Assessment Report

Hughes Safety Showers Limited

Assessment dates Assessment Location(s) Report author Assessment Standard(s)

28/02/2023 to 28/02/2023 (Please refer to Appendix for details) Stockport (000) Christopher Wright ISO 9001:2015

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Assessment Report.

Table of contents Executive summary … 3 Changes in the organization since last assessment … 4 NCR summary graphs … 4 Your next steps … 6 NCR close out process … 6 Assessment objective, scope and criteria … 6 Statutory and regulatory requirements … 6 Assessment participants … 7 Assessment conclusion … 7 Findings from previous assessments … 8 Findings from this assessment … 13 Opening Meeting: … 13 QMS Objectives, targets and management programmes: … 13 Management review: … 14 Internal audits QMS: … 14 Changes in context, interested parties and needs and expectations: … 15 Nonconformity and corrective action: … 15 Risks and Opportunities: … 16 Order Processing UK Order processing Decontamination: … 16 Goods receiving/stores: … 17 Assembly: Premier: … 18 Packing & Despatch: … 19 Resource, Competence, training and awareness: … 19 Major (1) nonconformities arising from this assessment. … 20 Minor (6) nonconformities arising from this assessment. … 21 Next visit objectives, scope and criteria … 27 Next visit plan … 28 Appendix: Your certification structure & ongoing assessment programme … 29 Scope of certification … 29 Assessed location(s) … 29 Certification assessment programme… 30 Expected outcomes for accredited certification … 31 Definitions of findings: … 32 How to contact BSI … 32 Notes … 33 Regulatory compliance … 33

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Assessment Report.

Executive summary

This audit was carried out remotely with agreement of the client and has been conducted using Information and communication technologies including Teams and WhatsApp IT methodology, which was also with full agreement and support of the client.

The planned audit objectives have been achieved, there were no connectivity issues which adversely affected the audit.

The organisation’s strategy is “To be the most trusted EHS partner to distributors and customers worldwide”.

During the course of this visit, the quality management system has demonstrated that it is generally supporting the achievement of the intended outcomes. Relevant quality risks and opportunities were seen to have been effectively managed, however following changes of personnel several issues were identified with the quality management system

A particular strengths of the system identified was the openness and attitude of the employees interviewed.

Of the four non-conformances outstanding from the last assessment, two have been successfully closed. 1 major and 6 minor NCR’s have been identified during the assessment

A one day close out visit has accordingly been booked for 27 April 2023. This will be conducted by a qualified assessor and will be used as part of your evaluation of compliance against ISO9001:2015. This is chargeable at standard rates.

A corrective action plan is required. Please submit this through the BSI Connect Portal detailing the nonconformities, the root causes, correctios and your proposed corrective actions, with responsibilities and timescales allocated. The plan is to be submitted no later than 07/03/2023. If the corrective action plan is not received by this date you may be putting your certification status at risk.

It was noted that the client is not in possession of ISO9001:2015. This can be purchased from www.bsigroup.com

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Assessment Report.

Changes in the organization since last assessment

The following changes in relation to organization structure and key personnel involved in the certified management system were noted: New Operations Manager New QHSE Manager planned, March 2023 Supply Chain Manger has left the business

No change in relation to the audited organization’s activities, products or services covered by the scope of certification was identified.

There was no change to the reference or normative documents which is related to the scope of certification.

NCR summary graphs

Areas of the standard(s) where BSI recorded findings

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Which standard(s) BSI recorded findings against

Assessment Report.

Where BSI recorded findings

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Assessment Report.

Your next steps

NCR close out process

Corrective actions with respect to nonconformities raised at the last assessment have been reviewed. Actions were not found to be effectively implemented in all areas. Such areas, identified in subsequent sections of the report, will be further reviewed for closure at the next assessment. Both major nonconformities and minor nonconformities requiring attention were identified. These, along with other findings, are contained within subsequent sections of the report. A minor nonconformity relates to a single identified lapse in the management system. A major nonconformity indicates a breakdown in the management system’s ability to effectively control the processes for which it was intended. The identification of a major nonconformity places the validity of certification at risk. It is necessary to investigate the underlying cause of any nonconformity to determine corrective action. The proposed action will be reviewed for effective implementation at the next assessment.

Please refer to Assessment Conclusion and Recommendation section for the required submission and the defined timeline.

Assessment objective, scope and criteria The objective of the assessment was to conduct a surveillance assessment and look for positive evidence to verify that elements of the scope of certification and the requirements of the management standard are effectively addressed by the organization’s management system; that the system is demonstrating the ability to support the achievement of statutory, regulatory and contractual requirements and the organization’s specified objectives as applicable with regard to the scope of the management standard; to confirm the ongoing achievement and applicability of the forward strategic plan and where applicable to identify potential areas for improvement of the management system.

The scope of the assessment is the documented management system with relation to the requirements of ISO9001:2015 and the defined assessment plan provided in terms of locations and areas of the system and organization to be assessed.

ISO9001:2015 Hughes management system documentation

Statutory and regulatory requirements The management system contains processes for legal and other requirements and identifies the sources to be used for researching which legal and other requirements are applicable to the organisation and its activities Company Law, Employment laws and health, safety and environmental legislation all apply

The processes involved were considered to be effective in that there are no known breaches of applicable legislation.

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Assessment participants

Name

Position

Opening meeting

Closing meeting

Interviewed (processes)

Assessment Report.

Paul Darlington

David Forster

Kevin Whalley

Wayne Tomlinson

Chris Fletcher

Chloe Chapman

Managing Director Operations Manager Head of Sales Materials Controller Logistics Manager HR Business Partner

Assessment conclusion

X

X

X

X

X

X

X

X

X

X

BSI assessment team

Name

Christopher Wright

Position

Team Leader

Assessment conclusion and recommendation

The audit objectives have been achieved and the certificate scope remains appropriate. The audit team concludes based on the results of this audit that the organization does fulfil the standards and audit criteria identified within the audit report and it is deemed that the management system continues to achieve its intended outcomes.

RECOMMENDED - Corrective Action Closure Required (‘Major’ findings): The audited organization may be recommended for continued certification, based upon satisfactory closure of all ‘Major’ findings, and a satisfactory corrective action plan for all ‘Minor’ findings as shown in this report.

Please submit a plan through the BSI Connect Portal detailing the nonconformity, the root cause, correction and your proposed corrective action, with responsibilities and timescales allocated. The plan is to be submitted no later than 07/03/2023. If the corrective action plan is not received by this date you may be putting your certification status at risk.

For any questions please contact your local BSI office, referencing the report number 3499417.

An additional 1 day visit over and above the continuing assessment plan will be necessary to verify that the planned corrective action has been effectively implemented. This visit will take place on 27/04/2023.

2014882-202101-N3 and 2203367-202206-N2 remain outstanding

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Assessment Report.

Use of certification documents, mark / logo or report

The use of the BSI certification documents and mark / logo is not effectively controlled. Refer to NCR 2299848-202302-N1

Details: Hughes Safety Showers Limited hss_brochure_1021_web.pdf claims • ISO 9001:2015 Quality Management System Certification • ISO 14001:2015 Environmental Management Systems Standard • ISO 45001:2018 Health and Safety Management Systems Standard The business is not registered to ISO14001 or ISO45001

Findings from previous assessments

Finding Reference Certificate Standard Location reference

Category

2014882-202101-N3

Certificate Reference

FM 14474

ISO 9001:2015

Clause

9.3.1

0008915578-000

Minor

Area/process:

Management System

Details:

The current process for management review does not ensure the QMS is adequately reviewed for suitability, adequacy and effectiveness.

At present an annual review meeting is held (last conducted Jan 2020). The annual review typically concludes that the system is effective, however the impartial review informally conducted by the management team would indicate to the contrary e.g. lack of ownership of processes, documentation not reviewed and updated effectively.

Objective Evidence:

Cause

Monthly top management reviews take place. It is understood that the organization will consider an agenda matrix, to ensure full coverage of requirements. Will follow up at the next audit. Annual Management Review is not fit-for-purpose.

Correction/containment

Monthly top management reviews take place. It is understood that the organization will consider an agenda matrix, to ensure full coverage of requirements. Will follow up at the next audit. Annual Management Review is not fit-for-purpose.

Corrective action

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Monthly top management reviews take place. It is understood that the organization will consider an agenda matrix, to ensure full coverage of requirements. Will follow up at the next audit. Annual Management Review is not fit-for-purpose.

Assessment Report.

Closed?:

No

Justification

Monthly top management reviews take place. It is understood that the organization will consider an agenda matrix, to ensure full coverage of requirements. Will follow up at the next audit. Annual Management Review is not fit-for-purpose.

09/12/2021 Good progress, however, 2022 Dploy review forthcoming, which may incorporate Management Review elements.

23-06-22 Top Management conduct monthly meetings and elements of the QMS are discussed. Thee are to be rolled out into a formal set of minutes and will be reviewed annually in the January audits.

28/2/2023

• No progress has been made. See Major NCR

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Assessment Report.

2142637-202112-N1

Certificate Reference

FM 14474

ISO 9001:2015

Clause

4

0008915578-000

3284875

Minor

Finding Reference Certificate Standard Location reference Assessment Number

Category

Area/process:

Context/issues, risks and opportunities; Interested parties and needs and expectations

Details:

Context of the organization has not been fully realised.

Objective Evidence:

Cause

JREMEA-HS-FM-026 00 Risk and Opportunities (Oct 2018).xlsx (4.1) Interested parties register 2020.xlsx (4.2)

• The above two docs are overdue a review.

Issue pre-dates current Operations Manager

Correction/containment

Context of the organisation power point created

Corrective action

Context of the organisation power point document 7/8/2022 seen and evidenced

Closed?:

Yes

Justification

23-06-2022 The document still requires a review as it is dated 15-04- 2020.

28/2/2023 Context of the organisation and associated documents evidenced and now satisfactory

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Assessment Report.

2203367-202206-N1

Certificate Reference

FM 14474

ISO 9001:2015

Clause

9.1.2

0008915578-000

3394466

Minor

Finding Reference Certificate Standard Location reference Assessment Number

Category

Area/process:

Non-conformity and Correctives Action, Customer Satisfaction and Complaints

Details:

Objective Evidence:

Cause

The process was not fully effective

Measure the levels of satisfaction from Customers and report at the management review meeting

While Hughes were able to demonstrate processes are managed well to deal with customer issues, there is little in place to show proactive, ongoing sampling of customer opinion etc (regardless of complaints.)

Correction/containment

Consider a formal survey.

Corrective action

Carry out a formal survey.

Closed?:

Yes

Justification

• Customer survey not used
• Days to close complaint measured.
• Customer complaint log in place. Evidenced
• QMS015, issue 1.4, 23/12/2020 refers

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Assessment Report.

2203367-202206-N2

Certificate Reference

FM 14474

ISO 9001:2015

Clause

7.1.5.2

0008915578-000

3394466

Minor

Finding Reference Certificate Standard Location reference Assessment Number

Category

Area/process:

Tank Showers and Test Bed

Details:

Objective Evidence:

Cause

The process was not effective

Ensure that all equipment is calibrated as specified and ensure that supporting certificates and labels are affixed to the equipment.

The issue here was a Fluke multimeter whose calibration had expired. The meter was pulled form a drawer by the Tanks team leader. Subsequent discussion confirmed that this meter had not been used for some considerable time, and that the area concerned was appropriately serviced by meters within expiration.

Correction/containment

Meter concerned was sent to PASS UK for calibration that next day.

Corrective action

Review calibration log and equipment on shopfloor for any issues. None found. Larger process is working

Closed?:

No

Justification

28/2/2023 Issue remains open. See also, further NCR

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Assessment Report.

Findings from this assessment

Opening Meeting:

• Business overview presented
• Meeting held with the MD and Operations Manager
• Visit scope and plan confirmed.
• Future visits planned
• A follow up of conclusions resulting from internal audits was carried out and there are two outstanding issues: 2014882-202101-N3, 2203367-202206-N2

QMS Objectives, targets and management programmes: Evidence:

• QMS000, issue 1.2 J Last updates: 25/2/2021
• Policy. Endorsed by Paul Darlington, MD, 25/2/2021
• Policy displayed on notice boards, and reception.

Objectives:

• Level 1 objectives set by Justrite Safety Group CEO. Growth, continual Improvement
• Level 2 objectives set by the MD. Strategy ‘X’ Chart used
• Level 3 objectives cascaded to departments and individuals as necessary

The objectives are defined in KPI’s:

• Maintain registration to BS EN ISO 9001:2015 Quality Standard
• Internal Audit Schedule Compliance
• Cost of Escaping Defects. Achieved 8/12 months
• Average time to close NCR <14 days. 10 days average throughout 2022
• Customer of customer complaints <8 per month. Achieved
• BOM accuracy 92.71%. Actual 92.56%
• Deployed objectives document seen. Satisfactory

Planned activities have been fully realised for the processes above

Methods and determination of process results.

• Management review
• The above objectives are measured and reported on a monthly basis, a colour coded system of tables and graphs are used to pictorially identify any trends or shortfalls.

Process results

• Planned activities have been achieved.

The above evidence demonstrates, the system’s ability to deliver its intended outcomes and the process is considered to be effective.

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Assessment Report.

Management review: Evidence:

There has been no management review +++ See Major NCR +++

Planned activities have not been fully realised for the processes above.

Methods and determination of process results.

• See Major NCR below

Process results

• Planned activities have not been achieved.

The above evidence does not demonstrate, the system’s ability to deliver its intended outcomes and the process is considered to be effective.

Internal audits QMS: Evidence:

• 2021/2022 plan seen
• 4 internal audits planned for 2022

Reviewed:

• QMS014, Manufacturing, Showers and Tanks, 06/2022, dated 10/1/2022. No issues

• QMS018, Fabrication. 07/2022, dated 23/2/2022. No issues

• Manufacturing Composites. 08/2022, planned for 22/5/2022. not available. Audit plan shows audit planned but not completed. Audit appears to be misfiled

• QMS systems planned for 29/5/2022. Not completed +++ See NCR +++

• No audits carried out so far in 2023

• Design (QMS051) last audited 17/6/2021. Evidenced

• Purchasing/Stores (QMS044) last audited 26/5/2021. Evidenced

• Packing (QMS025) last audited 13/9/2021. Evidenced. 1 NCR raised. Seen on log. Closed 13/12/2021

Planned activities have not been fully realised for the processes above.

Methods and determination of process results.

• Audit plan reviewed
• QMS003, issue 1.1 G

Process results

• Planned activities have been not been achieved.

The above evidence does not demonstrate, the system’s ability to deliver its intended outcomes and the process is considered to be effective.

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Assessment Report.

Changes in context, interested parties and needs and expectations: Evidence:

• Context of the organisation power point document 7/8/2022 seen and evidenced
• SWAT analysis in place
• Understanding context
• PESTLE analysis
• Needs ands expectations of interested parties
• Interested parties register Rev 3, 24/2/2022. also covers internal and external issues.

Planned activities have been fully realised for the processes above.

Methods and determination of process results.

• Reviewed by senior management and group CEO

Process results

• Planned activities have been achieved.

The above evidence demonstrates, the system’s ability to deliver its intended outcomes and the process is considered to be effective.

Nonconformity and corrective action: Evidence:

• Corrective action log QMD045 in place and evidenced, created 30/1/2019
• Records internal opportunities for improvement
• QMD045 Log unused since 2020/2021
• Audit programme used to record issues from 2021
• Issues raised at last assessment on 3/7/2022 are not entered on the log +++ NCR +++

Customer complaints/Customer Satisfaction:

• Customer complaint log in place. Evidenced
• 87 complaints since the last audit. 75 justified
• Customer Satisfaction is measured by repeat business and complaints
• QMS015, issue 1.4 23/12/2020 refers +++ NCR +++

Planned activities have not been fully realised for the processes above.

Methods and determination of process results.

• Please see NCR’s below

Process results

• Planned activities have not been achieved.

The above evidence does not fully demonstrate, the system’s ability to deliver its intended outcomes and the process is considered to be effective

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Risks and Opportunities: Evidence:

• Risks and opportunities log 2022, rev 3 seen and satisfactory. Links to SWOT and PESLTE analysis
• Impact, probability, significance all considered. Red=Significant, Green=insignificant

Planned activities have been fully realised for the processes above.

Assessment Report.

Methods and determination of process results.

• Annual review

Process results

• Planned activities have been achieved.

The above evidence demonstrates, the system’s ability to deliver its intended outcomes and the process is considered to be effective.

Order Processing UK Order processing Decontamination: Evidence:

• Sales Force used
• RFQ often requested from customers
• QMS009 Sales process, Issue 1E, 24/1/2019

Reviewed:

• Request for quote 3/9/2022, Flowtronix ltd, Q094403-5 (5th revision). All revisions saved

• Quotes seen. Lead time and shipping terms shown

• Certificate of Origin

• Export/Import duties arranged by customer

• Customer Purchase Order PO/FTJ/I/6676, 27/10/2022 (Quote Rev 6 accepted)

• Order entered onto Sage software

• Bill of Materials created

• Process for populating order demonstrated. All product lines added

• All orders held in separate folders on system

• Sales order 110692 seen

• Drawing approval required by customer for approval

• Commercial checks and financial and technical validation (contract review) carried out

• Order passed to operations and production for planning

Planned activities have been fully realised for the processes above.

Methods and determination of process results.

• Commercial checks and financial and technical validation (contract review) carried out

Process results

• Planned activities have been achieved.

The above evidence demonstrates, the system’s ability to deliver its intended outcomes and the process is considered to be effective.

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Assessment Report.

Goods receiving/stores: Evidence:

• Items arrive during the day, mainly carriers
• Supplier Manplas Delivery note 210142, 28/2/2023, PO No.229197. 2 product lines
• Items matched against delivery note
• Delivery paperwork matched against purchased
• Discrepancies reported to Purchasing Manager. Back orders normally required
• Stores personnel book items in. Log in provides traceability
• Any Certificates of Conformity passed to Engineering department
• Visual and quantity inspections carried
• Pre determined locations used. Card system used to control stocks
• New pars allocated permanent locations or temporary holding locations
• Slow moving stock assessed by engineering department
• Cycle count checks carried out daily. Each cycle takes about 1 month to complete
• Quarantine location provided. Purchasing department advised
• Purchasing department determine disposition of faulty/damaged items
• Delivery notes filed and passed to Finance for payment
• Production Team Leaders issue works order to stores
• Stores raise pick list. 57598: Internal (Hughes North America) 28/2/2023 evidenced
• Individual operators log items on own system and provides traceability
• Shows all details required by picker
• Stores issue to works and stocks reduced on system
• Items delivered to works areas by stores
• Sage system screenshots viewed

Planned activities have been fully realised for the processes above

Methods and determination of process results.

• Cycle counts carried out
• Stock accuracy monitored
• Slow moving stock assessed
• Random pick checks carried out

Process results

• Planned activities have been achieved.

The above evidence demonstrates, the system’s ability to deliver its intended outcomes and the process is considered to be effective.

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Assessment Report.

Assembly: Premier: Evidence:

• Process seen and virtual tour via WhatsApp

• Items recently picked seen on pick lists

• Works order 57118, SO111862: Johnson Matthey

• Job pack issued contains drawings, Bill of Material issued to operators. Team leaders responsible for issuing drawings and removing old ones

• Model 32K cubical showers seen in production.

• Finished goods area seen

• Operators sign works order as evidence of final inspection

• Works order 55347, signed by NH

• Works order 56324, sales order 111545, signed by JW

• Final inspection passed labels seen

• There is no evidence of controlled issue of drawings to operators and removal of older versions +++ See Minor NCR +++

• ELE008. Fluke multi meter Serial No. 43860322WS. Last calibrated 1/5/2022 (12 monthly) Pass calibration

• ELE004 Fluke multi meter Serial No. 38050340WS. Last calibrated 21/7/2022 (12 monthly) Pass calibration

• QMD022 Calibration Master inventory shows all calibrated items

• Green=valid. Black= out of use +++ See NCR +++

Planned activities have been fully realised for the processes above.

Methods and determination of process results.

• Daily production monitoring carried out
• Local QDCP Cell boards introduced (seen)

Process results

• Planned activities have been achieved.

The above evidence demonstrates, the system’s ability to deliver its intended outcomes and the process is considered to be effective.

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Assessment Report.

Packing & Despatch: Evidence:

• Job sheet from production confirms items ready for despatch
• Packing specification sheet attached to job sheet. Shows any packing requirements including special requirements
• Packing department pack according to schedule
• All items ticked when checked for specification and quantity
• Package details recorded, signed and dated (evidenced)
• 1116661: Vital Energi and 111700: Arco reviewed. Both completed and signed as required
• Shipping documentation completed for domestic and exports. Process described
• HRIS (Human Resource Integrated System) in use
• Annual competence assessments carried out each March. evidenced for JW and NH

Planned activities have been fully realised for the processes above.

Methods and determination of process results.

• Annual competence assessments

Process results

• Planned activities have been achieved.

The above evidence demonstrates, the system’s ability to deliver its intended outcomes and the process is considered to be effective.

Resource, Competence, training and awareness: Evidence:

Skills matrix previously used. Production Manager is recreating

• Competencies assessed
• All personnel issued with job description
• Personnel assessed by management
• 3 month probation period
• Induction, contract issued
• HRIS (Human Resource Integrated System) in use
• Annual competence assessments carried out each March. Evidenced for JW and NH

Planned activities have been fully realised for the processes above.

Methods and determination of process results.

• Annual competence assessments

Process results

• Planned activities have been achieved.

The above evidence demonstrates, the system’s ability to deliver its intended outcomes and the process is considered to be effective.

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Major (1) nonconformities arising from this assessment.

Assessment Report.

Finding Reference Certificate Standard Location reference Assessment Number

Category

2299848-202302-M1

Certificate Reference

FM 14474

ISO 9001:2015

Clause

9.3.1

0008915578-000

3499417

Major

Area/process:

Management review

Statement of non- conformance:

Clause requirements

Objective Evidence

Cause

Management Review

General Top management shall review the organization’s quality management system, at planned intervals, to ensure its continuing suitability, adequacy, effectiveness and alignment with the strategic direction of the organization.

No formal management review has been conducted since January 2020

Correction/containment

Corrective action

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Minor (6) nonconformities arising from this assessment.

Assessment Report.

Finding Reference Certificate Standard Location reference Assessment Number

Category

2299848-202302-N1

Certificate Reference

FM 14474

ISO 9001:2015

Clause

4.4.1

0008915578-000

3499417

Minor

Area/process:

Opening Meeting

Statement of non- conformance:

Clause requirements

Objective Evidence

Cause

The product brochure claims ISO Certified to standards that it is not registered to

The organization shall establish, implement, maintain and continually improve a quality management system, including the processes needed and their interactions, in accordance with the requirements of this International Standard.

Hughes Safety Showers Limited hss_brochure_1021_web.pdf claims: • ISO 9001:2015 Quality Management System Certification • ISO 14001:2015 Environmental Management Systems Standard • ISO 45001:2018 Health and Safety Management Systems Standard The business is not registered to ISO14001 or ISO45001

Correction/containment

Corrective action

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Assessment Report.

2299848-202302-N2

Certificate Reference

FM 14474

ISO 9001:2015

Clause

9.2.1

0008915578-000

3499417

Minor

Finding Reference Certificate Standard Location reference Assessment Number

Category

Area/process:

Internal audits QMS

Statement of non- conformance:

Clause requirements

Objective Evidence

Cause

The internal audit system is not effective

The organization shall conduct internal audits at planned intervals to provide information on whether the quality management system: a) conforms to:

1. the organization’s own requirements for its quality management system;
2. the requirements of this International Standard; b) is effectively implemented and maintained.

• Manufacturing Composites. 08/2022, planned for 22/5/2022. not available. Audit plan shows audit planned but not completed. Audit appears to be misfiled
• QMS systems planned for 29/5/2022. Not completed
• 2023 audit plan to be created

Correction/containment

Corrective action

Page 22 of 33

Assessment Report.

2299848-202302-N3

Certificate Reference

FM 14474

ISO 9001:2015

Clause

10.2.2

0008915578-000

3499417

Minor

Finding Reference Certificate Standard Location reference Assessment Number

Category

Area/process:

Nonconformity and corrective action

Statement of non- conformance:

Clause requirements

Objective Evidence

Cause

The requirements have not been met

The organization shall retain documented information as evidence of: a) the nature of the nonconformities and any subsequent actions taken; b) the results of any corrective action.

• QMD045 Log unused since 2020/2021

Correction/containment

Corrective action

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Assessment Report.

2299848-202302-N4

Certificate Reference

FM 14474

ISO 9001:2015

Clause

7.5.3.1

0008915578-000

3499417

Minor

Finding Reference Certificate Standard Location reference Assessment Number

Category

Area/process:

Nonconformity and corrective action

Statement of non- conformance:

Clause requirements

Objective Evidence

Cause

Document control requirements have not been fully met

Documented information required by the quality management system and by this International Standard shall be controlled to ensure: a) it is available and suitable for use, where and when it is needed; b) it is adequately protected (e.g. from loss of confidentiality, improper use, or loss of integrity).

Not all documents have been reviewed as required by QMS008 1.1H, 26/3/2021 eg:

• QMS015, issue 1.4, 23/12/2020
• QMS008, issue 1.1H, 26/3/2021
• QMS009, Issue 1.1E, 24/1/2019

Correction/containment

Corrective action

Page 24 of 33

Assessment Report.

2299848-202302-N5

Certificate Reference

FM 14474

ISO 9001:2015

Clause

7.1.5.2

0008915578-000

3499417

Minor

Finding Reference Certificate Standard Location reference Assessment Number

Category

Area/process:

Assembly: Premier

Statement of non- conformance:

Clause requirements

Objective Evidence

Cause

There is a lack of control regarding calibration

Measurement traceability When measurement traceability is a requirement, or is considered by the organization to be an essential part of providing confidence in the validity of measurement results, measuring equipment shall be: a) calibrated or verified, or both, at specified intervals, or prior to use, against measurement standards traceable to international or national measurement standards; when no such standards exist, the basis used for calibration or verification shall be retained as documented information;

The organization shall determine if the validity of previous measurement results has been adversely affected when measuring equipment is found to be unfit for its intended purpose, and shall take appropriate action as necessary.

ELE004 Fluke multi meter Serial No. 38050340WS. Last calibrated 21/7/2022 (12 monthly) Pass calibration. QMD022 Calibration Master inventory shows due 9/6/2022

QMD022 Calibration Master inventory shows:

• ELE001 Meggar Insulation Continuity Tester, due 1/4/2022
• ELE002 Meggar Loop RCD Tester, due 1/4/2022
• ELE005 Fluke PAT Tester shows calibration, due 1/4/2022

Correction/containment

Corrective action

Page 25 of 33

Assessment Report.

2299848-202302-N6

Certificate Reference

FM 14474

ISO 9001:2015

Clause

7.5.3.2

0008915578-000

3499417

Minor

Finding Reference Certificate Standard Location reference Assessment Number

Category

Area/process:

Assembly: Premier

Statement of non- conformance:

Clause requirements

Objective Evidence

Cause

There is a lack of control regarding issue of drawings to the shop floor

For the control of documented information, the organization shall address the following activities, as applicable: a) distribution, access, retrieval and use; b) storage and preservation, including preservation of legibility; c) control of changes (e.g. version control); d) retention and disposition.

There is no evidence of controlled issue of drawings to operators and removal of older versions

Correction/containment

Corrective action

Page 26 of 33

Assessment Report.

Next visit objectives, scope and criteria

The objective of the assessment is to conduct a surveillance assessment and look for positive evidence to verify that elements of the scope of certification and the requirements of the management standard are effectively addressed by the organization’s management system; that the system is demonstrating the ability to support the achievement of statutory, regulatory and contractual requirements and the organization’s specified objectives as applicable with regard to the scope of the management standard; to confirm the ongoing achievement and applicability of the forward strategic plan.

The scope of the assessment is the documented management system with relation to the requirements of ISO9001:2015 and the defined assessment plan provided in terms of locations and areas of the system and organization to be assessed.

ISO9001:2015 Hughes management system documentation

Please note that BSI reserves the right to apply a charge equivalent to the full daily rate for cancellation of the visit by the organization within 30 days of an agreed visit date. It is a condition of registration that a deputy management representative be nominated. It is expected that the deputy would stand in should the management representative find themselves unavailable to attend an agreed visit within 30 days of its conduct.

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Next visit plan

Date

Auditor

Time

Area/process

Clause

27/04/2023

Berkay Ozgil 09:00 Opening Meeting

Assessment Report.

09:30

NCR Close Out

12:30

Lunch

13:00

NCR Close Out

15:00

Report Preparation

16:00

Closing Meeting

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Assessment Report.

Appendix: Your certification structure & ongoing assessment programme

Scope of certification

FM 14474 (ISO 9001:2015) The design, development, manufacture and supply of industrial safety showers, eyebaths, decontamination units, cubicles and peripherals to company or customer specifications.

Assessed location(s)

The audit has been performed at Central Office, Permanent Locations.

Stockport / FM 14474 (ISO 9001:2015)

Location reference Address

Visit type

Assessment number

Assessment dates

0008915578-000 Hughes Safety Showers Limited Whitefield Road Bredbury Stockport SK6 2SS United Kingdom

Continuing assessment (surveillance)

3499417

28/02/2023

Deviation from audit plan

Total number of Employees

No

80

Effective number of Employees Scope of activities at the site The design, development, manufacture and supply of

80

industrial safety showers, eyebaths, decontamination units, cubicles and peripherals to company or customer specifications.

Assessment duration

1 day(s)

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Certification assessment programme

Certificate number - FM 14474 Location reference - 0008915578-000

Assessment Report.

Audit1

Audit2

Audit3

Audit4

Audit5

Audit6

Audit7

01/22

07/22

01/23

07/23

01/24

07/24

04/23

1

X

X

X

X

X

X

1

X

X

X

X

X

X

X

X

Business area/location

Date (mm/yy):

Duration (days):

QMS Objectives, targets and management programmes

Management review

Internal audits QMS

Changes in context, interested parties and needs and expectations

Risks and Opportunities

Customer satisfaction/complaints

Technical Design & Dev & drawing control

Servicing dept. (site visit once in cycle or office review of controls) - Not yet added to scope of certification

Goods receiving/stores

Purchasing/Supplier Management & Contractor control

Fabrication

Assembly: Tank showers Plus test bed

Assembly: Premier

Assembly: EXP

Order processing Export

Packing & Despatch

Resource, Competence, training and awareness

Nonconformity and corrective action

X

X

Order processing Decontamination

Order Processing UK

Leadership and commitment top management discussion

Recertification by strategic review

NCR Close Out

Page 30 of 33

1

X

X

X

X

X

X

X

X

X

X

X

X

1

X

X

X

X

X

X

X

X

X

1

X

X

X

X

X

X

X

X

X

X

X

X

1

1

X

X

X

X

X

X

Assessment Report.

Expected outcomes for accredited certification What accredited management system certification means? To achieve an organization’s objectives related to the Expected Outcomes intended by the management systems standard, the accredited management system certification is expected to provide confidence that the organization has a management system that conforms to the applicable requirements of the specific ISO standard.

In particular, it is to be expected that the organization • has a system which is appropriate for its organizational context and certification scope, a defined policy appropriate for the intent of the specific management system standard and to the nature, scale and impacts of its activities, products and services over their lifecycles, is addressing risks and opportunities associated with its context and objectives; • analyses and understands customer needs and expectations, as well as the relevant statutory and regulatory requirements related to its products, processes and services; • ensures that product, process and service characteristics have been specified in order to meet customer and applicable statutory/regulatory requirements; • has determined and is managing the processes needed to achieve the Expected Outcomes intended by the management system standard; • has ensured the availability of resources necessary to support the operation and monitoring of these products, processes and services; • monitors and controls the defined product process and service characteristics; • aims to prevent nonconformities, and has systematic improvement processes in place including the addressing of complaints from interested parties; • has implemented an effective internal audit and management review process; • is monitoring, measuring, analysing, evaluating and improving the effectiveness of its management system and has implemented processes for communicating internally, as well as responding to and communicating with interested external parties.

What accredited management systems certification does not mean? It is important to recognize that management system standards define requirements for an organization’s management system, and not the specific performance criteria that are to be achieved (such as product or service standards, environmental performance criteria etc).

Accredited management systems certification should provide confidence in the organization’s ability to meet its objectives related to the intent of the management system standard. A management systems audit is not a full legal compliance audit, and does not necessarily ensure ethical behaviour or that the organization will always achieve 100% conformity and legal compliance, though this should of course be a permanent goal.

Within its scope of certification, accredited management systems certification does not imply or ensure, for example: • that the organization is providing a superior product and service, or • that the organization’s product and service itself is certified as meeting the requirements of an ISO (or any other) standard or specification.

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Assessment Report.

Definitions of findings:

Nonconformity: Non-fulfilment of a requirement.

Major nonconformity: Nonconformity that affects the capability of the management system to achieve the intended results. Nonconformities could be classified as major in the following circumstances: • If there is a significant doubt that effective process control is in place, or that products or services will meet specified requirements; • A number of minor nonconformities associated with the same requirement or issue could demonstrate a systemic failure and thus constitute a major nonconformity.

Minor nonconformity: Nonconformity that does not affect the capability of the management system to achieve the intended results.

Opportunity for improvement: It is a statement of fact made by an assessor during an assessment, and substantiated by objective evidence, referring to a weakness or potential deficiency in a management system which if not improved may lead to nonconformity in the future. We may provide generic information about industrial best practices but no specific solution shall be provided as a part of an opportunity for improvement.

How to contact BSI

Visit the BSI Connect Portal, our web-based self-service tool to access all your BSI assessment and testing data at a time that’s convenient to you. View future audit schedules, submit your corrective action plans and download your reports and Mark of Trust logos to promote your achievement. Plus, you can benchmark your performance using our dashboards to help with your continual improvement journey.

Should you wish to speak with BSI in relation to your certification, please contact your local BSI office – contact details available from the BSI website: https://www.bsigroup.com/en-GB/UK-office-locations/

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Assessment Report.

Notes

This report and related documents are prepared for and only for BSI’s client and for no other purpose. As such, BSI does not accept or assume any responsibility (legal or otherwise) or accept any liability for or in connection with any other purpose for which the Report may be used, or to any other person to whom the Report is shown or in to whose hands it may come, and no other persons shall be entitled to rely on the Report. If you wish to distribute copies of this report external to your organization, then all pages must be included.

BSI, its staff and agents shall keep confidential all information relating to your organization and shall not disclose any such information to any third party, except that in the public domain or required by law or relevant accreditation bodies. BSI staff, agents and accreditation bodies have signed individual confidentiality undertakings and will only receive confidential information on a ‘need to know’ basis.

This audit was conducted through document reviews, interviews and observation of activities. The audit method used was based on sampling the organization’s activities and it was aimed to evaluate the fulfilment of the audited requirements of the relevant management system standard or other normative document and confirm the conformity and effectiveness of the management system and its continued relevance and applicability for the scope of certification.

As this audit was based on a sample of the organization’s activities, the findings reported do not imply to include all issues within the system.

Regulatory compliance

BSI conditions of contract for this visit require that BSI be informed of all relevant regulatory non- compliance or incidents that require notification to any regulatory authority. Acceptance of this report by the client signifies that all such issues have been disclosed as part of the assessment process and agreement that any such non-compliance or incidents occurring after this visit will be notified to the BSI client manager as soon as practical after the event.

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Project: Q-21699 - Saipem COMP2 Folder: Zipped