Quality Audits 2010-11
Report into Findings

Introduction

The Service Delivery (Protection) Department quality control programme for 2010/11 commenced on 1st April 2010 and represented the third year of sampling. It was planned to produce four quarterly inspections in line with the requirements of Standard Operating Procedure TFS-012.

It became apparent in the first quarter that the Service temporary re-structure implemented around that time would seriously affect our ability to run the entire programme as planned and as such it was decided by GM Parsons to reduce the “two home office and one away” SM -B designated inspections to one home inspection only. The station manager core re-skilling programme was then introduced in the Autumn and it became necessary to remove the requirement from the SM-B completely. This is the second year that other duties have prevented a full programme of inspections.

This summary is based on the findings from the Group Manager inspections conducted in quarter four by GM Parsons and Neville Mullings and is based on a total of 33 individual jobs.

Executive Summary

In general, the overall standard of audits sampled was found to be high however there were inevitable differences in office systems which lead to discrepancies in some administrative functions with items such as customer survey covering letters not being sent out with the survey form, use of appointment confirmation letters and job outcomes being incorrectly recorded.

The standard letters and standard paragraphs are being used in all cases (albeit with some local formatting adjustments) but the degree of additional recommendations and other information added to standard paragraphs varied greatly between inspectors. The use of the audit notes section also varied considerably and in many cases this section was not used at all.

It was not always possible to assess whether adequate notice was given prior to an audit due to appointments not always being confirmed by post. This may not be a critical omission as it is likely that an appointment was made by other means however the appointment letter does contain information on the audit process to the responsible person and provides us with a moral argument if the responsible person pleads ignorance in mitigation for being ill-prepared for an audit.

Findings in detail:

The letter history on CFRMIS was not complete in some cases due to the covering letter not saving with the notice schedule. This seemed to affect one member of admin staff only and appears to be a software problem that so far has remained unresolved. A full version of the letter is routinely saved to FISH as a work-around solution.

Corrective action: Request sent to AJ by NM to re-investigate the issue
The job reason code is still often "FSA" when a more specific code such as “LT” or “UFS” should be used to describe the reason for a full inspection.
This has been a common finding from previous years however the flowcharts now included in SOP - TFS027 should assist in identification of correct job reasons.

Corrective action: All job reasons should be allocated using the guidance in SOP TFS-027.
The job outcomes were not always correctly filled in. It was found for example that some jobs requiring a NOD had the outcomes screen indicated as “satisfactory” with a “report”.

Corrective action: FS Inspectors are to ensure that they enter this information themselves or that the instructions sent to admin staff are clear and concise depending on how the local administrative system is organised. The Inspector is responsible to ensure job outcomes are correctly recorded at the end of the job.
Jobs are not always completed by adding the completion date. This can leave completed jobs showing as outstanding on the system. Where this was discovered during the inspection, the CFRMIS records were corrected accordingly. This failure has been identified in previous inspections.

Corrective action: FS Inspectors are to ensure that they enter this information themselves or that the instructions sent to admin staff are clear and concise depending on how the local administrative system is organised. The Inspector is responsible to ensure jobs are properly completed.
Inspectors in general are still not making best use of the audit form notes section, whether for positive or negative entries. The notes, when properly used, are of value to anyone using a previous audit form for premises intelligence gathering or when assessing the suitability of recommendations made following an audit. It will also assist in justification for escalating action using the EMM and for quality control purposes.
This observation was made in the last inspection report and has been discussed at two training days since.

Corrective action: The need to use audit notes was reiterated at the team training day in February and will be monitored during future QA inspections.
A job was found to have been recorded as an enforcement notice when in fact it was a NOD. This was due to two possible outcomes depending on the proposed use of the premises.

Corrective action: FS Inspectors are to ensure that they enter this information themselves or that the instructions sent to admin staff are clear and concise depending on how the local administrative system is organised. The Inspector is responsible to ensure job outcomes are correctly recorded at the end of the job, especially when the circumstances may be unusual. The CFRMIS record in question was corrected during the inspection.
Two jobs were found to have an incorrect compliance level recorded on the premises details screen even though it was correctly shown on the audit form.

Corrective action: NM has sent the details to AJ to investigate as this is should auto-populate from the audit form.
NOTE; This has been detected on at least two more occasions since the inspection by Rob Wallbridge who will send details of the premises records affected to AJ under separate cover.
It was noted that the customer survey form was being sent out as part of the post visit process however it was not always accompanied by the CFRMIS generated covering letter. This letter is required to explain the reason for the survey and assure the responsible person that comments are important to us and not ignored.

Corrective action: Admin staff to be reminded that the covering letter needs to be generated at the same time as the post inspection letter(s).
In general, it was found that the EMM was being used correctly when there was any doubt as to the initial enforcement expectations returned by the audit process.
Where an enforcement notice had been served, the transfer of detail to the enforcement screens appeared to be completed correctly.
Contemporaneous notes were not thoroughly checked during this inspection however those that were available were generally found to be good.

Building Regulations:

A general observation was that the inspectors should be more forceful when commenting under Schedule AP

Corrective action: Ensure that all requirements are given adequate weighting when included in this schedule
For the second year it was noted that a consultation had been rejected due to a failure to provide insufficient information.
It was noted that offices may employ different policies on retention of plans following BR consultations as some had available plans and other did not. The quality control on BR jobs cannot be meaningful without a review of the plans submitted as the comments made are as a direct result of this process however, as there is no duty to retain plans, many have been destroyed following the consultation process making quality control after the event impossible.

Future Action: The role of BR quality control and/or the plan retention policy may need to be reviewed if the quality control process is to be credible.

Action Plan:

That this report is made available to all Service Delivery (Protection) staff before 1st April 2011.
The findings of this report are communicated to all fire safety inspectors at a future Department Training Day.
That this report is made publicly available on the website before 1st April 2011.
That the previous years report remains available on the website for reference.

2011/2012 Plan:

It is intended that a full programme of quality control will be implemented from 1st April 2011 however this may again need to be reviewed in line with the temporary re-structure.

Quality Audits 2010-11 Report into Findings