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Health, Safety and Wellbeing Procedure - Inspections, Plans, Audits and Reviews

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Section 1 - Purpose

(1) This procedure sets out the processes used to monitor, measure and evaluate the work health and safety (WHS) management system at Charles Sturt University (the University).


(2) This procedure has the same scope as the Health, Safety and Wellbeing Policy.

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Section 2 - Policy

(3) See the Health, Safety and Wellbeing Policy.

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Section 3 - Procedures

Part A - Overview

(4) A range of processes, completed at different organisational levels, support the University's WHS management system. These are set out in detail in Parts B-E of this procedure and summarised in the following table.

Organisational unit level
Workplace inspections
Inspection of physical workspaces and environments.
All staff, all work areas
Laboratory and other high-risk work area inspections
Inspection of high risk physical workspaces and environments.
Technical staff, high-risk work areas
Annual WHS management plan and review
Operational and financial planning for any WHS improvements to be completed during the year, and review and acquittal of the previous year’s plan.
Secondary organisational units (e.g. faculty/division/office etc.)
Tertiary organisational units (e.g. schools/units etc.)
WHS audits
Independent evaluation of WHS systems and processes.
As required/scheduled
Health, Safety and Wellbeing, Internal Auditor or external auditors complete for specific organisational areas/levels.
WHS management system review
Complete review of all elements of the WHS management system.
Primary (e.g. portfolios), secondary and tertiary organisational units.

Part B - Workplace inspections

(5) Workplace inspections identify, assess and eliminate or control hazards in the workplace. Regular inspections that are carried out diligently and identify and eliminate or control risks lead to higher standards of workplace health and safety and are the key to the prevention of incidents and improved workplace safety culture.

Consultation with workers

(6) An important element of successfully implementing work health and safety workplace inspections involves meaningful and effective communication with workers aimed at achieving commitment from all areas and levels within each organisational unit. Managers/supervisors need to plan for how consultation will be achieved and how ideas and actions will be communicated.

(7) For assistance or guidance on work health and safety consultation at the University, refer to the Health, Safety and Wellbeing website.

Conduct of workplace inspections

(8) All persons in charge of workplaces must ensure that WHS inspections of their workplaces are completed and appropriate controls are implemented. Records of all hazards identified and actions undertaken to rectify or control those hazards must be kept.

(9) When organising workplace inspections:

  1. where workplaces are geographically large or where there are a large number of facilities, it may be prudent to carry out inspections on the separate locations and combine them into a single report; this approach can be carried out over several months
  2. where facilities or workplaces are shared, the persons in charge of those facilities or who manage staff in the workspace must collaborate and organise how the workplace will be inspected and ensure records are kept by each unit
  3. where facilities or workplaces have no nominated person in charge, such as shared teaching spaces and lecture rooms, Facilities Management will nominate a person to coordinate and/or conduct inspections.

(10) Managers/supervisors should enlist the aid of their employees (with knowledge or expertise in the particular areas where relevant) to assist in the conduct of inspections. The number of persons needed to carry out an inspection is generally limited to about three persons. However, the task should be rotated to involve as many employees as possible in the workplace inspection program.

(11) Health and safety representatives (HSRs) have a legal right to inspect workplaces and may schedule this activity. Managers/supervisors should keep in contact with their HSR and may find it beneficial to conduct inspections with them.

(12) Health, Safety and Wellbeing will provide relevant workplace inspection checklists on their website. These can be used to form the basis of workplace inspection records.

(13) Workplace inspections are intended to detect hazards and should not be unduly critical or concerned with insignificant details. The approach of the inspection team should be to determine that everything is satisfactory rather than to determine how many things are wrong. The Health, Safety and Wellbeing website provides further information on the completion of workplace inspections.

(14) When the workplace inspection is completed, all unsatisfactory items recorded on the checklist (i.e. the hazards identified) must be addressed by raising a work order with Facilities Management or other appropriate action.

(15) Information from workplace inspection action sheets will be used to inform WHS annual management plans and reviews.

(16) Organisational units must make adequate resources available to manage WHS and to action any issues. These resources may be financial, physical (e.g. facilities and equipment) and/or human.

Part C - Annual WHS management plan and review

WHS management plans

(17) Each organisational unit must produce an annual WHS management plan within the first quarter of the year.

(18) Information in the WHS management plan should include:

  1. requirements for WHS information, instruction and training
  2. objectives and targets to minimise risks from hazards (see the WHS Procedure – Risk and Hazard Management)
  3. planning and programming of risk assessments and risk control measures (including development of operating procedures or other administrative controls where required)
  4. emergency and contingency plans
  5. achievable goals for the period, focusing on essential items that require attention
  6. action due dates and responsible persons, and
  7. items that have been rolled over from previous plans.

(19) The WHS management plan must be:

  1. communicated to all workers in the organisational unit
  2. retained in an appropriate records management system for at least five years
  3. provided, as required, to heads of the portfolio or faculty/division/office etc. for budget and WHS discussions, and
  4. provided to Health, Safety and Wellbeing for review and advice.

(20) Actions against the plans should be monitored throughout the year. Plans will be reviewed and acquittals completed annually in due diligence reporting.

Part D - WHS audits

General audit arrangements

(21) The University’s WHS management systems are audited to evaluate their effectiveness and facilitate continual improvement. This includes evaluating:

  1. levels of compliance with WHS policy, procedures and legislation, and
  2. implementation, maintenance and effectiveness of the WHS management system.

(22) WHS audits may be internal or external:

  1. Within the University there are three levels of WHS audit:
    1. WHS inspections (see Part B).
    2. WHS systems audits: audits conducted by Health, Safety and Wellbeing according to a plan and schedule. These audits are an objective assessment of the extent to which the University's WHS framework, policy and procedures have been implemented and compliance with statutory requirements.
    3. Internal Audits: audits conducted under the Internal Audit Charter.
  2. External Audits: audits by an external auditor or assessor independent of the University. This is to verify that the internal audits are a valid assessment of the University's WHS compliance.

WHS system audits

(23) The Manager, Health Safety and Wellbeing will:

  1. prepare a three-year WHS audit plan, and
  2. prepare an annual WHS audit schedule in consultation with the University Safety and Health Management Committee (USHMC) and the areas that will be audited), ensuring that audits do not conflict with peak business periods such as exams or on-campus intensive schools.

(24) WHS audit schedules will be based on risk (hazard profile, incidents, previous audit results and workplace inspection results).

(25) The outcomes of the WHS system audits, including levels of compliance/non-compliance and any corrective actions required, will be reported to the USHMC and Audit and Risk Committee. Corrective actions may be included in the University's enterprise action register.

Part E - WHS management system review

(26) All aspects of the WHS management system are reviewed at planned intervals to ensure its continuing suitability, adequacy and effectiveness.

(27) The Executive Leadership Team is responsible for the University WHS management system review.

(28) Heads of faculty/division/office are responsible for their organisational unit’s WHS management system review(s).

Faculty/division/office WHS management systems

(29) Each faculty/division/office executive leader will ensure their organisational unit’s WHS management system is reviewed, following advice from the Division of Safety, Security and Wellbeing.

(30) Reviews must be documented and plans developed to implement improvements where gaps are identified. A copy of reviews and associated plans must be sent to Health, Safety and Wellbeing.

(31) Faculty/division/office leadership teams must monitor open actions and ensure these are completed and the actions closed.

Continuous WHS management system reviews

(32) Health, Safety and Wellbeing will:

  1. continuously review the University's WHS management system
  2. monitor legislative changes and amend the University's WHS management system and supporting procedures accordingly, and
  3. provide due diligence reports to the Executive Leadership Team on the outcomes of WHS management system reviews.
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Section 4 - Guidelines

(33) Nil.

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Section 5 - Glossary

(34) This procedure uses terms defined in the Health, Safety and Wellbeing Policy, as well as the following:

  1. Work health and safety (WHS) management system - means the interrelated or interacting elements of the University that establish the WHS policy and objectives, and all of the processes and systems in place to achieve those objectives, with the intended outcome of preventing injury and ill health to workers and provide safe and healthy workplaces (AS/NZS ISO 45001:2018).