Standard Operating Procedures are designed to be shared with members and new member applicants in the interests of transparency

Key definitions:

Procedure:

Further guidance can be obtained from ADCH staff ([email protected])

External assessments (new and existing members)

1. For organisations with multiple sites (four or more), external assessment will consist of two phases:

• Phase 1 – a visit to the organisation’s Head Office to review their internal quality assurance processes. This will take place before
• Phase 2 – site visits are undertaken

Assessors allocated to multi-site (4 or more) assessments must receive prior training for phase 1, as this SOP4 process is significantly different from other assessments. Two assessors should always do phase 1 assessments, one of whom is designated on appointment as the lead assessor, to manage the communications and report writing. 

Assessors for phase 2 are appointed in the usual manner for any new assessment. 

Phase 1

 2. The visit to the Head Office will comprise a review of the following areas:

• Quality assurance and monitoring systems in place 
• SOPs and other similar frameworks and policies 
• Training provided to staff and volunteers in the implementation of policies and procedures  
• Management / supervision processes in relation to policies and procedures. 

Where animals are kept at / near to any HQ offices, assessment of their welfare should be treated as part of phase 2 and undertaken after the fact finding of phase 1 (e.g. later on the same day). Care should be taken not to generalise from the experience of HQ-based animal welfare as there is a risk that welfare standards at more remote sites might be harder to maintain, and the HQ might be a showcase/flagship of excellence. 

 3. Quality assurance (QA) and monitoring systems

Amongst ADCH’s whole Membership, just a small number are multi-site operations with 4 or more sites.  Each of them is unique, but there is also a number of variations possible in just this small number of Members. Assessors should first seek to understand: 

• The relationship of the Member’s own standards to ADCH’s Minimum Welfare and Operational Standards – They might be identical, or Members might have extra topics that they include. Their standards should not omit any aspect of ADCH standards that are applicable. 
• What data is held in relation to their standards, what system holds the data (spreadsheet, database, bespoke or proprietary), and regular reporting from that data as well as the potential for one-off reporting.  

• In particular, ascertain whether:  

• • All ADCH standards are represented in identical terms in their data fields; and  
  • Are they kept up-to-date when ADCH standards are updated. 

• What is the structure of the animal welfare part(s) of the organisation including types of locations (centres, rented commercial boarding, fosterers, branch structure. other) 
• Is there also an independent or integrated Internal Audit or Compliance function, and does it monitor ADCH compliance. 
• What are the management lines for these, including exceptions to the main operations management structure, for example if certain animals are cared for under different management from the main operations. 
• Is the data held on all locations where all animals are kept including all main and small centres, all fosterers, all boarding facilities used etc. 
• Which managers review regular reports (e.g. overview, exception, detail etc.) and can request or produce one-off reports. 
• Whether their systems have highlighted areas on which they would like ADCH’s help. 
• Whether relevant job descriptions clearly set out the roles of managers in relation to the points above.
• Whether the organisation’s risk management system recognises any animal welfare risks, how it describes them, and any controls and mitigations.

4. SOPs and other similar frameworks and policies

• Assessors should then consider the inter-relationship between the above and SOPs, policies etc. For example, how will it become apparent to management if a policy or SOP is not being followed. 

5. Supervision and training

• Assessors should consider details of training provided to staff and volunteers in the implementation of policies and procedures  
• They should also assess the management / supervision processes. 
• Overall Assessors should aim to satisfy themselves that the entire quality assurance process can reasonably be expected to make management aware of the degree of compliance with ADCH standards 
• Assessors should then consider whether management, including Trustees, can be and are aware of any areas of non-compliance, and also that remedial action is planned and actually undertaken. 

6. Sites

Sites should be categorised (e.g. commercial boarding, adoption centres, foster homes etc) to determine how many of each type need to be visited (see below) with a view to validating the outputs from the above processes. Assessors can then judge whether or not to include any HQ site in the numbers to be visited (it might have been visited later on the day of phase 1). A useful principle in selecting sites is the ‘best and worst’ principle – at least one of the highest and lowest scoring sites selected from the Member’s own QA system records. Assessors can seek guidance from Staff or SAWC on the number and selection of sites. 

7. Licenced Boarding Premises

In the case of any licensed boarding premises, compliance with relevant statutory standards and licensing should be evidenced by the applicant / member organisation, but this is not evidence of compliance with ADCH minimum standards since licencing standards are very different from ADCH standards, and there are significantly different risks inherent in commercial boarding as against rescue and rehoming. 

8. Phase 1 conclusion

At the end of phase 1, assessors should be able to satisfy themselves that they understand whether and how the Member’s trustees and management know the extent to which ADCH Standards are met.  

Assessors should produce a report on their findings from phase 1, and would normally share that report with the Member, checking for factual accuracy. The paragraphs in this SOP can be used as a template for the report, if applicable, to support any conclusions and recommendations. The report will be considered by SAWC. Assessors can refer their Phase 1 report to SAWC immediately, or (more usually) submit it at the same time as the Phase 2 assessments. 

Phase 2

9. Purpose

The purpose of phase 2 site visits is to validate the outputs from the Member’s own QA system reporting. It is good to involve different assessors in the phase 2 visits as fresh pairs of eyes will be helpful. One assessor per site is usually appropriate for phase 2 visits. It can be helpful to include a phase 2 written report to accompany or be merged into the phase 1 report. 

10. Submitting forms

When carrying out assessments, Assessors are acting for and representing the views of ADCH, and not their employer (if applicable). Applicants and assessors will be made aware of ADCH’s risk assessment for carrying out onsite risk assessments available here. 

The requirements for submitting assessment forms is the same as set out in SOP 1 (new members), SOP 2 (self-assessment) and SOP 3 (external assessment of existing member), depending on the assessment type. 

11. Site numbers

The following is a guide on the number of site visits that can be undertaken, but judgement is needed to balance assurance against resource usage. Lead assessors can consult staff (who might seek views of SAWC). Phase 1 Assessors should communicate with staff about phase 2 visits and explain if they advise more or less visits than usual to be included. That decision can be made after some site visits have taken place if that is helpful. 

12. Selection of sites

For organisations with multiple sites, different sites should be selected each time an assessment is done. 

For organisations with a variety of types of sites (e.g. owned; commercial boarding etc) all types should be represented in the visits. 

Self-assessments (see also SOP 2)

13. The number of self-assessments to be undertaken is as follows:

14. For organisations with multiple sites, different sites should be selected each time.