March 2024
LCA membership includes the requirement to have an annual external audit by one of our occupationally competent assessors. The LCA have evolved our auditing documents over the last few years and now look in more depth and detail at our Member’s work. The audit questions break down the Member’s process and procedure (their plan) and the output evidence (following their plan) into a series of questions.
There is more detail than before and as a result we have seen Members with more non-conformances to the Code of Conduct and Service Standards. This is not a reflection on the performance of Members as such, but a greater granular breakdown of the detail that is expected. The “exam” questions that will be asked at audit are publicly available in the audit template and Members are welcome and encouraged to use these for their own internal auditing.
The Assessment team are also noticing that, especially when we look at a Service Standard for the first time with a Member since their revision in 2021, we are seeing an increase in the number of non-conformances.
This increase in non-conformances is to some extent expected as we are asking more detailed questions. The trend we have seen is for Members to have more issues raised at audit and then need to make updates to process. While we are helping members identify and address weaknesses in their process, it results in work and time pressure for Members that is avoidable.
Where LCA Members have followed requirement 7 of the Code and completed their own internal audit this detail has normally been addressed prior to the external LCA audit. This results in audits without non-conformances.
Where Members have not kept up to date with their internal auditing it is not uncommon for the LCA Assessor to find a dozen or more non-conformances that require evidence of resolution.
In the 2021-22 audit year, following the update to the LCA Code and Service Standards, our focus was on Member’s compliance with the Code of Conduct. From 2022 to date we have focussed on Service Delivery Standards. With an increased focus on work output, we are auditing from the completed work back to the process that was followed and then the people who were involved.
One significant finding at audit is more member vulnerabilities with training and competence records. While it is common to see good records for the “technicians”, we are seeing significant gaps for the other roles within legionella control, such as, Surveyors, Designers and Planners. Often these are office or sales staff who might not deliver the service to the client, but they play a crucial role in gathering information to design a service, designing that service, quoting work to a client and then planning the work in with the client. For all these roles, being able to evidence staff competence is a requirement of LCA Membership.
If an LCA Member disagrees with any finding at audit, they are able to appeal in the two weeks following issue of the audit report. The appeal will be examined in line with the LCA Code and Standards requirements and if the LCA has asked the Member to do more than these require, the audit findings may be adjusted.
Generally, Members have 3 months to resolve a non-conformance, unless it is significant enough to result in a shorter timeframe or an immediate suspension. Ideally Members should make a response to all non-conformances, with evidence of compliance, within 6 weeks of receiving the audit report to allow for matters to avoid being suspended.
If the non-conformances have not been responded to, assessed, and accepted by 3 months following the audit report issue date, a Member would normally be suspended. At six months the suspended Member becomes liable for termination of Membership.