Quality Audits 2009-10
Report into Findings

Executive Summary

This report marks the second year that the Technical Fire Safety (TFS) Department has followed this format of Quality Assurance (QA) Audits on the work undertaken by the department.

As per 2008-9 it was pleasing to find a high quality of performance throughout the department. In total 34 separate QA audits were undertaken including both field and desktop audits. Of these 22 were quality checks on Fire Safety Audits (FSA) and 12 were of statutory consultations undertaken under Building Regulations (BR).

The QA audits discovered that the Community Safety Inspectors (CSI’s) are correctly using professional judgment in exercising their powers and those requirements prescribed as a result of serving notices were reasonable. The serving of notices and gathering of evidence under the guidelines in respect of the Police and Criminal Evidence Act (PACE) 1984 is being carried out correctly

The revised FSA form now offers CSI’s the chance to transparently apply the Enforcement Management Model. QA checks of this process have shown that CSI’s are using it diligently and its application is being used to both reduce and increase the level of enforcement outcome appropriately.

The administration of TFS activities is also found to be very efficient. It was found that out going correspondence were generally sent out within 24 hours of the completion of an FSA. The expected norm is 28 days. The only significant problem within the administrative duties is the incorrect use of job reason codes in respect of fire safety audits. This was also noted in last years report. The matter has not greatly improved even after training. It has been identified that the guidance on job reason codes is complex. To correct this, a revised guidance document will be released in April 2010 as part of the review of the Risk Management Strategy for TFS.

Issues Identified in the Report 2008-9 and Subsequent Findings

Both current types of QA forms available were used by managers carrying out internal quality audits. Though the forms provided findings they both also demonstrated shortcomings. A revised form has been in trial use for the majority of this years quality audits. It is due to be finalized for the 2010-11 round of quality audits.
The current Standard Operating Procedure (SOP) for TFS Internal Quality audits is not being followed to the letter. The SOP encourages office managers to review work in other offices to ensure standardization and share best practice. Due to high work demands on office managers, they have not been able to undertake this area of work. The Group Manager Protection however was able to undertake standardisation visits to all three offices. In 2009-10 it was discovered that generally the level of standardisation in the offices was very high. Again the level of standardisation was also found to be high. A revised QA SOP is due for release ready for 2010-2011.
On three occasions incorrect job reason codes were used on fire safety audits. This highlights the complexity of the workflow system currently in use. This is still proving to be a problem and a revised risk management SOP with a less complex system of job reasons will be released.
When undertaking an FSA, it was commonly found that the comments boxes next to articles in part B were either not used or the contents were not transferred by administrators to the database. With the advent of mobile working the latter will cease to be an issue however CSI’s will be encouraged to use comments boxes in the future as there inclusion creates a clearer picture of the audit findings. The use of Note boxes has improved but is still not widely adopted. This is an action point for future training.
The procedural guidance for Building Regulations Consultations and the Regulators’ Code of Compliance is very clear in its statement that requirements, recommendations and goodwill are clearly separated and identified. It was pleasing to see that all correspondence audited showed this to be the case. No instances were found where requirements, recommendations and goodwill were submitted incorrectly. The QA exercise undertaken in 2009-10 found this to be the same case. CSI’s are commended for their use of professional judgment.
On no occasion was it discovered that the incorrect level of correspondence was used as a result of an FSA. On at least two occasions errors were found with letter editing although none of these occasions in validated the letter. Again, on every occasion checked, the correct level of correspondence was utilised.
In general an appropriate period of notice was given before the undertaking of an FSA. It was interesting to note that even with up to five weeks notice some responsible persons were still under prepared for an audit visit. The letter notifying the responsible persons of the nature of the visit are very clear so is not deemed to be a reason for this. The use of appointment confirmation letters has reduced. This is noted as an action point.
It was pleasing to note that on one occasion an FSA was carried out, a less experienced CSI had the confidence to correctly apply the Enforcement Management Model (EMM) to reduce the enforcement expectation from a Notice of Deficiencies to a satisfactory letter. This years round of QA has again identified correct use of EMM by experienced and less experienced CSI’s alike.
In Building Regulations Consultations it was pleasing to note CSI’s rarely missed the opportunity to recommend the inclusion of sprinklers in their consultation replies. This years round of QA has again identified extensive use of such goodwill recommendations and the use of standard paragraphs on arson reduction measures has increased.
In Building Regulations Consultations it was pleasing to note one CSI’ regularly uses standard paragraphs to provide advice on arson reduction. This is best practice that other CSI’s will be encouraged to adopt. This years round of QA has again identified increased use of standard paragraphs on Arson reduction measures.

Summary of Findings of 2009-10 Quality Assurance Audits

Fire Safety Audits.

There is still a problem with the incorrect use of Job Reason Codes when assigning Fire Safety Audits. There is common use of code “FSA”. This should only be used with audits carried out as a result of a consultation (in combination with the appropriate “Inspection Type” for the type of consultation). Typically the only Job Reason Codes to be used with audits are LT (Locally targeted), CI, CG, CE (Complaints), UFS (Unwanted Fire Alarm), AFA (After Fire Audit).
In Part A of the audit form there is a common error in the “Occupancy Factor” field. This question asks for the “maximum number of persons in the most highly occupied compartment” but the numbers recorded are often the maximum number of persons likely to be in the whole premises. (i.e. the total number of care home residents, staff and visitors on the premises will not be the same as the maximum number of people in one compartment such as a the day-room or lounge area)
The use of Fire Safety Audit Appointment Letters is no longer consistent between all three offices with one office rarely using them at all. It is part of the adopted CFOA policy that, where possible, such letters are sent to responsible persons before commencing audit activities. Such letters also ensure the responsible person is given sufficient information to prepare relevant documents prior to the FSA.
Where reference is made to British Standards in correspondence, this should be further expanded to include reference to “current British or equivalent European standards”.
On only one occasion was there an unacceptable delay in sending out correspondence. This was due to an administrative oversight.
On one occasion there was no record of any correspondence in the letter history. This has been attributed to an administrative error.
The use of the Notes field in Part B of the audit form is still sporadic. All CSI’s are encouraged to use this form to justify their enforcement decisions against each article. It improves transparency and also acts as a useful record for any other CSI dealing with the file.
On one occasion it was discovered that a CSI didn’t fully understand that the audit form automatically populated the standard paragraphs in subsequent correspondence. This training need was identified and addressed before the QA had been carried out.
The Enforcement Pages on CFRMIS were being correctly completed. This is a relatively new burden on administrators. It was pleasing to see how well these important data fields were being completed as the information is used to inform the Statutory Enforcement Register. Only one error was found in all the records checked as part of the QA process.
The forwarding of information to the Central TFS team for recording was also found to be carried out correctly.
The Revised Audit form has a new facility for showing transparency in enforcement decisions being made using the Enforcement Management Model. This new facility was found to be used diligently and appropriately by both experienced and inexperienced CSI’s alike. It was also pleasing to note that the model was used to both decrease and increase the level of enforcement carried out.
The QA process also discovered that, when required to collect evidence, the guidelines issued under Police and Criminal Evidence Act 1984 were being followed diligently. Code B notices were regularly being served. It was noted that on two occasions that the reverse of a Code B form had not been completed. Whilst incorrect, it would not render the notice being deemed as served incorrectly. The Contemporaneous Note Books of the majority of CSI’s were inspected. It was clear that the notebooks were being completed to a very high standard. Minor errors detected included “crossings out” that were not initialled on a few of occasions. CSI’s are reminded that it is important to time as well as date the signing off of contemporaneous notes.

Building Regulations Consultations

CSI’s regularly confine their comments to Schedule BR. A small number of CSI’s correctly make the majority of their observations in schedule FS when it can be regarded as a requirement we would be likely make under the Fire Safety Order. Schedule BR is then annotated to refer to schedule FS for the comments. This is best practice and should be adopted by the rest of the department.
It was noted on a minority of occasions that CSI’s could have been more forceful in pointing out quite serious deficiencies in submissions.
It was pleasing to note regular comments offered in respect of ensuring there is adequate provision for means of escape for disabled persons.
The use of sprinkler and arson reduction standard paragraphs is increasing and all CSI’s are encouraged to use these standard paragraphs.
It was pleasing to note the use of standard paragraphs in schedule FS in respect of Construction Design and Management Regulations, in premises subject to alterations while occupied.
It was also pleasing to note that on one occasion that was inspected that a CSI had the confidence to, quite correctly, refuse to undertake a consultation due to insufficient information provided by an approved CSI.

Action Points

That this report is made available to all TFS staff before 1st April 2010.
The findings of this report are communicated to all TFS CSI’s at a future Department Training Day.
That this report is made publicly available on the website before 1st April 2010.
That the Risk Management Strategy with revised workflow processes is released before 1st April 2010.
That the use of standard paragraphs on Arson prevention continues to be promoted to all CSI’s carrying out Building Regulations Consultations.

Quality Audits 2009-10 Report into Findings