas have actively with support from the Head of
encouraged the reporting of near misses and minor incidents so Safety Services.
increases in health and safety related events may be linked to Date: August 2024
improved reporting practices, however it is difficult to evidence
this. There is variation in the safety cultures across disciplines
and departments and varying perspectives of who is responsible
for safety. See Finding 2.
2 Roles, Responsibilities and Accountability High

The University Health and Safety Policy and organisational
arrangements sets a standard framework for Health and Safety
related positions, however we note that there has been some
deviation from this. It is acknowledged that there may be some
variation depending on the nature of the role and area of work,
however local arrangements should broadly reflect the University
arrangements.
Our audit testing confirmed that the job descriptions for safety
advisors broadly follow the model roles set out in the Health &
Safety Arrangements, however there are additional duties
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included in some areas e.g., in the FoH it includes an Estates

Manager aspect to the role. In other areas, the local safety 2.1 The University should review the job Central Faculty
advisor role is not written in to the job description, for example titles for Safety Advisors with a view Professional Level
in the Student Experience Directorate, the local Safety Advisor to improving alignment and to Services
role is an add on and there is no monetary aspect to it. clearly reflect their responsibilities
 
for health and safety.
We noted that there is variation in job titles and job
descriptions for safety staff across faculties and directorates Owner: P&OD (Neil Chamberlain) in
across grade, 5, 6 and 7 posts. As an example, the variation in the consultation with the Head of
grade 6 posts job titles is as follows: Safety Services. To be implemented
by the Head of Planning
Compliance and Governance
• FoH – Compliance Safety and Estates Manager
(FMBH), Deputy Director of Faculty
• FMBH – School Compliance and Risk Manager Operations and Head of Planning,
• FSE – Health, Safety and Compliance Advisor. Compliance and Special Projects
(FSE), Head of Planning,
• Directorate for Student Experience – Health, Safety and
Compliance and Governance (FoH),.
Compliance Officer
Date: August 2024
Staff feedback suggests that these job titles are causing

confusion and that staff are not always clear who to go to if they
have a health and safety related problem. Feedback also 2.2 The University should consider that Central Faculty
suggests that the ‘compliance’ aspect of the safety advisor job line management for Safety Advisors Professional Level
title is creating a perceived bridge rather than it being viewed as is in line with the University Health Services
a supportive/advisory role. See proposed action 2.1. and Safety Arrangements. Faculties
 
should clarify their arrangements
using the Health and Safety
We also noted variation in the job titles for faculty Senior
Organisation Chapter as a starting Owner: Lead by the Head of Safety
Managers with responsibility for health and safety and variation
point. Services in consultation with P&OD
in reporting lines for example, the Compliance Safety and
Estates Manager in FoH is line managed by the Director of (Neil Chamberlain). To be
Faculty Operations rather than the Head of Planning, Compliance implemented by Head of Planning,
and Governance. This is a deviation from the University Compliance and Governance (FoH).
arrangements. See proposed action 2.2. Date: February 2024
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There has been no consultation with the Compliance and Risk 2.3 There should be a formal collective Central Faculty
Directorate regarding these job titles or job descriptions for at discussion and/or annual review of Professional Level
least five years so this is an historical lack of consultation and any further proposed changes to Services
roles e.g., senior managers are now firmly embedded. This ensure they do not deviate from the
 
increases the risk of further deviation from the University University’s agreed arrangements.
arrangements. See proposed action 2.3. This should be covered by the annual
review of the Organisational Owner: Head of Planning
Arrangements discussed at the Compliance and Governance
There have been significant organisational changes that have
Health, Safety & Wellbeing (FMBH), Head of Planning,
impacted on staff capacity and the clarity of roles and
Committee. Compliance and Special Projects
responsibilities for health and safety as follows:
(FSE), Head of Planning,
The University has lost a number of experienced staff through
Compliance and Governance (FoH),
voluntary redundancy, including the Deputy Head of Safety
and the Head of Safety Services.
Services meaning that experience and specialisms have been
lost. In addition, some new staff with safety roles have also Date: February 2024
joined the organisation during and post-Covid. Staff advised
that there has been a loss of organisational memory with
previous arrangements not always being clear and documented. 2.4 Finalise the FSE review of the Health
See proposed actions 2.4 and 2.5. & Safety team structure, capturing Central Faculty
roles & responsibilities across the Professional Level
Safety and new Technical teams to Services
ensure that the models are realising  
The Faculty of Science and Engineering (FSE) accounts for the planned benefits, any gaps are
largest proportion of health and safety related events across the suitably addressed and that
University; 38% (663) of total reported events between August specialist areas have appropriate Owner: Head of Planning,
2019 and April 2023. (See Appendix B). This is not surprising health and safety expertise available Compliance and Special Projects
given the profile of the faculty and the activities undertaken to support them. (FSE) with support from Head of
within the FSE in terms of laboratory and workshop related Safety Services.
activities. However, the FSE has seen the biggest relative Date: March 2024
increase in health and safety related events post-Covid, with
events in the faculty almost doubling between 2019/20 and
2022/23 (from 119 to 227). Management advised that at the last
OHSTAG it was reported that 30% of FSE reported incidents were
Estates related issues. Within FSE there has been a restructuring
of the faculty, an ongoing review of the health and safety
advisors, a technical review and changes connected with the
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MECD bringing about changes to processes and ways of 2.5 The University should review Central Faculty
working. Feedback suggests that the combination of these organograms to clearly show the Professional Level
factors has given rise to a lack of clarity of roles and responsibilities for health and Services
responsibilities for health and safety management in the faculty. safety management at local level
 
See proposed action 2.4. and ensure they are communicated
appropriately.
In the FSE they are currently reviewing the structure of the Health Owner: Head of Planning
and Safety team in order to provide greater resilience. Compliance and Governance
Management advised that they are in the process of assigning (FMBH), Head of Planning,
the work. Safety Advisors are being brought in from the Schools Compliance and Special Projects
into a faculty safety team with specialist themes. Feedback from (FSE), Head of Planning,
staff is that this move may create greater distance between the Compliance and Governance (FoH),
safety advisors and the schools and departments. Management with support from the Head of
advised that the proposal is that each department/disciplinary Safety Services.
area will still have defined points of contact for health and Date: April 2024
safety. Structurally the teams haven’t moved, however before
MECD the staff were more spread out and physically based in a
departmental building so the moving to a central location may
have created a perception of a physical barrier.
Feedback also suggests that there are possible disconnects

between Institutes and the Faculty in terms of who is
responsible for what and who reports to who. Feedback from
Research Institutes is that whilst the Directors have
responsibility for health and safety, and the Institutes are
provided with a Health and Safety Advisor., previously they had
dedicated staff within the department/research institutes that
had technical knowledge and understood health and safety
within that area of specialism/lab. The Health and Safety
Advisors still support the institutes they are affiliated to,
however there is a perception that this level of expertise and
support is no longer there. See proposed action 2.4 and
proposed action 3.3.
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A technical review in FSE has resulted in significant changes for 2.6 The University should ensure that Central Faculty
technical staff who now cover multiple areas according to there are clear and formal arrangements Professional Level
disciplines/specialisms and are no longer dedicated to one or in place to provide visibility of who is Services
two areas. Staff feedback suggests that there are gaps from the responsible for the ownership of
 
transition of technical staff from old role to new role and areas buildings. Consideration should be
where nobody is picking issues up. Management advised that given to reinstating Building User
there is a triage process through general safety staff to respond Groups which report in to the Health Owner: Head of Safety Services and
to specialist queries. and Safety governance structures. Head of Estates in consultation
with Head of Planning Compliance
and Governance (FMBH), Deputy
The Technical Review has consisted of 4 phases (Cohorts 1-4). It
Director of Faculty Operations and
is now at cohort 4 (Cohort 1 was completed 2 years ago). FSE is
Head of Planning, Compliance and
further ahead than FoH with technical review and FBMH don’t
Special Projects (FSE), Head of
have as many labs. A scope is being drafted for an evaluation of
Planning, Compliance and
the technical review, however the evaluation metrics were not
Governance (FoH).
agreed at the outset so they are working on agreeing the baseline
and assessing what data is available. Date: April 2024
Feedback from Central Safety Services in relation to recent work

on building decommissioning has highlighted that it is not clear
who is in control of University buildings. See proposed action 2.6.
Accountability and ownership for health and safety came across

as an area of concern during our discussions with staff. This
links to the need for clear training on roles and responsibilities 2.7 The University should consider Central Faculty
for those with health and safety management roles e.g., PI’s and reviewing the appraisal process and Professional Level
promotion process to ensure that all Services
academic leads. We noted that governance arrangements were
depicted in organisational charts, however there were no staff with a health and safety  
organograms to clearly show the responsibilities for health and management role are held accountable
safety across the University and at local level. See proposed for their health and safety
actions 7.2, 7.3, 7.4 and 3.5. responsibilities. Owner: P&OD (Neil Chamberlain)
with the Head of Safety Services.
Date: October 2024
The appraisal process is not mandatory and feedback suggests
that it doesn’t focus on broader health and safety management
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responsibilities therefore there is a gap in terms of the

accountability of staff in health and safety management roles.
See proposed action 2.7.
3 Health and Safety Governance Arrangements Moderate
Health and Safety Committees are established and meeting at 3.1 The University should consider Central Faculty
faculty, school and department level. The Faculty Health and reviewing the remit and Professional Level
Safety Committees report into the Occupational Health Training membership of the Mental Health Services
Advisory Group (OHSTAG) which reports to the University Health and Wellbeing Advisory Group.
MHWAG 
Safety and Wellbeing Committee (HSWC).
There may be a need to look at the role and remit of the Mental Owner: Chair of Mental Health and
Health and Wellbeing Advisory Group and how it fits into the Wellbeing Advisory Group. Terms of
HSW Governance Structure. The membership of the Mental Reference to be sent to HSW
Health and Wellbeing Advisory Group does not include Committee for review.
Occupational Health or Health & Safety representatives. From Date: February 2024
our review of the HSW minutes, we observed that the Mental
Health and Wellbeing Advisory Group did not meet between
3.2 Management should review the Central Faculty
March 2022 and February 2023. See proposed action 3.1.
standing agenda items for Faculty Professional Level
and local Health and Safety Services
The faculty committees are as follows: Committees to ensure there is
 
• FoH – Compliance Committee alignment with the organisational
arrangements and that key issues
• FBMH – Faculty Health, Safety & Wellbeing Committee such as health and safety training Owner: Head of Planning
(HSWC) and inspections are regularly Compliance and Governance
• FSE - Health, Safety and Wellbeing Committee (HSWC). included on agendas. (FMBH), Head of Planning,
Compliance and Special Projects
We reviewed agendas and terms of reference for the three (FSE), Head of Planning,
Faculty Committees and a sample of School level committees Compliance and Governance (FoH).
and identified the following: Date: January 2024
• At local level there is good coverage of standing agenda
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items, however there could be better alignment with 3.3 Heads of Departments / Schools Central Faculty
University suggested agenda items and with agenda should communicate to all Professional Level
themes discussed at Faculty Committees to ensure a members of the Health & Safety Services
‘golden thread’ approach and that key items are not Committees that attendance at the
 
missed. See proposed action 3.2 meetings should be a priority.
• From our review of meeting minutes, we did not identify
any issues in terms of low attendance, however Owner: Head of Planning
management feedback suggests that attendance is not Compliance and Governance
always sufficient at local committees and there is a need (FMBH), Head of Planning,
to raise the profile of the meetings and make it a priority Compliance and Special Projects
for people to attend. See proposed action 3.3 (FSE), Head of Planning,
Compliance and Governance (FoH)
with support from Dean/Deputy
• We noted that Health & Safety Training and Inspections Dean/DoFO where required
were not included as standing agenda items on all
Date: December 2023
meetings and there is disparity in terms of how the local
and faculty level committees track actions and
improvement plans. See Finding 4.1. We would expect
Health and Safety Training to be regularly discussed at
Committees, however this may be linked to the reporting
issues highlighted at proposed action 7.1. 3.4 Management should take steps to
• The Terms of Reference (ToR) for the FMBH Faculty HSWC ensure there is appropriate Central Faculty
does not provide standing agenda items and states that Professional Level
technical/PI/Researcher
Services
the meeting agenda will be generated by the Compliance representation at Health & Safety
and Risk Senior Manager. Committees.  
• At school level, there is inconsistency of technical Owner: Deans, Head of Planning

representation at School Health & Safety Committees. Compliance and Governance
Feedback from staff discussions is that some PIs and (FMBH), Head of Planning,
technical managers are not involved in Health and Safety Compliance and Special Projects
Committees and that they are not receiving (FSE), Head of Planning,
communications/information from Faculty Health and Compliance and Governance (FoH).
Safety Committees and that this is a gap in terms of Date: December 2023
reporting and receiving information. Management
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feedback also suggested that there should be more 3.5 Engineering (FSE) should prioritise Central Faculty
researcher representation at the meetings as it is the finalisation of governance Professional Level
important there is representation from people who are reporting arrangements for health Services
working in the labs. See proposed action 3.4 and safety under the new structure
 
and ensure that any reporting gaps
are sufficiently addressed.
• There are local variations in terms of how Committees
are structured e.g., in FBMH there are 18 Divisional Health Owner: Head of Planning,
& Safety Committees reporting in to the Faculty level Compliance and Special Projects
meeting. In FSE the School of Natural Sciences has (FSE).
departmental Health & Safety Committees and all five Date: December 2023
institutes have their own Committees. In Engineering the
Committees at departmental level have been disbanded
and replaced with a new single School Health & Safety
Committee with sub-groups by discipline reporting into
the School Committee. Management advised that there
is still work to be done on the governance reporting
arrangements. They have gone from four departments to
seven departments and there is a challenge in terms of
how they get things reported to the School Committee
and to the departments under them. This has been
ongoing for the past year and needs to be worked out to
ensure there are no reporting gaps. See proposed action
3.5.
There is a potential gap in terms of the consideration of

/consultation on Health & Safety issues in the decision making
processes for projects and restructures. During our discussions
with staff the following projects were highlighted whereby health
and safety arrangements/responsibilities did not appear to form
part of the initial planning considerations;
1. FoH Doctoral academy. – This used to be local PGR/PGT but

now all brought together under one umbrella. Since January,
there’s been an urgency via Task and Finish Groups to clarify
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policy, roles, responsibilities and processes for health and

safety as this was not considered from the outset.
2. MECD – Given a lack of clarity in relation to the original 3.6 Management should ensure that
business cases for MECD, implications for health and safety there is consideration /consultation
arrangements were not considered early in the decision Central Faculty
on health and safety issues built in Professional
making process. Management advised that a 3 year Level
to the decision making process for Services
evaluation programme for MECD will be launched this year to major projects and restructures,
ensure lessons are learned. The Steering Group for the and that these issues are picked up  
evaluation starts in September with lessons learned being by Health & Safety Committee
fed into the Finance Committee and OHSTAG. agendas.
Owner: Head of Planning
Compliance and Governance
We would expect significant projects and restructures that (FMBH), Head of Planning,
impact on health and safety arrangements to follow a formal Compliance and Special Projects
business case approach and to flow through the relevant Health (FSE), Head of Planning,
and Safety Committee agendas. See proposed action 3.6 Compliance and Governance (FoH),
with support from the Head of
Annual safety inspections are carried out by Safety Advisors. The Central Safety Services.
methodology and scheduling approach for local health and Date: April 2024
safety inspections is not formally documented in procedures.
There is also no consistent approach to reporting outcomes and
3.7 Management should ensure that Central Faculty
actions to the School Health & Safety Committees and reporting
the scheduling/coverage of local Professional Level
of inspection activity and actions is not considered mandatory
inspections is risk based and Services
in all areas. See proposed action 3.7
arrangements for the reporting of  
Safety staff have expressed concern around the robustness of inspection activity/actions through
the HASMAP self- assessment process. Feedback also suggests Health & Safety Committees is
this self-inspection approach can be viewed as a ‘tick box’ aligned with the Health and Safety Owner: Head of Central Safety
exercise and there are differing levels of engagement with the Committee Arrangements Chapter. Services
process across the faculties. From our review of HASMAP
evidence we noted that there is a lack of evidence in some areas Date: February 2024
to demonstrate why they have self-assessed as being 100%
compliant. See proposed action 3.7.
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The Central Safety Services (CSS) team have a role in level two Central Faculty
assurance and there is a need for CSS to pick up a proportional 3.8 Central Safety Services should build Professional Level
amount of audits to provide level two assurance for the on and enhance the current Services
organisation. Competing demands and staff capacity challenges schedule of audit activity in order to  
have recently impacted on the amount of proactive work provide increased coverage of level
undertaken by CSS. We confirmed that some audit activity has two assurance for health and safety
been carried out by CSS in respect of HASMAP self-assessments management. Priority areas should Owner: Head of Central Safety
and there is schedule of audit based on the University work plan be agreed with faculties and the Services
for a co-ordinated audit in each area. The Director of Risk and schedule should be communicated Date: February 2024
Compliance advised that they intend to develop this in the near at local level to increase visibility
future. See proposed action 3.8. and awareness.
The first line of assurance is Schools/Faculty managers with Central Faculty

support from health and safety professionals. The second line of Professional Level
assurance is the Compliance and Risk Directorate alongside the 3.9 The University should review and Services
Health Safety and Wellbeing Committee (HSWC). External consider the level of external
assurance sought in relation to  
assurance is the third line of assurance (out with the regulatory
system). Internal audit is the third line of assurance, however health and safety management in
this is limited in that it is cyclical and there is currently no order to strengthen the third line of Owner: Director of Compliance and
annual cycle of internal audit activity in relation to Health and assurance and report to OHSTAG Risk
Safety to provide independent assurance. This leaves a gap in and HSW,
Date: February 2024
terms of the third line of assurance and the University may wish
to consider how it obtains sufficient third level assurance for
Health and Safety, for example, through external peer review.
See proposed action 3.9
4 Reporting, Recording, Tracking and Analysis Moderate 4.1 Consideration should be given to
The current approach to reporting and analysing incidents is implementing an online reporting Central Faculty
very manual and labour intensive and staff feedback suggests tool for health and safety related Professional Level
that this could potentially be a barrier to reporting. Currently events in order to remove barriers to Services
there is no online system for reporting incidents and they are reporting and improve efficiency.
 
reported on a form which is available on the staff intranet and This could include an automated
University website. The completed form is then attached to an dashboard to help enhance data Owner: Director of Compliance and
email to the Safety Services Team. In order to collate and insight, access to reports and to Risk
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analyse health and safety event data, information is thereafter reduce duplication of effort. It could Date: December 2024
‘double-keyed’ into databases.. There Is duplication of effort as also include alerts and workflows so
the data is analysed by different people centrally, at faculty and that there is robust oversight of
at local level. During our discussions with staff it became event categorisation, actions,
apparent that reports in relation to the analysis of health and progress with investigations and
safety related events are not always disseminated at a local level. dissemination of lessons learned.
The Head of Central Safety Services is currently working with IT

on developing an events database and work with IT on how to
migrate data.
Our benchmarking exercise and work with other HE institutions,

indicates that HE providers most commonly use an online
reporting system with automated reporting and dashboard
capabilities for health and safety data reporting.
5 Communication, Collaboration and Sharing Best Practice and Low 5.1 We agree with the formation of the Central Faculty
Lessons Learned cross faculty operational forum. It is Professional Level
recommended that a clear Terms of Services
Due to the federated nature of health and safety structures in the
University, faculties and schools tend to work in a silo approach. Reference be developed for the  
Opportunities to collaborate on solutions have been missed and group and that it has appropriate
faculties are tackling common issues in different ways and with ownership and membership,
different levels of resource. For example, work in relation to the including Central Safety Services Owner: Head of Planning,
development of local health and safety training and developing representation. We also recommend Compliance and Special Projects
SharePoint for managing risk assessments could have been that Health and Safety is a priority (FSE), Head of Planning Compliance
projects progressed in collaboration for a consistent approach standing agenda item on this group and Governance (FMBH), Head of
and to prevent duplication across faculties. Cross-faculty and that there are formal Planning, Compliance and
working (where possible) would help achieve efficiencies and arrangements for linking into the Governance (FoH) with the Head of
provide a mechanism for the sharing of best practice and health and safety governance Safety Services.
lessons learned. Management advised us that a cross faculty structure and for sharing best Date: March 2024
forum bringing together the faculty Senior Managers with practice.
responsibility for health and safety has recently been formed.
This is not a formally recognised committee and at the time of
the audit fieldwork, no terms of reference had yet been agreed.
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The approach to the dissemination of lessons learned varies 5.2 The faculties should consider Central Faculty
across schools and faculties. From our discussions with staff, implementing a formal process for Professional Level
some areas feel they do this well whereas others have nothing the sharing of lessons learned Services
formal in place to share lessons learned. There is a formal across faculties and schools.
 
process in place for sharing lessons learned via the OHSTAG,
however it has been identified that this is not operating as
effectively as it could be therefore OHSTAG has generated actions Owner: Head of Planning,
for schools to share information and a specific action for faculty Compliance and Special Projects
representatives to report back on what they have done around (FSE), Head of Planning Compliance
lessons learned.. Safety circulars are communicated in relation and Governance (FMBH), Head of
to serious events, however there is no formal mechanism in Planning, Compliance and
place to share lessons learned between schools and faculties. Governance (FoH) with the Head of
There is a risk that lessons learned are not being effectively Safety Services.
communicated at local level and that issues could reoccur
Date: March 2024
causing harm to students or staff. See proposed actions 5.1 and
5.2.
5.3 Consideration should be given to re-

Prior to Covid, safety staff networking events were run twice per introducing the twice yearly safety Central Faculty
year facilitated by Learning and Organisational Development. Professional Level
staff networking events. These
These events were for everyone with a health and safety role. Services
events should include all safety
Feedback from staff is that these networking events were useful staff including technical staff, PIs  
and should be reintroduced. See proposed action 5.3. and academic leads.
Owner: P&OD (Neil Chamberlain),
Our benchmarking exercise highlighted that, in addition to
with Head of Central Safety
routine governance reporting, HE providers are also using the
Services, Head of Planning,
following methods of communication and collaboration; alerts
Compliance and Special Projects
and notifications via Teams groups and emails, Departmental
(FSE), Head of Planning Compliance
Safety Co-ordinators networks and forums, an online advice
and Governance (FMBH), Head of
system where any member of staff can contact the health and
Planning, Compliance and
safety central unit to ask for advice and work collaboratively on
Governance (FoH).
any health and safety topic, intranet pages and posting health
and safety topics in the University digest. Date: April 2024
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6 Health & Safety Training and Competency Assessment High 6.1 Given the implications in terms of Central Faculty
potential non-compliance with Professional Level
It is currently very difficult for the University to demonstrate
statutory requirements and risks to Services
compliance with statutory and mandatory health and safety
training. There is no central learning management system for staff/student safety, the University  
recording and reporting training completion, and the current should review options to implement
approach is that data is collated manually at a local level for the LMS to ensure that compliance
annual reporting purposes. A new Learning Management System with statutory and mandatory Owner: Escalation to PSLT through
has been purchased by the University, however it is on hold due health and safety training can be Director of Compliance and Risk
to IT resource capacity challenges. The delivery of the LMS is formally monitored. If there is to be and Head of Safety Services
critical in terms of ensuring role specific training requirements further delay with delivery of the Date: TBC
that are delivered and auditable. Safety leads don’t have access LMS, the University should ensure
to ongoing lists of who hasn’t completed mandatory training.. that robust interim arrangements
We also note that there is no clear policy in terms of what the are put in place to provide the
consequences are if the training is not completed therefore it is information until such time as the
challenging to mandate training. See proposed action 6.1. LMS is implemented. It is also
recommended that policies relating
to statutory and mandatory Health
Previously there was a Health and Safety Training Co-ordinator and Safety training clearly articulate
post in Learning and Organisational Development. This role no the sanctions if this training is not
longer exists and it is currently not clear where the responsibility completed.
for the central co-ordination and management of health and
safety training sits. See finding 6.2. Currently there is no clear
strategy for health and safety training and the University is 6.2 The University should ensure that
unable to measure training compliance(See proposed action 6.2. there is an appropriate lead role for
health and safety training.
Central Faculty
From our benchmarking exercise, all HE providers who Professional Level
responded are using a learning management platform for the Services
recording and reporting of mandatory health and safety training.
 
Probationary arrangements state that the line manager should
ensure that all mandatory induction training (including health
and safety) is completed by the probationer, however it is not Owner: Director of Compliance and
clear to what extent this is followed up. Reports on induction Risk, Head of Safety Services and
training are collated manually and provided to OHSTAG by P&OD (Neil Chamberlain).
Learning and Organisational Development, however these merely Date: April 2024
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provide a completion rates and there is no information to state

who hasn’t completed the training. Some areas maintain a local 6.3 The University should ensure that
tracker of who has completed induction training, however there all line managers are aware of their
is no formal monitoring or reporting of this. See proposed action responsibilities to complete and
6.1 return the Health and Safety Central Faculty
Induction Checklist to the local Professional Level
Services
The University Health &Safety Policy states that a completed Safety Advisors.
Health & Safety Induction Checklist should be returned to the  
local Safety Adviser and Line Manager for checking and retaining.
These checklists do not appear to be used systematically and are
Owner: P&OD (Neil Chamberlain)
not being returned to the local Safety Advisors. Feedback
with Head of Safety Services.
suggests that some line managers are not aware of the
checklist. See proposed action 6.3. 6.4 The University should ensure that Date: January 2024
managers with responsibility for
health and safety attend the
Data is available for some courses that are co-ordinated
appropriate IOSH management
centrally by the Safety Services Training Co-ordinator. We Central Faculty
training and refreshers, where
reviewed manager health and safety training data covering the Professional Level
appropriate.
last three years) August 2020 - June 2023) for the following Services
courses:
 
• TLCA550 IOSH Managing Safely Online (41 staff completed)
• TLCA555 IOSH Managing Safely (0 staff completed – not
Owner: P&OD (Neil Chamberlain)
completed since pre-lockdown)
with Head of Central Safety
• TLCA551 IOSH Managing Safely Refresher (0 staff completed Services
– not completed since pre-lockdown)
Date: August 2024
6.5 At University level, health and safety
Management advised that these courses have not been available training should be developed for
post-Covid, therfore no staff have completed refresher training line managers (academic line
over the past three years which is an opportunity to remind managers, PI’s and PS line Central Faculty
people of roles and responsibilities. See proposed action 6.4 managers) to ensure they are made Professional Level
aware of their roles and Services
responsibilities for health and  
Annual Compliance updates are provided for senior managers safety management.
e.g., Heads of Schools. Heads of Departments), with 20 minutes
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on the agenda dedicated to Health and Safety. There is no Owner: P&OD (Neil Chamberlain)
specific health and safety training for line managers (academic with Head of Central Safety
line managers, PI’s and PS line managers) and new academic Services and managed through
staff. Feedback provides that it is not clearly pointed out to them normal line management and
what they have responsibility for. For example, someone may appraisal system.
come in as a new academic or PI and complete a general health Date: August 2024
and safety induction but there is no training on what their health
and safety responsibilities are. See proposed action 6.5.
We identified that there is a lack of awareness and engagement

6.6 The University should ensure that
in relation to the Competency Framework for Safety Advisors.
there is a consistent approach to
There is a strategic objective within the University Occupational
competency assessment and
Health and Safety Strategy in relation to the monitoring of the
identifying training needs for staff Central Faculty
application of the Safety Advisors Competency Development Professional Level
in health and safety management
Framework to ensure that relevant competent advice can be Services
roles, including academic line
provided at local level. See proposed action 6.6.
managers, PIs, and PS line  
There is an inconsistent approach to identifying health and managers. Monitoring of the
safety training needs. Some areas are in the process of building application of the Safety Advisors
a training matrix with essential and recommended courses for Competency Development Owner: Head of Central Safety
safety advisors, however most of the areas we engaged with Framework should be reported at Services, P&OD (Neil Chamberlain).
don’t have anything formal in place. Managers advised that it is faculty Health & Safety Committees. Date: April 2024
a very manual process and they have to collate training
information annually.
Feedback suggests that identifying staff health and safety
training needs doesn’t stretch far enough to include academic
line managers, PIs and other PS line managers. For example, 6.7 Formal training on risk assessment
where the checking and validation of risk assessments require should be provided for staff who
Central Faculty
in depth knowledge of techniques and technical expertise of prepare risk assessments and for Professional Level
senior academic colleagues. See proposed actions 6.5 and 6.6 supervisors to ensure they are Services
Supervisors need to be competent to sign off risk assessments. competent to sign-off risk
assessments.  
Risk assessment training is not consistent across the University.
Some areas have developed risk assessment training (e.g., FBMH
have risk assessment training in Blackboard) and some areas Owner: P&OD (Neil Chamberlain).
deliver toolbox talks, whereas others have nothing formal in
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place. There is also an online training module owned by P&OD, Date: August 2024
- Confidential - 21
Appendix A - Audit Background and Scope
A1. Scope
The contents of the following table provide a high-level overview of the key risks for the audit.
# Risk Risk Management Approach (i.e. Test Objective Summary of Findings

Controls)
1 Appropriate and timely action may 1. Health and safety events Review the analysis of H&S 1. Reports containing trend analysis of
not be undertaken (in a consistent formal reporting process. related events reported to H&S related events are reported to
manner) to address the increase in 2. Analysis and reporting of OHSTAG and HSWC to confirm the Occupational Health Training
events. For example, the potential quarterly health and safety that it contains a robust analysis Advisory Group (OHSTAG). The
impact of students with less events data to OHSTAG and and explanation of possible root reports contain a detailed analysis of
awareness of health & safety HSWC. causes. H&S related events data. No matters
expectations, changing roles of PIs 3. Induction training and ongoing arising
and staff with technical support training for students and staff 1. Carry out an analysis of pre-and 2. Refer to Appendix B
responsibilities, and multi- (See Risk 4) post-covid health and safety 3. The FSE has seen the biggest relative
disciplinary labs and shared 4. Competency Assessment related incident data to identify increase in health and safety related
spaces. 5. Risk Assessments patterns and trends that may events post-Covid, with events in the
help explain the increase in faculty almost doubling between
events. 2019/20 and 2022/23 (from 119 to
227). Within FSE there has been a
restructuring of the faculty,
restructuring of the health and
safety advisors, a technical review
and the MECD which has brought
about changes to processes and
ways of working. Feedback suggests
that the combination of these
factors has given rise to a lack of
clarity of roles and responsibilities
for health and safety management in
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Controls)
the faculty. See proposed action 2.4.

4. Reduced supervision due to hybrid
working was the most frequently
stated contributory factor for the
increase in health and safety related
events. This is not the case across all
faculties, for example in the FoH,
labs are managed by technical staff
who are on site five days per week.
Feedback also suggests that prior to
Covid, many academic supervisors
were often off-site due to work
related travel and meetings.
Academic supervisors can delegate
supervisory duties to PHD students
and PDRA’s. During Covid there was
reduced exposure to practical lab
work, meaning that the PHD
students who are
training/supervising undergraduate
students, are now less experienced
than they would have been pre-Covid.
There does not appear to be a formal
consistent approach for the
delegation of supervisory duties to
ensure those being delegated to are
- Confidential - 23
Controls)
clear on their roles and

responsibilities and are suitably
competent. See proposed action 1.1.
5. Hybrid working is also impacting on

the availability and coverage of
supporting health and safety roles
such as first aiders and fire
evacuation marshals. Post-Covid it
has been difficult to recruit into
these voluntary roles, and where
people are already in the roles, it is
not always known when they are on-
campus due to hybrid working. See
6. There has been a long term shift in

practice towards the use of multi-
disciplinary shared laboratories and
workspaces. This has been a gradual
evolution which has led to a dilution
and deterioration of supervision in
these environments which has been
amplified by the recent round of
voluntary redundancy, restructures
- Confidential - 24
Controls)
and hybrid working. From our

discussions with staff, in some
areas there appears to be a
perception that technical staff
should take responsibility for shared
lab areas. See proposed action 1.3.
2. Review the approach to reporting. 7. Currently there is no online system

recording and analysing health for reporting incidents and they are
and safety data to confirm it reported on a form which is available
ensures the integrity and on the staff intranet and University
timeliness of reporting. website. The completed form is then
attached to an email to the Safety
Services Team. In order to collate
and analyse health and safety event
data, information is thereafter
‘double-keyed’ into databases. There
Is duplication of effort as the data is
analysed by different people
centrally, at faculty and at local level.
2 Roles and responsibilities for 1. Health and Safety 1. Review the University’s Health 1. Roles and responsibilities are
managing health and safety may Policy/Arrangements and Safety Policy and documented in the University Health
not be clear leading to potential Chapters/Model Roles organisational structure to and Safety Policy within the
non-compliance, and risks to confirm that roles and Organisation and Arrangements
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Controls)
staff/student safety. 2. Statements of Intent responsibilities for health and Chapters. The Policy delegates the
3. Staffnet pages safety across the institution are responsibility for producing local
4. Job Descriptions clearly documented. policies to Deans of Faculty and
5. Competency Assessment (See senior managers. The H&S Policy
Risk 4) states that each Faculty/Directorate
should have its own H&S Policy
setting out the specific
organisational arrangements within
the Faculty/Directorate. At School
level, there should also be a local
H&S Policy/Statement of Intent with
the organisational arrangements for
each School/Unit. We confirmed that
Faculty and School level Health &
Safety Policies/Statements of Intent
are in place. No matters arising.
2. Feedback in some areas is that they
2. Interview key staff across the are unclear on who to contact for
three faculties to assess if their H&S advice. Feedback from staff is
roles and responsibilities are that responsibilities are only clear to
understood. those who know how the Health and
Safety network works, but they are
not clear to other staff. Job titles and
roles for safety staff are different
across faculties and some have
additional responsibilities meaning
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Controls)
that job titles are not clear. This is

leading to confusion around roles
and responsibilities for Health &
Safety. See proposed action 2.1
3. In the FSE they are reviewing the
structure of the Health and Safety
team. Safety Advisors are being
brought in from the Schools into a
faculty safety team with specialist
themes. Feedback from staff is that
this move may create greater
distance between the safety advisors
and the schools and departments, as
previously they were working with
the support and authority of the
Heads of Schools. Feedback also
suggests that there are possible
disconnects between Institutes and
the Faculty in terms of who is
responsible for what and who reports
to who. Feedback from Research
Institutes is that whilst the Directors
have responsibility for health and
safety, health and safety officers
have moved to the faculty level and
the Institutes are provided with a
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Controls)
Health and Safety Advisor. Previously

they had dedicated staff within the
department/research institutes that
had technical knowledge and
understood health and safety within
that area of specialism/lab. There is
concern this level of expertise and
support is no longer there.
4. A technical review in FSE has
resulted in significant changes for
technical staff who now cover
multiple areas according to
disciplines/specialisms and are no
longer dedicated to one or two areas.
Staff feedback suggests that there
are gaps from the transition of
technical staff from old role to new
role and areas where nobody is
picking issues up. There doesn’t
appear to have been any evaluation
of the technical review to measure
the impact/benefits and to identify
gaps and improvements. See
5. There is variation in job titles and job
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Controls)
descriptions for safety advisors

across faculties and directorates, for
example we confirmed that the
following job titles are used for the
School Safety Advisor (SSA) role:
• FoH - Compliance Safety and
Estates Manager
• FMBH - School Compliance and

Risk Manager
3. Assess where structures differ
• FSE - Health, Safety and
across faculties and identify any Compliance Advisor.
gaps and best practice. Where
local structures differ, confirm • Directorate for Student
that the arrangements are Experience – Health, Safety and
Compliance Officer
formally recorded and assess if
they deviate from the University’s
health and safety framework.
6. Given the different risk profiles
across the faculties there is a need
4. Review job descriptions/roles and for some local variation in roles,
responsibilities for local Safety however there is inconsistency in
Advisors, Risk Compliance job titles and some of these roles
Managers, Academic Safety Leads have a different focus (for example
and other roles with health and in FMBH there is an Estates/Project
safety responsibilities to confirm Management aspect to the role).
This is causing confusion and roles
they detail clear roles and
and responsibilities are not clear.
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Controls)
responsibilities for health and There is not a consistent

safety and are aligned with the framework for all Health and Safety
agreed structures and with the related positions across the
responsibilities detailed within University. See proposed actions
2.1, 2.2 and 2.3.
the Health and Safety Policy.
7. There has been no consultation
with the Compliance and Risk
Directorate with regards to job
titles or job descriptions for these
safety roles. Without this
consultation, there is a risk that
these arrangements will deviate
from the agreed organisational
Health & Safety arrangements set
out in the University Health &
Safety Policy. See proposed action
2.3
8. Feedback from staff is consistent

that differences in SSA job titles is
complex and causes confusion as
it is not always clear that these
SSA/LSA roles have a dedicated
Health & Safety role. There are also
variations in roles at school level
and staff advised that it can take a
while for people to network and
understand the SSA /LSA role.
- Confidential - 30
Controls)
9. FSE are undertaking a review and

safety advisors have a new job title
of Health Safety and Compliance
Advisor. Feedback from staff
suggests that having ‘compliance’
in the job title means there is a
perception that it isn’t a
support/advisory role and it has
effectively widened the gap.
10. Staff in Safety Advisor roles

advised us that they have been
asked to take on additional tasks
(some of which are not aligned
with their job descriptions)
11. Feedback from Central Safety

Services in relation to recent work
on building decommissioning has
highlighted that it is not clear who
is in control of University buildings.
12. The appraisal process is not

mandatory and feedback suggests
that it doesn’t focus on broader
health and safety management
responsibilities therefore there is a
gap in terms of the accountability
of staff in health and safety
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Controls)
management roles. See proposed

action 2.7.
3 Governance arrangements may not 1. Health, Safety and Wellbeing 1. The University Health, Safety &
1. Review the central and devolved
be clear or effective, resulting in Committee and Occupational Wellbeing Committee (HSWC) is the
governance framework for health
health and safety issues not being Health and Safety Training and safety. main decision-making body in
identified in a timely manner Advisory Group (OHSTAG) relation to health and safety issues
and/or not being adequately 2. Faculty, School and and is supported by a number of
addressed, leading to potential Department Health and Safety specialist Advisory Groups -
non-compliance, and risks to Committees Radiation, fire and biohazard
staff/student safety. 3. Annual Monitoring incidents are reported fully through
4. Faculty Risk Profiles their respective Advisory Groups. At
School level monitoring reports are
5. Central and devolved roles and
responsibilities reported quarterly to the Faculty
Health and Safety Committees and
6. Schedule of Inspection
issues can be escalated from
7. HASMAP
School level via the Faculty Health
8. Risk Assessment Review
and Safety Meeting and on to
9. Three lines of assurance
OHSTAG. No matters arising.
2. There is regular performance
monitoring of H&S related events,
KPIs and metrics by the
Occupational Health Training
Advisory Group (OHSTAG) and the
Health Safety and Wellbeing (HSW)
Committee. No matters arising.
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Controls)
3. Annual objectives are included in

Faculty and School Annual
Monitoring Reports with owners and
completion dates. The faculty come
up with their own objectives and
cascade to school to then add their
own objectives. The monitoring
report action plan is reported every
quarter. School Safety Advisors
complete their Section Unit Report
which goes to the Faculty Health
and Safety Committee (or
equivalent).
4. We reviewed agendas and terms of
reference for the three Faculty
Committees and a sample of School
level committees and identified the
following:
• At local level there is good
coverage of standing agenda
items, however there could be
better alignment with University
suggested agenda items and with
agenda themes discussed at
2. Review the Terms of Reference Faculty Committees to ensure a
and meeting minutes from local ‘golden thread’ approach and that
Health and Safety Committees key items are not missed. See
- Confidential - 33
Controls)
and the Health, Safety and proposed action 3.1

Wellbeing Committee to confirm
• From our review of meeting
that reporting/oversight
minutes, we did not identify any
requirements are being met and
issues in terms of low
that issues are being raised at the
attendance, however
appropriate forum. management feedback suggests
that attendance is not always
sufficient at local committees
and there is a need to raise the
profile of the meetings and make
it a priority for people to attend.
• We noted that Health & Safety

Training and Inspections were not
included as standing agenda
items on all meetings. See
Finding 3.1. We would expect
Health and Safety Training to be
regularly discussed at
Committees.
• The Terms of Reference (ToR) for

the FMBH Faculty HSWC does not
provide standing agenda items
and states that the meeting
agenda will be generated by the
Compliance and Risk Senior
- Confidential - 34
Controls)
Manager.
• At school level, there is

inconsistency of technical
representation at School Health
& Safety Committees. Feedback
from staff discussions is that
some PIs and technical managers
are not involved in Health and
Safety Committees and that they
are not receiving
communications/information
from Faculty Health and Safety
Committees and that this is a
gap in terms of reporting and
receiving information.
Management feedback also
suggested that there should be
more researcher representation at
the meetings as it is important
there is representation from
people who are working in the
labs. See proposed action 3.3
5. There are local variations in terms

of how Committees are structured
e.g. in FBMH there are 18 Divisional
Health & Safety Committees
reporting in to the Faculty level
- Confidential - 35
Controls)
meeting. In FSE the School of

Natural Sciences has departmental
Health & Safety Committees and all
five institutes have their own
Committees. In Engineering the
Committees at departmental level
have been disbanded and replaced
with a new single School Health &
Safety Committee with sub-groups
by discipline reporting into the
School Committee. Management
advised that there is still work to be
done on the governance reporting
arrangements. They have gone from
four departments to seven
departments and there is a
challenge in terms of how they get
things reported to the School
Committee and to the departments
under them. This has been ongoing
for the past year and needs to be
worked out to ensure there are no
reporting gaps. See proposed action
3.3
6. Feedback from staff is consistent
- Confidential - 36
Controls)
that the governance framework for

Health and Safety is large and
complex but generally effective
(notwithstanding the current gaps
within FSE).
7. During our discussions with staff
the following projects were
highlighted whereby health and
safety
arrangements/responsibilities did
not appear to form part of the initial
planning considerations
8. FoH Doctoral academy. – This used
to be local PGR/PGT but now all
brought together under one
umbrella. Since January, there’s
been an urgency via Task and Finish
Groups to clarify policy, roles,
responsibilities and processes for
health and safety as this was not
considered from the outset.
9. MECD – Management advised that
with the iterations of the business
case for MECD necessary finer detail
was missing i.e. implications for
health and safety arrangements
- Confidential - 37
Controls)
were not considered early in the

decision making process. We would
expect significant projects and
restructures that impact on health
3. Speak with staff to gain their and safety arrangements to follow a
feedback on the effectiveness of formal business case approach and
the University’s health and safety to flow through the relevant Health
governance framework. and Safety Committee agendas. See
10. There is an annual inspection
process and actions are reported at
quarterly school/divisional
meetings (although arrangements
are different across faculties). There
is also no consistent approach to
reporting outcomes and actions to
the School Health & Safety
Committees (reporting is not
considered mandatory in all areas)
11. Annual safety inspections are
carried out by Safety Advisors. The
methodology and scheduling
approach for local health and safety
inspections is not formally
documented in procedures. There is
also no consistent approach to
- Confidential - 38
Controls)
reporting outcomes and actions to

the School Health & Safety
Committees and reporting of
inspection activity and actions is
not considered mandatory in all
areas. See proposed action 3.6
12. HASMAP audits were in the past
conducted by the Central Services
Safety Team, however they have now
been devolved to faculties and
schools. There is no audit by central
services so they are self-auditing
and self-inspecting and this is due
to a resource issue. Safety staff
have expressed concern around the
robustness of the HASMAP self-
assessment process. Feedback also
suggests this self-inspection
approach can be viewed as a ‘tick
box’ exercise and there are differing
levels of engagement with the
process across the faculties. From
review of HASMAP evidence we
noted that there is a lack of
evidence in some areas to
demonstrate why they have self-
- Confidential - 39
Controls)
assessed as being 100% compliant.

4. Confirm if there is a programme
of inspection that provides
The Central Safety Services (CSS) team
feedback and which is monitored
have a role in level 2 assurance and
at a senior level for improvements. there is a need for CSS to pick up a
proportional amount of audits to
provide level 2 assurance for the
organisation. Competing demands and
staff capacity challenges have recently
impacted on the amount of proactive
work undertaken by CSS. There is
currently no schedule of audit in place,
See proposed action 3.7.. The first line of
assurance is Schools/Faculty managers
with support from health and safety
professionals. The second line of
assurance is the Compliance and Risk
Directorate alongside the Health Safety
and Wellbeing Committee (HSWC).
Internal audit is the third line of
assurance, however this is limited in
that it is cyclical and there is currently
no annual cycle of internal audit activity
in relation to Health and Safety to
provide independent assurance. See
proposed action 3.8
- Confidential - 40
Controls)
4 Processes for health and safety 1. Minimum health and safety 1. Speak with key staff to confirm 1. It is currently very difficult for the
may not be followed (due to poor training requirements detailed that staff health and safety University to demonstrate
engagement / training / in Health and Safety Policy training needs are identified, and compliance with statutory and
ownership) or may be poorly 2. Induction training appropriate training is provided mandatory health and safety
designed, leading to potential non- 3. Induction checklists and kept under review. training. There is no central learning
compliance and risks to 4. Ongoing and refresher health management system for recording
staff/student safety. and safety training and reporting training completion.
5. Monitoring of mandatory See proposed action 6.1.
training completion
6. Competency assessment 2. Supervisors need to be competent
7. Training needs analysis to sign off risk assessments. Risk
assessment training is not
consistent across the University.
Some areas have developed risk
assessment training (e.g., FBMH
have risk assessment training in
Blackboard) and some areas deliver
toolbox talks, whereas others have
nothing formal in place. See
proposed action 6.7. Annual
Compliance updates are provided
for senior managers e.g., Heads of
Schools. Heads of Departments),
with 20 minutes on the agenda
dedicated to Health and Safety.
There is no specific health and
- Confidential - 41
Controls)
safety training for line managers

(academic line managers, PI’s and
PS line managers) and feedback
provides that it is not clearly
2. Confirm the competency pointed out to them what they have
frameworks in place for local responsibility for. For example,
safety advisors and students and someone may come in as a new
review and assess their academic or PI and complete a
effectiveness. general health and safety induction
but there is no training on what
their health and safety
responsibilities are. See proposed
action 6.5
3. Interview key staff to gather 3. There is a lack of awareness and

feedback on the competency engagement with the Competency
framework/assessment process Assessment process. No formal
and how it is being followed. training needs analysis process.
4. Confirm arrangements for the

No matters arising.
corporate and local health and
safety induction processes for
staff.
- Confidential - 42
Controls)
5. Confirm that a health and safety No matters arising. Linked to proposed

induction is provided for all new action 6.1
undergraduate students.
- Confidential - 43
A2. Key Stakeholders
We met with the following staff during the audit fieldwork:
Name Role
Dr David Barker Director of Compliance and Risk
Dr Patrick Seechurn Head of Safety Services
Mr Patrick Hackett R,S & COO
Prof Nalin Thakker Vice President/Chair of OHSTAG
Prof Martin Schröder Dean (FSE)
Prof Melissa Westwood Associate Vice President for Research
Prof Nigel Hooper Associate Vice President for Research
Local safety chair on behalf of HOS and
academic lead; also sits on HSW as Chair of GM
Prof Simon Turner Bio Advisory Group.
Head of Planning, Compliance and Special
Dani Murtagh Projects (FSE)
Head of Planning, Compliance and Governance

Nichola Ellis (FoH)
Fiona Marriage Compliance and Risk Senior Manager (FBMH)
Julia Cheung Safety Compliance and Risk Manager (FSE)
Executive and Compliance Support Officer
Lynda Rowlinson (FoH)
John Moore Head of Technical Operations (FoH)
Osen Kilic-Yildirim Compliance, Safety and Estates Manager (FoH)
Fidel Peacock Compliance, Safety and Estates Manager (FoH)
Compliance, Safety and Estates Administrator
Johnny Brewster (FoH)
- Confidential - 44
Brent Collins School Compliance and Risk Manager (FBMH)
Lisa Grady School Compliance and Risk Manager (FBMH)
Assistant Director of Estates and Facilities &
Jon Ashley Head of Estates Support
Principal Estates and Facilities Health and
Martin Blake Safety Manager
Carl Jackson Health, Safety and Compliance Advisor (FSE)
Suzanne Raw School Compliance and Risk Manager (FBMH)
Michelle Jackson Technical Operations Manager (FBMH)
Prof Melissa Westwood Associate Vice President for Research (FBMH)
Sylvester Boon Health, Safety and Compliance Advisor (FSE)
Prof Nigel Hooper Associate Vice President for Research (FSE)
Craig Hopper Head of Technical Operations (FSE)
UCU Safety Representative and School Safety
Dr Nicola Hutchings Adviser (FSE)
FBMH - Local safety chair on behalf of HOS and
academic lead; sits on HSWC as Chair of GM
Prof Simon Turner Bio Advisory Group.
Kevin Gaskell-Clow Unison Safety Representative
Kevin Jackson Head of Technical Operations (FSE)
Health, Safety and Compliance Officer,
Sarah Gumusgoz Directorate for Student Experience
Kenneth Drury Unite Safety Representative
Vice Dean and Head of School, School of Natural
Prof Chris Hardacre Sciences, (FSE)
Prof Alice Larkin Head of School of Engineering (FSE)
Programme Director for Mechanical
Prof Lee Margetts Engineering (FSE)
- Confidential - 45
Prof Andy Weightman Associate Dean Teaching Academy (FSE)
Robert Jones Head of Operations, Dalton Nuclear Institute
A3. Key Report Distribution
The following staff will receive the draft and final audit report
Name Role Stage of report

Dr David Barker Director of Risk and All drafts and
Compliance final.
Dr Patrick Head of Safety Services All drafts and
Seechurn final.
Patrick Hackett R,S and COO Final draft and
final
Dani Murtagh Head of Planning, Final draft and
Compliance and Special final
Projects (FSE)
Matt Crofts Head of Planning, Final draft and
Compliance and Governance final
(FBMH)
Niqui Ellis Head of Planning, Final draft and
Compliance and Governance final
(FoH)
Uniac strive to provide a high-quality internal audit service. We would

encourage you to provide any feedback (link) you may have following this
audit and report.
- Confidential - 46
Appendix B – Analysis of Health and Safety Related Events
Analysis of Health and Safety Related Events Aug 2019 – April 2023
Post-Covid, the University has seen an increase in the number of reported health and safety related events. It could be expected that as
activity levels returned to normal following the lockdown period, that there would be a return to pre-Covid levels. There is a concern
however, that levels are continuing to increase and are now exceeding what they were pre-Covid. It can be seen in Chart 1 below, that the
number of recorded health and safety related events peaked during February and March 2023. Table 1 highlights that the number of
reported events per month during August 2019 – April 2023 is increasing year on year.
- Confidential - 47
Table 1: Average Health & Safety Related Events per Month (Aug 2019 – Apr 2023)
Total Events Avg. per Month

Aug 2019-July 2020 432 36
Aug 2020-July 2021 349 29
Aug 2021-July 2022 506 42
Aug 2022- April 2023 478 53
Where a cause was provided, the highest level of incidents were said to have been caused by Chemical/Laboratory (30%) and Equipment
(17%).
The number of RIDDOR reportable incidents have also increased indicating an increasing trend in more serious incidents.
Table 2: RIDDOR Reportable Health & Safety Related Incidents (Aug 2019 – Apr 2023)
RIDDOR Reportable Incidents Avg.per month

Aug 2019 - July 2020 12 1
Aug 2020 - July 2021 14 1.17
Aug 2021 - July 2022 14 1.17
Aug 2022 - April 2023 15 1.67
The faculties with highest levels of health and safety events during April 2019 – April 2023 were:
• FSE
• Estates
• FBMH
• Student Experience
- Confidential - 48
FSE accounted for 38% of total reported events between August 2019 and April 2023. This is not surprising given the profile of the faculty
and the activities undertaken within the FSE in terms of laboratory and workshop related activities. FSE has seen a notable increase post-
Covid with health and safety related events in the faculty doubling between 2019/20 and 2022/23 (from 119 to 227). Table 3 below
highlights that there were significant increases in reported events in FSE during 2021/22 and during August 2022-April 2023.
Table 3: Total Events in FSE Aug 2019 – April 2023
Total Events Avg. Events per Month

Aug 2019- Jul 2020 119 9.9
Aug 2020 - Jul 2021 124 10.3
Aug 2021 - July 2022 193 16.1
Aug 2022 - April 2023 227 25.2
The highest levels of events in FSE relate to Chemistry and Materials and during August 2019 – March 2023, the following buildings
accounted for over 50% of reported events in FSE:
- Confidential - 49
• Chemistry, Brunswick Street - accounted for 30% (197) of reported events in FSE
• Royce Hub Building (Sir Henry Royce Institute - accounted for 10% (64) of reported events in FSE
• Manchester Interdisciplinary Biocentre (MIB) John Garside Building – accounted for 8% (53) of reported events in FSE.
• MECD – accounted for 8% (53) of reported events in FSE.
• Estates – Increasing post-covid accounting for 20% (344) of total events between August 2019 and April 2023. The highest levels of events
attributed to Estates were building related, equipment related and fire related events.
• FBMH – Has seen a steady increase in events post-Covid, however not back to pre-pandemic levels. Accounts for 18% (314) of total events
between August 2019 and April 2023). The highest levels of events in FBMH related to equipment and chemical/laboratory.
• Student Experience – continued increasing trend post-covid. Relatively low numbers. Accounting for 16% (274) of total events between
August 2019 and April 2023.
Analysis of Reasons for the Overall Increase in Reported Health & Safety Events
During our audit fieldwork we met 39 staff from across the faculties and professional services. We discussed possible reasons for the
increase in health and safety related events, the level of management in place locally and how this was managed pre-covid compared to
how it is currently managed. From our analysis of data and meetings with staff, it is clear that there are a number of contributory factors
as follows:
1. Reduced Supervision due to Hybrid Working

Staff feedback suggests that hybrid working post-Covid is one of the main contributory factors for the increase in reported health and
safety related events across the University. Staff advised that due to hybrid working there is less supervision than there was pre-Covid.
Hybrid working by academic staff, PI’s, technical staff and professional services staff means that there is not the same footfall of staff on
site. If there is less footfall due to hybrid working, there are less staff to identify and inform Estates of maintenance issues that could be
- Confidential - 50
addressed before an incident occurs. The FoH laboratory areas have not been impacted by hybrid working to the extent of FSE and FMBH as
they are managed by technical staff who are on site 5 days per week.
Hybrid working is also impacting on the availability of supporting health and safety roles such as first aiders and fire evacuation marshals.
Post-Covid it has been difficult to recruit into these voluntary roles and where people are already in the roles, it is difficult to know when
they are on-campus due to hybrid working.
1. Reduced Practical Experience due to Covid Lockdown

During the Covid lockdown, students had less practical experience in laboratories/technical areas so they don’t have the hands on
experience they would have had pre-Covid. This is compounded by hybrid working and a reduction in the level of supervision. Some PIs
delegate tasks to PHD students and Postdoctoral Research Assistants (PDRAs). There are areas where 2nd year PHD students train 1st year
PHD students who train 3rd year undergraduate students, however the PHD students also had less exposure to practical laboratory work
during Covid.
2. Increased use of Shared Labs/Technical Areas

There has been a gradual evolution to the use of multi-disciplinary shared laboratories/technical areas which has given rise to a dilution
and deterioration of supervision in those environments. For the FSE in particular, the move to the MECD building has increased the use of
shared spaces. From our discussions with staff there is an issue with ownership and accountability for shared areas which is impacting
upon levels of supervision as roles and responsibilities are unclear.
There is nothing prescriptive in place to manage shared labs/technical spaces and staff feedback suggests that there is a need to set clear
ground rules and roles and responsibilities for these areas. For example, defining responsibilities for managing health and safety, space
allocation, rotas for cleaning, ordering supplies and equipment maintenance. In FSE, for the dry labs, we were advised that a Community of
Practice was set up for academic leads, and technical leads to work together to define roles and responsibilities and to drive how they
wanted the technical spaces to work. This approach has not been followed for other shared laboratories/technical spaces. Management
- Confidential - 51
advised us that for MECD the intention is to look to having an individual who has responsibility for co-ordination and checking day to day
that agreed activities are being carried out.
3. MECD Engineering Buildings Arrangements and Health and Safety Staff

MECD is a major project which has included the transfer of staff and equipment from north campus to the Engineering Buildings. A
number of different depts have moved and there are associated changes to processes. MECD has provided an opportunity for the FSE to
reflect as a faculty on the structure of health and safety roles. Feedback suggests that some areas in MECD are well developed in terms of
health and safety management whereas others need to catch up. In FSE they are currently reviewing the structure of the health and safety
team.
4. Students from Diverse Backgrounds

The University is recruiting more international students and staff advised us that in particular, within Chemistry there are challenges in
terms of monocultural labs. These students have been trained in a culture that is not UK centric in terms of Health and Safety. We were also
advised that there are more students with non-chemistry first degrees doing PHDs in Chemistry and these students may not have had the
same level of practical lab exposure as students who have first degrees in Chemistry.
Student numbers at the University have increased post-covid, therefore increased footfall may be a factor in the increased health and
safety events. We reviewed Student Numbers by faculty and identified the following:
• An overall increase of 5385 students (13.3%) across the three faculties from 19/20 – 22/23. FBMH – an increase of 1244 students
(10.7% increase)
• FoH – an increase of 3117 students (18.4% increase)
• FSE – an increase of 1024 students (8.6% increase).
This highlights that both FBMH and FoH have had higher % increases in overall student numbers than FSE, however they have not had the
same level of increase in health and safety related events. This suggests that increased student numbers is not an overriding factor.
- Confidential - 52
Appendix C – Summary Findings Mapped to Assurance Requirements
The table below summarises the number of mapped to key assurance requirements:
Finding Ratings Internal Risk Governance Sustainability Data Value for Money OfS Conditions
Control Management
High 2 - - - - - -
Moderate 1 - 1 - 1 - -
Low 1 - - - - - -
Advisory - - - - - - -
4 - 1 - 1 - -
- Confidential - 53
Appendix D - Report Conclusion and Finding Definitions
D1. Report Conclusion Definitions

The following is the method by which we arrive at the conclusions in the report. The table below indicates our report conclusions, and the rationale behind assigning
specific levels of assurances. These are linked to the nature and extent of individual findings, that are defined overleaf. Please note the following:
• We will not provide a conclusion on Efficiency/Economy if we conclude with a limited or inadequate risk assurance rating.
• A benchmark rating will only be given if Uniac has enough information on the activity under review to make an informed judgement.
# Conclusion Rating Risk Assurance Description Efficiency / Economy Description Benchmark Rating Description
1 Substantial We offer substantial assurance We offer substantial assurance that Sector Leading The University’s systems,
Assurance that the system of internal the system of internal control is processes and practices are
control and governance is efficient and economic (although ahead of other institutions and
designed adequately and is potential enhancements may have operate within best practice,
operating effectively. been identified) based upon Uniac’s judgement
Potential enhancements may at the time of the review.
have been identified.
2 Reasonable We offer reasonable assurance We offer reasonable assurance that Within Norm The University’s systems,
Assurance that the system of internal the system of internal control is processes and practices are
control and governance as efficient and economic, however the operating within the norm of
designed is adequate and is audit did identify some opportunities the sector, based upon Uniac’s
generally operating effectively, to improve the efficiency / economy of judgement at the time of the
however the audit identified the system of internal control review.
some opportunities for
improvement.
3 Limited We offer limited assurance The audit identified significant Behind Norm The University’s systems,
Assurance because the audit identified opportunities to improve the efficiency processes and practices are
significant opportunities to / economy of the system of internal operating behind the sector,
improve the adequacy and control based upon Uniac’s judgement
effectiveness of the system of at the time of the review.
internal control and governance.
4 Inadequate The design of the system of The system of internal control is not
Assurance internal control and efficient / economic
governance is inadequate.
- Confidential - 54
D2. Risk Rating Definitions
The Risk Rating category allocated to findings is defined in the below table to illustrate the potential risk of the finding and the suggested
urgency of the implementation response.
Suggested Implementation
Category Explanation
Responsibility and Timescale
The finding highlights our assessment of the adequacy and/or effectiveness of control, which we judge Governing Body/Accountable officer
could lead the University to high-risk exposure or the activity is not efficient or economic. level
This could have a significant impact on the operational objective and performance of the activity; a Action in 0-3 months to reduce risk
High significant breach of organisational policy (or an absent policy); a breach in compliance with legislative exposure
and regulatory obligations leading to significant sanctions (including financial); significant reputational
damage at national and international scale; a negative student experience, or a significant impact on
finances and financial reporting.
The finding highlights our assessment of the adequacy and/or effectiveness of control, which we judge Senior Management Team (cross-
could lead the University to moderate-risk exposure. It also highlights some opportunities to secure value departmental)
for money. Action in 3-6 months to reduce risk
Moderate Management response is necessary to mitigate the potential impact on the operational objective and exposure
performance of the activity; a breach in organisational policy; a breach in compliance with legislative and
regulatory obligations leading to sanctions or additional scrutiny; regional reputational damage; a
negative impact on the student experience; or potential for impact on finances and financial reporting.
The finding highlights our assessment of the adequacy, effectiveness, economy and efficiency of control, Departmental Management
which we judge could lead the University to an increasing risk exposure or enhancing the efficiency and Action in up to 12 months to reduce
economy of the activity. risk exposure
Low Although the control is designed and/or operating reasonably, there are opportunities for
improvement to further enhance the management of risk in the area/activity, that should be
implemented to ensure the risk is managed and continues to be managed within risk appetite.
We have identified further enhancements that would provide best practice development in the To be considered for
Advisory adequacy, effectiveness and economy of internal control for the activity under review. implementation by the
Departmental Management.
- Confidential - 55
Appendix E – Peripheral Issues Observed During the Audit
Additional Issues Raised (considered slightly outwith scope)
1. Legacy items – There is an ongoing issue with legacy items left in labs by former staff. These legacy items are creating estates utilisation and
health and safety issues. Whilst there is a process in place it doesn’t seem to be enforced. Lab clearance is often falling to the technical staff.
There is a need to define roles and responsibilities for this. Linked to Risk 2.
2. MECD Engineering Buildings Access Issue – The engineering building is open access with some areas (workspace/lab/research) restricted by
swipe card access. No security, no reception staff. Tailgating risk. Management advised they are introducing bright yellow lanyards and will
raise awareness with building users, however they don’t want to put turnstiles in the building. Whilst we recognise the broader community
civic responsibilities around the buildings, there are potential health and safety and security risks with the open access approach given the
size of the building. We were advised that the Head of Safety Services (the competent safety lead) recommended a reception desk be installed,
however this advice wasn’t followed.
3. Gas passport training – externally places for training are limited and there are long waiting lists. There are a handful of people designated to
fill the void but staff advised us that they are aware of incidents whereby people are not waiting for training and then having incidents with
gas (connecting up gas when they shouldn’t as they haven’t yet attended training).
- Confidential - 56

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OHST 88-2023-A5 UNIAC Audit Report UoM - Health and Safety 2022-23 Final IA Report 10.07.14

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OHST 88-2023-A5

Internal Audit Report of Health and Safety

Overall Conclusions* Summary of Findings by Risk Rating*

Risk Assurance Limited Total Number of Findings: 6

High Moderate Low Advisory

1.1 Audit Context

We raise the following High Risk findings:

During the review, we identified the follow areas of good practice:

# Finding Risk Proposed Management Action Management Response

1 Contributory Factors Moderate

Reduced supervision due to hybrid working was the most

1.2 For supporting roles, for example fire Central Faculty

In recent years, the Head of Safety Services proposed that a

2 Roles, Responsibilities and Accountability High

included in some areas e.g., in the FoH it includes an Estates

Staff feedback suggests that these job titles are causing

Feedback also suggests that there are possible disconnects

Feedback from Central Safety Services in relation to recent work

Accountability and ownership for health and safety came across

responsibilities therefore there is a gap in terms of the

3 Health and Safety Governance Arrangements Moderate

• At school level, there is inconsistency of technical Owner: Deans, Head of Planning

There is a potential gap in terms of the consideration of

1. FoH Doctoral academy. – This used to be local PGR/PGT but

policy, roles, responsibilities and processes for health and

The first line of assurance is Schools/Faculty managers with Central Faculty

The Head of Central Safety Services is currently working with IT

Our benchmarking exercise and work with other HE institutions,

See proposed action 5.1.

5.3 Consideration should be given to re-

provide a completion rates and there is no information to state

We identified that there is a lack of awareness and engagement

# Risk Risk Management Approach (i.e. Test Objective Summary of Findings

the faculty. See proposed action 2.4.

clear on their roles and

5. Hybrid working is also impacting on

6. There has been a long term shift in

and hybrid working. From our

2. Review the approach to reporting. 7. Currently there is no online system

that job titles are not clear. This is

Health and Safety Advisor. Previously

5. There is variation in job titles and job

descriptions for safety advisors

• FMBH - School Compliance and

responsibilities for health and There is not a consistent

8. Feedback from staff is consistent

9. FSE are undertaking a review and

10. Staff in Safety Advisor roles

11. Feedback from Central Safety

12. The appraisal process is not

management roles. See proposed

3. Annual objectives are included in

and the Health, Safety and proposed action 3.1

• We noted that Health & Safety

• The Terms of Reference (ToR) for

• At school level, there is

5. There are local variations in terms

meeting. In FSE the School of

6. Feedback from staff is consistent

that the governance framework for

were not considered early in the

reporting outcomes and actions to

assessed as being 100% compliant.

safety training for line managers