Further Detail

Following review, a revised Certificate of Assurance process was developed. The revised process is a thematic audit undertaken by divisions and departments across the organisation. The audit themes will be identified on a risk basis by the Health and Safety Department and will be facilitated using the force electronic survey tool to record divisional responses and supporting evidence, with the force action tracking system providing an audit trail for any improvement actions arising from the thematic audit.

The thematic audit approach is assessed as being more focussed, with a reduced administrative impact on participants. The process is supported by the Health and Safety Department through direct engagement from Health and Safety Advisors (HSA) assigned to divisions and departments across the force.

The revised Certificate of Assurance process was the subject of a proof-of-concept pilot during January 2024, with two divisions providing detailed responses to a short 4 question online questionnaire focussing on divisional approaches to risk assessment. The proof-of-concept questionnaire is attached at Appendix A.

Participating divisions were supported to complete the questionnaire by their respective divisional HSA. Following submission, responses were assessed against an audit evaluation matrix, which is attached at Appendix B.

The audit evaluation assessment identified the following:

• There were some areas that met the HIGH criteria, giving assurance that process is being followed.
• The audit highlighted some areas for development by divisions and the Health and Safety team, which will further support continuous improvement.

A separate survey was conducted with pilot participants and Health and Safety staff who had been involved in the thematic audit. The participant survey reported the following:

Reflection from Divisional Commanders:

• Straightforward approach, however, support from HSA was required initially.
• Digitising the process worked well, could benefit from more capability to submit more evidence.
• More focussed approach.

Reflection from HSA:

• Both parties benefitted from process in terms of gap analysis.
• Divisional support through the process will be needed from HSAs in initial stages.
• HSAs would gain from more guidance on scoring and expectation aligned with organisational policy and risk appetite.

Updated guidance for HSAs has been developed in response to this feedback.

The revised Certificate of Assurance process together with the outcomes from the proof-of-concept were presented to the Health and Safety Board on 9 February. Following discussion, the revised Certificate of Assurance process was approved for introduction from April 2024, with thematic audit progress updates and improvement action resolution outcomes being reported to the Health and Safety Board on a quarterly basis thereafter.