Business Regulation Service Plan 2023-2024 CaH 22 08 23
Renfrewshire Council · 22 August 2023
Back to Communities and Housing Policy Board — 22 August 2023 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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To: Communities and Housing Policy Board On: 22 August 2023 Report by: Director of Environment, Housing and Infrastructure Heading: Business Regulation Service Plan 2023/2024 1. Summary 1.1 Renfrewshire Council is required by Food Standards Scotland (FSS) to produce a Service Plan to provide detail on the work being undertaken in Food Law across Renfrewshire Council. 1.2 The team who cover this for Renfrewshire Council (Business Regulation Team within Environment, Housing and Infrastructure) also lead on workplace health and safety and other areas of Environmental Health work which are included within the plan. 1.3 The Service Plan sets out the objectives, what work is undertaken, service delivery, resources and quality assurance. 1.4 The Business Regulation Service Plan 2023/24 is attached to this report as an appendix. 2. Recommendations It is recommended that the Communities and Housing Policy Board: 2.1 Approves the Business Regulation Service Plan 2023/24. 3. Background 3.1 Business Regulation forms part of the Climate, Public Protection and Roads Service within Environment, Housing and Infrastructure.
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3.2 The team provide an effective regulatory service for food law, and occupational health and safety at work on behalf of Renfrewshire Council, ensuring the Council’s statutory responsibilities are met. The objective of the service is to improve the quality and effectiveness of these regulatory activities, and in doing so ensure public health and safety are maintained. 3.3 In terms of food law enforcement, Renfrewshire Council is a statutory food authority under the Food Safety Act 1990 for all food businesses within Renfrewshire. The Council is also an enforcing authority in terms of Section 18 of the Health & Safety at Work etc. Act 1974, the Service is the enforcing authority for health & safety legislation in certain types of premises within Renfrewshire. This is determined by the main activity being undertaken at the premises as laid down in the Health and Safety (Enforcing Authority) Regulations 1998. 3.4 Section 18 of the Health and Safety at Work etc Act 1974 puts a duty on the HSE and Local Authorities (LAs), as Enforcing Authorities, to make adequate arrangements for enforcement. The Section 18 Standard sets out the arrangements that LAs and HSE’s Field Operation Directorate should put in place to meet this duty. 3.5 The Business Plan 2023/24 highlights the work undertaken by the Business Regulation Team, the current position with regards to premises (as of 1 April 2023) and the planned work for the coming 12 months. 3.6 Due to the Covid-19 pandemic, the Minister for Public Health and Sport granted local authorities a deviation from the Food Law Code of Practice (Scotland) The deviation was reviewed and extended several times throughout 2020 and 2021 and ended on 1 September 2021. 3.7 As a result, and in agreement with Food Standards Scotland, all local authorities were required to produce and submit an updated Service Plan detailing how they were going to inspect premises and recover from the Covid pandemic in the coming years. 3.8 The Board should note that whilst some programmed interventions at lower risk groups ceased over the 18 months from 1 September 2021 to 31 March 2023, a risk-based approach was taken to ensure higher risk premises such as approved premises, those in Group 1 and newly registered businesses, maintained a high standard. 3.9 In addition, intelligence driven interventions at all food business establishments continued where possible. Intelligence included information that suggested fraudulent activity or risk to public health, e.g. consumer complaints, or credible allegations of food poisoning. Implications of the Report 1. Financial – none 2. HR & Organisational Development - none
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3. Community Planning Renfrewshire is safe – By implementing the attached Service Plan, Environment, Housing and Infrastructure will ensure that food that is prepared and consumed in Renfrewshire is safe and that workplace Health & Safety is regulated. 4. Legal – none 5. Property/Assets - none 6. Information Technology - none 7. Equality & Human Rights - The Recommendations contained within this report have been assessed in relation to their impact on equalities and human rights. No negative impacts on equality groups or potential for infringement of individuals’ human rights have been identified arising from the recommendations contained in the report 8. Health & Safety – where staff are required to visit premises, all risk assessments and safe working procedures have been developed. 9. Procurement - none 10. Risk - none 11. Privacy Impact - none 12. CoSLA Policy Position - None 13. Climate Risk - None List of Background Papers None Author: Robert Marshall, Environmental Health (Business Regulation) Manager e-mail: Robert.marshall@renfrewshire.gov.uk
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1 A Business Regulation Service Plan 2023-2024 Environment, Housing and Infrastructure
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Business Regulation Service Plan 2023-2024 2 Contents 1. Service Aims and Objectives .............................................................. 4 1.1. Aims and Objectives .............................................................................. 4 1.2. Links to Corporate Objectives and Plans .............................................. 4 1.3. Overview ................................................................................................ 5 2. Background ........................................................................................ 5 2.1. Organisational Structure ....................................................................... 5 Role of Public Protection within Climate, Public Protection and Roads .................. 5 Environment, Housing and Infrastructure ............................................................... 6 2.2. Scope of the Service .............................................................................. 6 2.3. Local Authority Covid-19 Recovery Project ........................................... 7 2.4. Demands on the Service ....................................................................... 8 2.5. Performance Management ................................................................. 12 2.6. Enforcement Policy & Procedures ....................................................... 12 3. Service Delivery ................................................................................ 13 3.1. Food and Health & Safety Premises Inspections ................................ 13 3.2. Food and Health and Safety Service Requests ................................... 16 3.3. Investigation of Accidents ................................................................... 17 3.4. Enforcement Management Model (EMM) ............................................ 17 3.5. Home Authority Principle & Primary Authority Scheme...................... 17 3.6. Advice to Business ............................................................................... 19
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Business Regulation Service Plan 2023-2024 3 3.7. FHIS & EatSafe ..................................................................................... 19 3.8. Sampling ............................................................................................. 20 3.9. Control and Investigation of Outbreaks and Food Related Infectious Diseases ............................................................................................... 21 3.10. Food Incidents ..................................................................................... 22 3.11. Liaison with Other Organisations ........................................................ 22 4. Resources ......................................................................................... 23 4.1. Financial Allocation ............................................................................. 23 4.2. Staffing Allocation ............................................................................... 23 4.3. Employee Development Plan .............................................................. 24 5. Quality Assessment .......................................................................... 25 5.1. Quality Assessment & Internal Monitoring .......................................... 25 6. Review 2021-23 ................................................................................ 25 6.1. Review of Food Law Activity ................................................................ 25 6.2. Review of Health and safety activity. ................................................... 27 6.3. Areas for Improvement ........................................................................ 29 7. Emerging Issues 2023/24 ................................................................. 29 Appendix: Climate, Public Protection and Roads Staff Structure
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Business Regulation Service Plan 2023-2024 4 1. Service Aims and Objectives 1.1. Aims and Objectives The Food and Health & Safety Service is provided by Environment, Housing and Infrastructure, Climate, Public Protection and Roads. This function is delivered by the Environmental Health, Business Regulation Team. Which is based within the Climate, Public Protection and Roads area of the Service. The aim is to provide an effective regulatory service for food law, and occupational health and safety at work on behalf of Renfrewshire Council, ensuring the Council’s statutory responsibilities are met. The objective of the service is to improve the quality and effectiveness of these regulatory activities, and in doing so ensure public health and safety are maintained. In order to achieve this aim, Environment, Housing and Infrastructure will: o Apply the relevant legislation at premises regulated by the Local Authority in line with the Scottish regulators’ strategic code of practice. o Work in partnership with agencies such as Food Standards Scotland (FSS) and the Health and Safety Executive (HSE) to achieve nationally agreed strategic aims, o Ensure that all staff undertaking enforcement activity are properly qualified and competent to undertake their duties, o Operate a risk based approach to inspection and regulation, o Carry out a programme of specific, targeted and appropriate interventions in order to improve food safety, quality and health & safety standards, o Work with local businesses in an open and transparent manner, o Investigate and take appropriate action upon receipt of accident notifications, service requests, food borne infection notifications and complaints. 1.2. Links to Corporate Objectives and Plans The Environmental Health, Business Regulation Service Plan 2023-24 contributes to Climate, Public Protection and Roads outcomes as well as Renfrewshire Council’s Corporate Objectives and Plans. In particular, the service has a critical role to play in supporting sustainable economic development, ensuring the health and safety of the public, addressing the impact of poverty and the protection of both the public and legitimate businesses from criminal activities.
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Business Regulation Service Plan 2023-2024 5 1.3. Overview In terms of food law enforcement, Renfrewshire Council is a statutory food authority under the Food Safety Act 1990 for all food businesses within Renfrewshire. The Council is also an enforcing authority in terms of Section 18 of the Health & Safety at Work etc. Act 1974, the Service is the enforcing authority for health & safety legislation in certain types of premises within Renfrewshire. This is determined by the main activity being undertaken at the premises as laid down in the Health and Safety (Enforcing Authority) Regulations 1998. Section 18 of the Health and Safety at Work etc Act 1974 puts a duty on the HSE and Local Authorities (LAs), as Enforcing Authorities, to make adequate arrangements for enforcement. The Section 18 Standard sets out the arrangements that LAs and HSE’s Field Operation Directorate should put in place to meet this duty. 2. Background 2.1. Organisational Structure The Food Safety and Health & Safety service is delivered by suitably qualified officers within the Business Regulation Team operating in Environment, Housing and Infrastructure as part of the Climate, Public Protection and Roads service. (Appendix 2) Role of Public Protection within Climate, Public Protection and Roads Public Protection within Climate, Public Protection and Roads, consists of the Business Regulation, Community Safety, Public Health and Trading Standards teams. Their combined role is to protect the health, safety and welfare of the local community and to safeguard public health, the quality of the local environment and to enhance economic, social and environmental welfare by improving and maintaining standards of fair trading in terms of safety, quality, quantity and price.
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Business Regulation Service Plan 2023-2024 6 Environment, Housing and Infrastructure The Service is based at: Climate, Public Protection and Roads Renfrewshire House Cotton Street Paisley PA1 1BR The Service can be contacted by: email: b-serv.es@renfrewshire.gov.uk, or phone: 0300 300 0380 2.2. Scope of the Service The main role of Environmental Health, Business Regulation is to undertake regulatory functions of relevant legislation in terms of Food Law and Occupational Health and Safety at Work on behalf of Renfrewshire Council. The aim is to secure compliance with the standards laid down in primary legislation, associated regulations and codes of practice. The key activities of Environmental Health Business Regulation are based on the implementation of inspection/intervention, survey and sampling programmes and other appropriate monitoring and investigative activities, including responding to, and learning from food complaints, accidents and incidents at work. Under Section 5 of the Food Safety Act 1990, Renfrewshire Council is a statutory Food Authority, responsible for delivery of official controls under the Act and associated Regulations. Statutory appointments of Head of Food Service and Lead Officer for Food Safety are detailed in the Council’s Scheme of Delegated Functions. Enforcement of the legislation, under Section 6 of the Food Safety Act 1990, includes food hygiene and food standards covering the safety, quality, presentation and labelling of food. To this end, a programme of food business inspections and the surveillance of food is carried out by co-ordinated food sampling and a food standards inspection programme. Food and premises hygiene complaints are investigated where required. The investigation and control of food-borne infections within food premises is carried out in conjunction with NHS Greater Glasgow and Clyde. The Service acts as the originating authority to those large-scale food manufacturers within the area, co-ordinating and assisting in complaints and enquiries from other Food Authorities within the UK and third Countries.
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Business Regulation Service Plan 2023-2024 7 As an Enforcing Authority, the Service also has responsibility for the provision of health & safety enforcement services in a range of business activities covering approximately 2500 premises and an estimated 10,000 employees. The enforcement of health & safety legislation is split between the Local Authority (Renfrewshire Council) and the Health & Safety Executive (HSE), depending on the main activity being undertaken at the premises as laid down in the Health & Safety (Enforcing Authority) Regulations 1998. The HSE are responsible for the more traditional “factory” or industrial premises. The premises within the remit of the Council include: offices, shops, warehouses, leisure, hotel and catering premises. The principal activities of the service, outlined above, have relevance to the Planning, Building Standards, Civic Licensing and Alcohol Licensing services of the Council. The service also delivers official controls in relation to food law in all Renfrewshire Council food operations. The Service provides advice and guidance to all businesses to ensure compliance with statutory requirements. 2.3. Local Authority Covid-19 Recovery Project The measures taken by UK and Scottish Governments in March 2020 in response to the Covid-19 pandemic resulted in the closure of a large proportion of food establishments. Additionally, physical distancing requirements meant that Local Authority Authorised Officers were prevented from conducting routine, programmed interventions/Official Controls at most of those businesses who continued trading. Food Standards Scotland (FSS) secured Ministerial agreement to allow a relaxation from the Food Law Code of Practice and the Interventions Code of Practice. This relaxation ended on 31 August 2021. Food Standards Scotland acknowledged that Local Authorities intervention programmes would be adversely affected as numerous interventions would not be undertaken when due and create a backlog of ‘missed’ interventions. In Renfrewshire this figure was around 1012 missed inspections at the time the programme re-started.
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Business Regulation Service Plan 2023-2024 8 It was, consequently, agreed that measures to address this situation should be considered and a project should be delivered in order to enable all Local Authorities to rectify the position. This had the principle aim of delivering a clear and accurate Local Authority and national view of the food establishment profile – including the Food Law Rating System (FLRS) risk-rating of all establishments and the Local Authority capacity to undertake the necessary Official Controls therein. The backlog of inspections in all but the lower risk Group 3B category have been completed. These will be done within the 48-month period (end September 2025) as agreed with Food Standards Scotland and will be incorporated into the annual inspection programmes going forward from April 2023. The 2023/24 Business Regulation Service plan provides data and information for the period 1 September 2021 to 31 March 2023. 2.4. Demands on the Service Table 1: Profile of food businesses in Renfrewshire Premises Number Caring Establishment 179 Hotels and Guest Houses 26 Mobile Traders 54 Primary Food Producers 10 Pubs/Clubs 154 Restaurant/ Caterer 407 Takeaway Premises 219 Retail 357 Schools and Colleges 82 Manufacturers and Packers 46 Importers/Exporters 8 Distributors/Transporters 23 TOTAL 1563
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Business Regulation Service Plan 2023-2024 9 Table 2: Profile of Businesses for Health & Safety Enforcement Premises Number Retail 757 Wholesale 119 Offices 323 Catering 565 Hotels etc 26 Residential Care 19 Leisure 195 Consumer Services 424 Others 64 Total 2429 The Food law and Health & Safety Services provided by Renfrewshire Council operate solely from Renfrewshire House, Cotton Street, Paisley, PA1 1BR. The Service’s standard working day is 8.45am - 4.45pm Monday to Thursday, and 8.45am - 3.55pm on Friday, with an out of hour’s service also being provided in cases of emergency. Officers operate a hybrid model where they are operating from home, in the office and in the field e.g. inspecting premises and investigating incidents. The Service works in a number of complex areas, which include: Glasgow International Airport As Glasgow International Airport lies within the Authority, this adds further elements of work to the Environmental Health, Business Regulation Team. Consignments of food, particularly fruit and vegetables come through Glasgow Airport from third Countries. These foods are subject to controls administered by Environmental Health, Business Regulation. The Service is also involved in the surveillance of exports from the Airport and provides export certificates to those businesses exporting foodstuffs from Renfrewshire. The Business Regulation Team provides a port health role at the airport. Renfrewshire Port Health Authority was originally set up with the primary objective of preventing dangerous epidemic diseases entering the country. Although this can still occur, if a person is patently unwell, this function is now more realistically aimed at contacting and monitoring persons who may be carrying a communicable disease and preventing further cases arising from environmental contamination of aircraft.
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Business Regulation Service Plan 2023-2024 10 There are also currently 2 businesses which operate flight catering within the airport estate and these are subject to inspection by the service. EHOs operate on a rota basis, with one officer allocated for each day of the working week. The officer carries out all imported food functions at the airport on his/her allocated day. In addition, on weekends and public holidays an emergency call out service is in place to deal with port health incidents and any other Environmental Health related emergencies. Communication and Language The Council area has several food businesses operating for whom English is not a first language. This can introduce communication challenges during the course of inspection and enforcement visits. In order to address this issue, information leaflets translated into other languages have been produced. A translation service is available to officers if required during inspections and other meetings. Council Operated Food Businesses The control of food enforcement in Local Authority catering operations provided by Facilities and Property Services is a complex and sensitive area of work. These premises include catering in residential establishments such as those run by the Council’s Social Work Services as well as schools and nurseries. The service employs the same approach to enforcement in these premises. Approved/Authorised Premises There are 9 approved/Authorised Businesses operating within Renfrewshire, all of which are approved/authorised under Regulation (EC) 853/2004. These are: DNATA Airline Catering Arran Avenue, Paisley, PA3 2AY Gate Gourmet Airline catering Campsie Drive, Paisley, PA2 8DP Gormack Foods Sandyford Road, Paisley, PA3 3HP CFPU RAH Hospital Corsebar Road, Paisley, PA2 9PJ Scottish Leather Group Seedhil Road, Paisley, PA1 1JL Scottish Leather Group Baltic Works, Bridge of Weir Gleddoch Family Butchers Glasgow Road, Paisley, PA1 3PW Lomond Cold Store Blackstoun Road, Paisley, PA3 3AF Rice and Spicy Eddison street, Hillington, G524JW
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Business Regulation Service Plan 2023-2024 11 Events A significant number of events are held throughout Renfrewshire on an annual basis, particularly, but not exclusively, during the summer months. These events require a food law enforcement presence in response to the level of external food retailers and caterers providing food for the large number of visitors and this can result in a minor short-term impact on the food service. The Service also works closely with Renfrewshire Councils Events Team. Health & Safety Enforcement The review of Health & Safety enforcement activities by the UK Government has influenced the approach in this area. HSE priority planning guidance directs the work of Local Authorities in relation to Health & Safety, with an emphasis on targeting resources on higher risk activities and reducing the number of routine inspections. An Intervention Plan based on this guidance has been developed which takes into account local conditions and priorities. Enforcement within Arm’s Length Organisations – OneRen Health & Safety enforcement in arm’s length organisations connected with Renfrewshire Council presents a challenge to the Local Authority. In 2019, the Health & Safety Executive (HSE) advised Renfrewshire Council that enforcement within Council owned leisure facilities operated by arm’s length organisations, are: in accordance with The Health and Safety at Work Act 1974, the enforcement responsibility of the Local Authority. This presents significant challenges and burdens as there are close relationships between the Council and One Ren including the corporate control as the Council is the sole shareholder of the Company. The Council does not have outright control of One Ren, as the charity has an independent board of directors, but it does have the right to appoint and remove some of the directors. As a result, strategic decisions affecting the operation of One Ren are at the very least influenced, and could (in some instances) be directed, by the Council.
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Business Regulation Service Plan 2023-2024 12 Further to this, staff from Renfrewshire Council Facilities and Property Services may be involved in the maintenance of buildings and installations. The buildings and assets themselves are still within the ownership of the Council and although the liabilities reside with One Ren, should an incident/accident occur this could cause a further conflict of interest. In addition, the transfer of enforcement responsibility has the potential to add a significant burden to the workload of the Environmental Health Business Regulation Team. 2.5. Performance Management Elected Members receive quarterly reports on performance in key areas including Food Safety/Health & Safety enforcement and Managers provide an operational update at a bi- monthly Management Meeting. Certificates of Compliance and formal notices are reported to elected members via the Regulatory Functions Board and Information Bulletin reports. Performance reviews are carried out on a six-monthly basis with staff involved in Food Safety and Health & Safety enforcement, to maintain performance. 2.6. Enforcement Policy & Procedures An Integrated Enforcement Policy is in place to ensure the consistency of enforcement across all areas of Environment, Housing and Infrastructure. The Policy sets standards clearly outlining the level of service which the public and businesses can expect to receive. It encourages fair and open regulation and commits the Service to ensuring our enforcement service works with businesses to assist them in complying with the law. Information Systems Premises records are held on the Authority Public Protection (APP) system, which is used to manage the inspection programme and record details of inspections, accidents, complaints and enquiries. The database is regularly reviewed and updated to facilitate the planning of inspection programmes and production of management reports. Progress towards local, regional and national outcomes is monitored on a monthly basis using the reporting functions of the system. Statutory returns are made using data from the APP system.
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Business Regulation Service Plan 2023-2024 13 3. Service Delivery 3.1. Food and Health & Safety Premises Inspections In accordance with the Food Law Code of Practice (Scotland), all food premises are risk- assessed for food law. Risk assessments are entered in the Services database, which generates a target inspection date. A report is generated from the database of visits due for each officer. The Service undertakes a full inspection programme based on the risk category of premises. Regulatory activity in relation to Health and Safety at Work is determined in accordance with the HSE priority planning guidance. The tables below illustrate the number of premises in Renfrewshire in each risk category for Food Law and Health & Safety. Table 3 - Total premises (Food Law) with Group & Rating GROUP RATING NUMBER 1 A 7 1 B 11 1 C 6 1 D 0 1 E 0 TOTAL 24 GROUP RATING NUMBER 2 A 27 2 B 532 2 C 292 2 D 24 2 E 0 TOTAL 875 GROUP RATING NUMBER 3 A 38 3 B 432 3 C 139 3 D 1 3 E 0 TOTAL 610
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Business Regulation Service Plan 2023-2024 14 Table 4: Premises per group Rating Category Group Number of Premises 1 24 2 875 3 610 Food Standards Only 3 Approved 9 Farms 8 Sub Total 1529 Unrated 45 Total 1574 The food Law risk rating of a food business is based on a number of elements. Hygiene, structure, food safety management and food standards are assessed to determine the risk posed by an establishment and the frequency of intervention by the local authority. These are numerically scored and used to derive the rating that is presented as the 'score', A-E; Category E posing the highest risk. Where a business have registered with the service but are awaiting inspection, these are listed as “unrated”. Table 5: Profile by Health & Safety risk category Risk Category Total number in category A 1 B1 33 B2 764 C 1565 Unrated 465 Total 2828 The tables below illustrate the number of inspections programmed for 2023/24 in each risk category for Food Law. A total of 903 food law programmed interventions are projected for the 12 months commencing 1 April 2023.
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Business Regulation Service Plan 2023-2024 15 Table 6: Food Law Programmed Interventions for 2023/2024 GROUP RATING NUMBER 1 A 3 1 B 10 1 C 6 1 D 0 1 E 0 TOTAL 19 GROUP RATING NUMBER 2 A 9 2 B 399 2 C 284 2 D 19 2 E 0 TOTAL 711 GROUP RATING NUMBER 3 A 1 3 B 105 3 C 66 3 D 1 3 E 0 TOTAL 173 The inspection programme for 2023/24 has been developed to comply fully with the Food Law Code of Practice (Scotland) and LAC Circular 67/2 (Rev 7) Health & Safety priority planning. So far as the inspection of premises outwith normal working hours is concerned, our policy is to ensure that, where premises are only open outwith normal hours, then appropriate provision is made for them to be visited in accordance with at least the minimum number of visits determined by their risk rating. 7.0 full time equivalent officers carry out the work of the Business Regulation team, including the Business Regulation Manager. The staffing allocation to food law enforcement is 75% of 7.0 FTE’s, with the other 25% allocated to Health & Safety enforcement. Officers are allocated premises within specific geographical areas.
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Business Regulation Service Plan 2023-2024 16 It is considered that the Service has adequate expertise to provide a competent and full portfolio of enforcement and educational roles in relation to Food Law and Health & Safety. However, where necessary, we are able to draw on expertise from Food Standards Scotland, Glasgow Scientific Services – the Public Analyst, Health Protection Scotland, the Director of Public Health, Animal and Plant Health Authority (APHA), The Health & Safety Executive and other local authorities. 3.2. Food and Health and Safety Service Requests Complaints and Service Requests are dealt either by the duty Business Regulation Officer or by the officer responsible for the premises which are the subject of the complaint/request. All service requests are logged in the APP database against the premises concerned. The Service has documented policies relating to the investigation and handling of complaints and service requests which ensure that all complaints are investigated in accordance with the appropriate Code of Practice. All complaints are recorded and their risk evaluated to distinguish between those which require an on-site investigation and others which may be resolved by telephone or written advice. The numbers of complaints and service requests, detailed by category, estimated for the year 2023/24 are shown in the table below: Table 7 - Estimated Complaints and Service Requests 2023/2024 Service Request Category Requests Sept.01 /21 - March 31 /2023 Estimated Requests 2023/2024 Advice to Consumer 14 40 Advice to Business 81 100 Food Hygiene Complaint 65 60 Food premises Complaint 51 50 Food Standards 29 30 Section 50 Certificates/ Building warrant 8 10 Licensing Consultation 75 250 Imported Food 2 2 H&S Enquiries 32 other 3 Total 329 540
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Business Regulation Service Plan 2023-2024 17 The number of service requests received in the period Sept.1/2021 to March 31/2023 appear lower than predicted. It is likely that service requests remain an area where there is under reporting by officers, and this has been addressed at team meetings. 3.3. Investigation of Accidents A procedure is in place for the investigation of notified accidents designed to ensure consistency and quality of the accident investigation service. It is not possible or appropriate to investigate all incidents and a systematic approach has been adopted to ensure that the more serious incidents are investigated. 3.4. Enforcement Management Model (EMM) The Guidance in the LAC22/18 along with detailed guidance that was issued for use by EHOs is used to promote consistency of enforcement between individual officers, LAs and with HSE. All officers in the team have been trained in the use of the Enforcement Management Model. The model is used by officers when considering the most appropriate action to take in more complex situations which are occasionally encountered, including serious accident investigations. It is also used as a monitoring tool by management. 3.5. Home Authority Principle & Primary Authority Scheme For companies operating under two or more local council jurisdictions, Primary Authority provides reliable and consistent regulatory advice from a single source when dealing with key aspects of environmental health, trading standards, health & safety, and licensing services. Renfrewshire Council currently has no partnerships in relation to health & safety advice and enforcement. The Primary/Home authority principle is applied when dealing with food complaint investigations and also routinely in relation to food standards and labelling issues. It is considered to be an aid to good enforcement practice. The Council has no formal agreements in place to act as a Home Authority with any specific business, but has listed the following significant establishments as ones which are considered as home authority/originating authority premises:
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Business Regulation Service Plan 2023-2024 18 Table 8- - Originating Authority Businesses A&A Bakers Moss Road Linwood PA3 3HR DNATA Arran Avenue Paisley PA3 2AY AP Jess Sandyford Road Paisley PA3 4HP Aulds Delicious Desserts Barnsford Avenue Inchinnan PA4 9RG Big Bear Bakery 15 Edison Street Hillington Park G52 4JW Buon Giorno 11A Queen Street Renfrew PA4 8TR Davidson Butcher Mossedge Paisley PA3 3HR Diageo Global Supply 1 Argyll Avenue Renfrew PA4 9EA Diageo Global Supply 500 Renfrew Road Renfrew G51 4SP Faodail Foods Westway Renfrew PA4 8DJ G Porrelli & Co Ltd 25 Lacy Street Paisley PA1 1QN G&A McHarg Dalziel Road Hillington Park G52 4NN Gate Gourmet Glasgow Airport Paisley PA2 8DP Gleddoch Family Butchers 60 Glasgow Road Paisley PA1 13W Hannah's of Johnstone 18-20 Walkinshaw Street Johnstone PA5 8AB Henderson Meats Hillington Glasgow PA8 6BS Ingram Brothers 15 East Lane Paisley PA1 1QA Jenier Limited Earl Haig Road Hillington G52 4JU John Scott Meats Sandyford Paisley PA3 3HR Kismet Lyon Road Linwood PA3 3BQ Kerry Foods (UK) Ltd) 55-59 Kelvin Avenue Hillington Park G52 4LT MacSpice/McAusland Crawford 79/81 Abercorn Street Paisley PA3 4AS Linburn Farm Linburn Erskine PA8 6AW Scottish Leather Ltd Kilbarchan Road Bridge Of Weir PA11 3RL Rice 'n' Spicy 15 Edison Street Hillington Park G52 4JW Sutherland Cakes 15-17 Earl Haig Road Hillington G52 5JU Glasgow Distillery Company Deanside Road Renfrew G52 4XB The Elderslie Scottish Tablet Co 37 Glenpatrick Road Elderslie PA5 9AE W P Tulloch 22a Skye Crescent Paisley PA2 8EL Dargavel Brewery West Glen Farm Langbank PA146YL Rise and Grind Roastery 104 Abercorn Street Paisley PA34AY
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Business Regulation Service Plan 2023-2024 19 3.6. Advice to Business The Environmental Health, Business Regulation Team undertakes an on-going advisory role to all businesses in Renfrewshire. A range of information and promotional material is made available for businesses by Environmental Health Officers during visits. 3.7. FHIS & EatSafe The Food Hygiene Information Scheme continues to operate in Renfrewshire with around 1500 food premises who sell food to the public being included. Currently 98% of premises within Renfrewshire have a pass certificate. The scheme is currently under review by Food Standards Scotland. The review will take account of the changes to the food law code of practice and the introduction of the risk rating scheme for food law. There are 12 premises with Eat Safe Awards within Renfrewshire. This is the highest award in the scheme. These are: Table 7 -Eat Safe Award Recipients Premises Name Premises Address Accord Hospice Morton Avenue, Paisley, PA2 7BW Mosswood Care Home Moss Road, Linwood, PA3 3FA Capability Scotland Wallace Court, 191 Main Road, Elderslie, PA5 9EJ Erskine mains Care Home Meadow drive, Erskine, PA8 7ED Hanover(Scotland) Housing Association Newton Court 23 Maree Road, Paisley, PA2 9DH Hanover(Scotland) Housing Association, Ailsa Court 1 Ailsa Drive, Paisley, PA2 8HE Hanover(Scotland) Housing Association Orchard Court "Orchard Court", Orchard Street, Renfrew, PA4 8RZ Hanover(Scotland) Housing Association, Walikinshaw Court Walkinshaw street, Johnstone, PA5 8AF Kibble Education & Care Centre Goudie Street, Paisley, PA3 2LG Holiday Inn Caledonia Way, Glasgow Airport PA3 2TE Leaps and Bounds Nursery 23 Clarence Street, Paisley, PA1 1PU Rashilee Care Home Little Inch, 8 Rashilee Avenue, Erskine, PA8 6HA
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Business Regulation Service Plan 2023-2024 20 3.8. Sampling Renfrewshire Council, along with 9 other local authorities have a Service Level Agreement with Glasgow City Council for the provision of analytical services. The analyst service is provided by Glasgow Scientific Services, Colston Laboratory, 64 Everard Drive, Glasgow G21 1XG. Glasgow Scientific Services are this Authority’s appointed Public Analyst for chemical analyses of all food samples, Food Examiner for all microbiological examination of food samples and Agricultural Analyst for all feeding stuffs samples taken. The sampling programme for 2023/24 is attached as Appendix 1 to this Service Plan. The programme will focus on high-risk premises in Renfrewshire, whilst reflecting national priorities recommended by FSS and the Scottish Food enforcement Liaison Committee (SFELC). Food sampling will also be undertaken at Glasgow International Airport to monitor the quality, composition and labelling of foods imported through the airport as part of the Service’s imported food controls. It is not possible to estimate sample numbers or types for this sampling at present. The Health and Safety programme for 2023/24 has been drawn up with reference to Local Authority Circular, LAC 67/2 (Rev 12) Health & Safety priority planning. (See Table 8) The LAC provides LAs with guidance and tools for priority planning and targeting of interventions taking a proportionate and consistent risk-based approach to, enable Renfrewshire Council to meet the requirements of the National Local Enforcement Authority Code (hse.gov.uk) (the Code). Planned regulatory activity is focussed on improved outcomes and reduced injuries to employees or members of the public. The Code provides flexibility for LAs to address local priorities alongside the national priorities set by HSE.
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Business Regulation Service Plan 2023-2024 21 Table 8 Health and Safety Priorities 2023/24 Special Interventions Carry out special interventions at animal visitor attractions in an effort to reduce the risk of contamination especially to children. Carry out special interventions for safety in swimming pools and spas where Health & Safety is enforced by the Local Authority to reduce the risk to employees and the public from Health & Safety and Public Health incidents. Carry out special interventions at children’s indoor soft play visitor attractions in an effort to reduce the risk of accidents to children. Carry out special interventions at commercial catering establishments to assess gas safety and where the risk of carbon monoxide may be present. Carry out special interventions at premises, especially licensed premises that use stored gas to minimise the risk of explosion. Proactive inspection of industrial retail/wholesale premises to ensure adequate control of work at height, workplace transport and loading and unloading of vehicles. Intervention to ensure that Cellar Safety is being adhered to in licensed premises. Intervention to ensure Legionella controls are in place. Carry out special interventions in relation to Crowd management at large scale events. 3.9. Control and Investigation of Outbreaks and Food Related Infectious Diseases Environment, Housing and Infrastructure works closely with NHS Greater Glasgow and Clyde Health Board Consultants in Public Health Medicine in outbreak control situations and the routine investigation of infectious disease. In addition, the Health Board has produced an outbreak control plan for dealing with major outbreaks of food related illness to which this authority has had a major input. The Business Regulation Team work in partnership with the Public Health Protection Unit at NHS Greater Glasgow and Clyde Health Board to ensure the plan is adhered to. In addition, an outbreak control and investigation of notifications of food borne disease procedure is in place. Present resources within Environment, Housing and Infrastructure are adequate to meet current levels of notification; however, in the event of a major outbreak, any required additional resources would be made available by seconding Environmental Heath Officers from other service areas.
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Business Regulation Service Plan 2023-2024 22 3.10. Food Incidents Food incidents are dealt with in accordance with the relevant codes of practice the Food Law Code of Practice (Scotland) Notifications of incidents are received from Food Standards Scotland (FSS) by e-mail or telephone. In case of emergencies, an Officer is on stand-by and has contact details for all relevant members of staff. Procedures for food safety incidents are in place and are available to all staff. This allows for alerts to be appropriately actioned, investigations set in motion and warnings issued if necessary. Any enforcement activity which is required in support of an incident is carried out within the terms of the relevant legislation and the Council’s enforcement policy for assuring the safety of food. In addition to responding to notified incidents, Renfrewshire Council will, where necessary, initiate Food Alerts in accordance with Code of Practice Guidance and will liaise with Food Standards Scotland in such situations. 3.11. Liaison with Other Organisations To ensure enforcement and other activities carried out by the Service are consistent with neighbouring Authorities and to ensure best practice, Renfrewshire Council actively participates in the West of Scotland Food and Health & Safety Liaison Groups. The groups meet regularly throughout the year and comprise representatives from the 14 authorities, which previously made up Strathclyde Regional Council, together with representatives from Glasgow Scientific Services, Food Standards Scotland and the Health & Safety Executive. The groups are attended by the Business Regulation Manager or a suitable deputy. The Service also has formal and informal links to a range of other organisations and agencies. These Include: NHS Greater Glasgow and Clyde Health Board Association of Port Health Authorities Royal Environmental Health Institute for Scotland Society of Chief Officers of Environmental Health in Scotland Society of Chief Officers of Trading Standards in Scotland Scottish Food Enforcement Liaison Committee Health Protection Scotland Food Standards Scotland Health & Safety Executive Glasgow Scientific Services
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Business Regulation Service Plan 2023-2024 23 Animal and Plant Health Agency Marine Scotland Border Force H.M. Revenue and Customs APP Scottish Users Group 4. Resources 4.1. Financial Allocation The budget detailed below indicates the level of resources available 2023/24 to deliver the necessary services. As highlighted at 3.1 above the resource allocation within the Business Regulation Team is 75% of Food Law enforcement and 25% on Health & Safety enforcement. This split is at the discretion of the Environmental Health - Business Regulation Manager and can be amended where there is a service demand. Budget 2023/24 Employee Costs £520,140 Supplies and Services £173,347 Travel and Subsistence £0 Training £1600 Total £695,087 Projected Income Source 2023/24 Export Health Certificates £300 Sales, Fees and Charges £0 Miscellaneous Income £5000 Total £5,300 4.2. Staffing Allocation Within the context of this plan, the allocation of staff is designed to provide an effective enforcement service for food law and occupational health and safety at work on behalf of Renfrewshire Council.
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Business Regulation Service Plan 2023-2024 24 All food enforcement officers are authorised in accordance with the Food Law Code of Practice (Scotland) commensurate with their training and experience. A range of additional relevant qualifications are held including: the REHIS Advanced Food Hygiene Diploma, the REHIS Certificate in the Inspection of Meat and Other Foods, Certificate in Nutrition & Health and the RIPHH Certificate in HACCP Principles. Three officers have completed the ISO 9000 Lead Assessors course and All current Food Law officers have attended and passed the Official Controls verification Course. The Service secures administrative support from a pool of administrative and support staff in the Council’s Business Support Service. 4.3. Employee Development Plan The Service is committed to ensuring all officers are suitably qualified, trained and remain competent in terms of the Food Law Code of Practice (Scotland) and in terms of Section 18 of the Health & Safety at Work Act 1974. This is facilitated by the provision of in-house training, and all employees have the opportunity on a rotation basis to attend relevant external training events. Any employee attending such a course is required to “cascade” the relevant information accrued as a result of their attendance to other officers. Business Regulation Team meetings are held weekly, where performance, enforcement and other relevant issues are discussed. Matters arising from the quality assessment model for inspections, consistency issues and interpretation issues are discussed. Liaison Group minutes are stored in the staff manual for all officers to use. Relevant points from the Liaison Groups are also discussed at Team meetings. In addition, all staff have full access to, and are trained in the application of, policies and procedures, which are a requirement of the framework agreement on local authority food law enforcement. Training records are maintained for each officer. All officers have completed a training needs analysis and will have individual development plans prepared for 2023/24.
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Business Regulation Service Plan 2023-2024 25 5. Quality Assessment 5.1. Quality Assessment & Internal Monitoring The Service has a documented “Internal Monitoring Procedure – Internal Checks” quality assessment model for inspections. The Business Regulation Manager has primary responsibility for carrying out quality assessments within the Service. The Head of Climate, Public Protection and Roads has a secondary responsibility to oversee the performance of the Business Regulation Manager and to ensure that quality assessments are being carried out consistently throughout the Service. The Internal checks include file checks, one-to-one discussions, team discussions and accompanied inspections. Records of these are retained by the Business Regulation Manager and the Head of Climate, Public Protection and Roads. This quality assessment model facilitates the Service’s requirement in accordance with annex 2 of the Food Law Code of Practice (Scotland) and the Section 18 guidance issued by the HSE to ensure that all staff engaged in enforcement activities retain their competence. The Business Regulation Manager reviews a monthly report on the performance indicators to ensure that the targets are met. The monthly report also details performance information relating to inspection deadlines, complaints and service requests received and food sampling activity are also monitored. 6. Review 2021-23 6.1. Review of Food Law Activity Group Band Estimated Total Interventions Actual Interventions 1 A 1 5 1 B 12 23 1 C 6 9 1 D 4 2 1 E 0 0 Total 23 39
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Business Regulation Service Plan 2023-2024 26 Group Band Estimated Total Interventions Actual Interventions 2 A 7 23 2 B 420 400 2 C 370 402 2 D 102 69 2 E 0 0 Total 899 894 Group Band EstimatedTotal Interventions Actual Interventions 3 A 6 25 3 B 350 156 3 C 164 45 3 D 32 2 3 E 0 0 Total 552 228 Group Estimated Total Interventions Actual Interventions Food Standards Only N/A 5 0 Farms N/A 11 5 Approved Premises N/A 9 5 New Business Inspections Group1-3 Group2-167 Group3-44 214 Businesses Ceased Trading Group1-3 Group2-123 Group3-39 165 REVISITS ~254 194 Table 9 - Estimated Formal Enforcement Notices Programmed Food Hygiene Inspections: The Food Law Code of Practice (Scotland) states that” Intervention programmes should be planned so that establishments receive an intervention no later than 28 days after the scheduled date as detailed in Annex 5”. Type of Notice Estimated Number Actual Remedial Action Notice 6 16 Hygiene Improvement Notice 11 24 Voluntary Closure 12 5 H&S Improvement Notice 8 28 H&S Prohibition Notice 4 21
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Business Regulation Service Plan 2023-2024 27 During the period 1/9/21 to 31.3.23 1171 Food Law interventions were carried out. 92% (1081) interventions were completed within the 28 days specified in the code of practice. 8% (90) Interventions were not completed within the 28 and this was mainly due to access difficulties brought about by the pandemic where businesses changed their operating model such as, operating only at weekends or temporary closure. In additional some seasonal businesses were included within this grouping. A total of 12 visits are outstanding from this grouping however, it is likely that some of this number have permanently closed and officers are attempting to contact the business operators. Sampling: The review against sampling is included in the Sampling Programme attached at Appendix 1. 6.2. Review of Health and safety activity. In the year 1 September 2021 to 31 March 2023, the following Health and Safety interventions were undertaken: Intervention Category 1 September 2021 to 31 March 2023 Estimated work to be undertaken 2023/24 Accident / incident/Complaint investigations 16 10 New Premises Interventions 149 100 Advice visits to Businesses 10 10 Interventions 85 60 Revisits 25 25 Licensing Visits 51 30 RIDDOR reportable notifications received 111 100 Total 336 235 Specific Health and Safety Projects/Interventions carried out 1 September 2021 to 31 March 2023: Gas Safety Interventions Special interventions at commercial catering establishments to assess gas safety and where the risk of explosion or carbon monoxide may be present were carried out. As well as being a National priority theme, this was an important local intervention due an incident where on call Environmental Health Officers were called by the gas provider following a gas leak into a tenemental property. Investigations established that the owner of a takeaway beneath the residential properties had previously been disconnected and had his meter removed. He had then by-passed the system from the emergency cut off
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Business Regulation Service Plan 2023-2024 28 valve with garden hose and adhesive tape and reconnected his gas equipment. A report was prepared for the procurator fiscal but the owner disappeared before the case could be progressed. As can be seen from the results of the interventions, this is an area of concern. A total of 37 interventions were carried out with 22 businesses being found non-compliant. 10 Prohibition, 13 Improvement Notices and 9 written warnings were issued as a result. 2 of the businesses were found to have forged gas safety certificates. The businesses concerned received follow up checks to ensure compliance. Animal visitor attractions Intervention An intervention was carried out at an animal visitor attraction to reduce the risk of contamination especially to children. Some recommendations were made to the management and these were put in to place. Golf Course Intervention 11 interventions were carried out at all private Golf courses within Renfrewshire to ensure safety in golf course operations. 1 prohibition notice was issued to one business and no other formal warnings were issued. Recommendations and advice were issued to all of the businesses. Legionella Intervention The interventions focused on premises providing hot tubs or spa baths within a hotel setting or those with multiple lodge style accommodation and individual hot tub. A total of 5 businesses were visited. One business received a written warning for structural defects and 2 for inappropriate cleaning regimes and use of chemicals. Recommendations and advice were given to all businesses and follow up checks where defects were noted, were carried out. Health & Safety in Care Homes Three interventions were carried out at care homes, triggered by RIDDOR reports where service users had sustained fractures from falling. Although the interventions concentrated on moving and handling of service users, all aspects of Health and Safety were examined during the visits. No issues were found and no warning letters were issued as a result.
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Business Regulation Service Plan 2023-2024 29 6.3. Areas for Improvement Further development of the APP electronic database will take place during 2023/24. In addition, the power BI system will be used to assist in performance monitoring and review. An electronic filing system for Business Regulation premises files has been initiated and this is expected to be complete by year ending 2023/24 7. Emerging Issues 2023/24 Food Crime This continues to be a focus for FSS and Food Authorities. It is expected that due to the challenges post pandemic, Brexit and the cost-of-living crisis that there will be an increase in Food Fraudulent activity. This in turn will have resource implications for the service. Food Crime erodes confidence and disempowers consumers. This leads in turn to financial losses, negative economic impact and poses a threat to jobs and exports. Tackling food crime is so Nationally/Internationally important that The Scottish Food Crime and Incidents Unit (SFCIU) was established and the Business Regulation Team already work closely with this team and will continue to build on the established working relationships with them and other partner Agencies. Brexit The challenges and uncertainties relating to the UK exit from the EU remain. Officers regularly attend meetings in relation to port issues and discussions continue into inland import checks and the impacts that this may have on the service.
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30 Environment, Housing and Infrastructure Renfrewshire Council Renfrewshire House Cotton Street Paisley PA1 1BR
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Appendix 1 Climate, Public Protection and Roads BUSINESS REGULATION FOOD SAMPLING PROGRAMME 2023/24
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1. Introduction 1.1 The annual sampling programme for 2023-24 is designed to fulfil aims and objectives in line with the Services Food Sampling Policy. The programme outlines the sampling priorities for the year, however it is recognised that circumstances and priorities may change, which require the programme to be flexible in order to respond to these changing circumstances. 1.2 Most samples are taken informally for the purpose of monitoring, surveillance and information gathering however; formal samples will be taken where enforcement action is anticipated. Environmental Health Officers, Food Safety Officers and other authorised officers are responsible for undertaking the food sampling functions of the Council. 1.3 At present there is a Service Level Agreement in place with Glasgow City Council to provide analytical services to Renfrewshire Council. The analyst is: Glasgow Scientific Services, Colston Laboratory, 64 Everard Drive, Glasgow, G21 1XG. 2. Approach to Sampling Renfrewshire Council complies with the requirements of the Food Safety (Sampling and Qualifications) Regulations 1990 and the Food Law Code of Practice. The sampling programme for 2023/24 is designed to be more focused on high risk/high value products which are manufactured in Renfrewshire. Focussing on these items will ensure that those which pose the greatest risk to the public of Renfrewshire are adequately controlled. 2.1 Informal Samples An informal sample may be taken covertly, however; the food business operator will always be informed of the results of the sample where this fails. For enforcement purposes formal sampling must be undertaken overtly. 2.2 Formal Samples In accordance with the Renfrewshire Council Integrated Enforcement Policy, which promotes action which is consistent, fair and proportionate, formal samples will generally be taken after routine samples have been found to fail statutory requirements and no satisfactory remedial action has been taken.
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2.3 Sampling Priorities Food Standards Scotland and The Scottish Food Enforcement Liaison Committee have identified, through intelligence, the areas deemed to be priorities in terms of sampling. The priority plan considers the Scottish perspective but also takes account of the UK. FSA. priorities. In addition to National priorities, Renfrewshire Council will focus on areas of particular interest to the authority. 2.4 Manufacturing/Approved Premises Renfrewshire Council will continue to concentrate on sampling from manufacturers and approved premises in our area. These premises will be sampled at least annually. Where possible, samples will be taken in advance of Food Hygiene/Food Standards inspections in order to discuss sample results with the food business operator. 2.5 Sampling Plan 2023/24 The sampling plan for 2023/24 outlines the project work to be undertaken by Renfrewshire Council in high-risk areas. The sampling plan is outlined at point 4.0. 3. Complaints and Food Borne Disease Investigations In response to complaints and notifications of food borne disease received the service may opt to take samples in order to resolve any issues arising as a result of any investigations. 3.1 Co-ordinated Sampling Where appropriate, the Service will participate in food surveillance programmes arranged by regional and national bodies such as Food Standards Scotland, SFELC and the West of Scotland Food Liaison Group. 3.2 Imported Food In order to monitor the quality, composition and labelling of imported foods, samples of foods imported through Glasgow Airport will be submitted to the Public analyst for examination.
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3.3 Special Investigations There may be circumstances whereby an incident will require special investigation and resources may have to be directed towards dealing with the investigation. In addition, this may involve liaison with other partners including Health Protection Scotland and Greater Glasgow & Clyde Health Board. 4. Priority Actions The following topics have been identified as priority actions by FSS and will be the subject of sampling activity during 2023/24, along with other local surveillance activities. Food Type Premises Type Testing parameters Number of Samples Dry spices and spice mixes Retailers Salmonella 3 Cultivated 'exotic', fresh mushrooms (e.g. Enoki mushrooms) Retailers Listeria monocytogenes detection and enumeration, generic E.coli 3 Cooked and cured sliced meats and smoked fish Retailer Listeria monocytogenes detection and enumeration, generic E.coli, 3 Blue veined and mould- ripened cheese Retailers Listeria monocytogenes detection and enumeration, generic E.coli, 3 Cooked shellfish Retailers Listeria monocytogenes detection and enumeration, generic E.coli, 3 Pate Retailers Listeria monocytogenes detection and enumeration, generic E.coli 3 Flour Manufacturers Retailers Bake houses STEC, generic E. coli 3 Rice and noodle dishes Catering Bacillus cereus 3 Dried figs Retailers Aflatoxins, Ochratoxin A 3 Domestic, fresh fin-fish, cephalopods and crustacean Manufacturers Processors Retailers Heavy metals, PFAS, iAs 3 Spinach Retailers Heavy metals (lead, cadmium, mercury) 3 Pre-packed beef mince Retail Fat & Connective tissue 3
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Naan bread and other flat breads Retail Propionic acid 3 Frozen processed pork products Retailers Meat Speciation 3 Frozen processed beef products Retailers Meat Speciation 3 Coffee (drink) Caterers Milk 3 Egg-free take away meals Caterers Egg 3 4.1 Routine Sampling The project sampling initiatives listed above will be the focus of sampling activities however, in the course of routine work, officers will take samples as appropriate. Review A total of 187 samples were taken during the period of 1st September 2021 – 31st March 2023: 63 for microbiological examination of which, 13 failed for high numbers of bacteria including pathogens such as E.coli and 124 for chemical/ compositional analysis of which 6 failed to meet compositional standards including; undeclared allergens, low meat content, substitution and additive levels above legal maximum. Where samples were found to be unsatisfactory, visits to the businesses concerned were undertaken by officers, the results discussed, and advice given in respect of how the sample may have failed and how to ensure compliance in future. Where available, resamples were taken.
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Appendix 2