Corrective Action Report 015¶
A M Water Services Limited¶
QEHS/NCR Ref: NCR-IMS-2026-015
Date: 09/09/2026
CAR ID: CAR-2026-015
Document Number: FORM_CAR001 Rev 1 ID 01/09/2025
Process/Area/Department: Support / Training & Competence · Emergency Preparedness
Requirement/Clause No.(s): ISO 45001:2018 Clause 10.2 (effectiveness of corrective action) · Clause 7.2 (competence) · Regulatory Reform (Fire Safety) Order 2005 Art. 21
Type: ☐ Internal Audit ☐ Client Audit ☐ Inspection ☐ Complaint ☐ Sub-contractor ☑ Management System Review
Classification: ☑ Nonconformity ☐ Observation ☐ Opportunity for Improvement
Details of Nonconformity¶
Statement of Nonconformity: A closed corrective action did not hold. CAR-2026-003 was closed on 26/05/2026 on the evidence that three expired statutory certificates had been renewed or rebooked. Reviewed on 09/09/2026 against the reissued risk assessments, the position is:
| Certificate | Evidence at closure, 26/05/2026 | Position at 09/09/2026 |
|---|---|---|
| Jason May — Fire Marshal | On file, completed 24/07/2025, expiry 24/07/2026 | Expired 24/07/2026. AMWS has been without a second Fire Marshal since |
| Leanne Mason — Fire Marshal | On file, completed 15/11/2025, expiry 15/11/2026 | Valid, but expires within the quarter |
| Leanne Mason — Emergency First Aid at Work | Rebooked, "certificate to be filed on completion" | Certificate not yet on file at that date. Resolved — on file 22/09/2026, expiry 16/06/2029 |
The evidence accepted at closure included a certificate close to its expiry and one line that was a forward commitment rather than a record. This is a Clause 10.2 finding on the effectiveness of corrective action.
Planned Actions¶
Containment Action(s), including correction, with supporting completion date(s):
- Fire Marshal cover was a single point of failure while Jason May was out of certificate. He has since been recertified to 21/07/2029; Leanne Mason’s certificate expires 15/11/2026. Both premises are small, single-storey, with short travel distances and a tested evacuation procedure (2.8 minutes, 14/01/2026). The arrangement is workable in the interim but is not to be relied on beyond it.
- Fire evacuation arrangements briefed at the weekly Director / HSQE compliance call and confirmed to all office staff.
Root Cause¶
Primary Cause: The closure test applied was "has the action been done?" rather than "will the evidence still be valid when it next matters?" No control existed requiring a certificate's expiry date to be checked against the closure date, so a certificate with two months to run closed a CAR as convincingly as one with two years.
Contributing Factors:
- One closure line ("certificate to be filed on completion") was a commitment, not a record. Accepting it as closure evidence meant the report closed before the evidence existed.
- Certificate expiries live in a spreadsheet that is not read at the point a CAR is closed.
Proposed Corrective Action¶
| # | Action | Owner | Target |
|---|---|---|---|
| 1 | Jason May Fire Marshal recertification booked and completed — Fire Marshal certificate on file, renewed 21/07/2026, expiry 21/07/2029 | Leanne Mason | Complete 27/09/2026 |
| 2 | Leanne Mason Fire Marshal recertification booked before the 15/11/2026 expiry | Leanne Mason | 31/10/2026 |
| 3 | Leanne Mason Emergency First Aid at Work certificate obtained and filed — Emergency First Aid at Work certificate on file, expiry 16/06/2029 | Leanne Mason | Complete 27/09/2026 |
| 4 | Second first aider identified and trained so cover does not rest on one person — Jason May holds the Highfield Level 3 Award in Emergency First Aid at Work (RQF), awarded 29/11/2025, expiry 29/11/2028, certificate on file | Aaron Mason | Complete 28/09/2026 |
| 5 | Control change — closure of any CAR evidenced by a certificate now requires the expiry date to be recorded on the closure note. A certificate with less than six months remaining does not close a CAR on its own; the CAR stays open against the renewal | Sean Ashton | Complete 09/09/2026 — in force from that date |
Verification¶
Closure of this CAR requires all of the following, and no forward commitments will be accepted:
- [x] Jason May Fire Marshal certificate on file, expiry 21/07/2029 — confirmed at the 22/09/2026 site visit
- [ ] Leanne Mason Fire Marshal certificate on file, renewed, with the expiry date recorded
- [x] Leanne Mason Emergency First Aid at Work certificate on file, expiry 16/06/2029 — confirmed at the 22/09/2026 site visit
- [x] Action 5 evidenced — actions 1 and 3 of this CAR were closed on 27/09/2026 under the new test, each with the certificate expiry recorded (21/07/2029 and 16/06/2029), both clear of the six-month limit
- [x] Second qualified first aider evidenced — Jason May, Emergency First Aid at Work, expiry 29/11/2028, recorded under the action 5 test with more than six months to run
Points noted¶
- Migrate certificate currency to ComplianceTrack so expiries surface automatically rather than being read from a spreadsheet on request.
- At each Management Review, report certificates expiring within six months as a standing input, not just certificates already expired.
Feedback & Acknowledgments¶
Raised by the September 2026 management system review during the reissue of RA_HO_06, RA_HO_16 and RA_HO_17. Recorded in APP_21 Issue 9.
It records a corrective action failure identified by AMWS through its own certificate monitoring.
Corrective Action Report Prepared By¶
| CAR Prepared By | Signature | Position | Date |
|---|---|---|---|
| Sean Ashton | S. Ashton | HSQE Consultant | 09/09/2026 |
| CAR Reviewed By | Signature | Position | Date |
| --- | --- | --- | --- |
| Leanne Mason | L. Mason | Director | 05/10/2026 |
Corrective Action Close Out¶
Target Completion: 31/10/2026 for action 2; actions 1, 3 and 4 complete; action 5 in force from 09/09/2026.
Status: OPEN — owner Leanne Mason; target close 31/10/2026
Progress at 24/09/2026 — two of the three certificates now hold, the third does not yet
Evidence collected at the site visit of 22 September 2026:
| Item | Position at 24/09/2026 |
|---|---|
| Jason May — Fire Marshal | Resolved. Renewed certificate on file, valid to 21/07/2029. Second Fire Marshal cover is restored |
| Leanne Mason — Emergency First Aid at Work | Resolved. Certificate on file, valid to 16/06/2029. The commitment accepted as closure in May 2026 is now a record |
| Leanne Mason — Fire Marshal | Not yet resolved. Current certificate remains valid to 15/11/2026 and cover is in date. Rebooking was stated as intended in the week of 22/09/2026; the booking confirmation and certificate are awaited |
Reviewed again on 28/09/2026 against the certificates filed on the portal: action 4 is also complete. Jason May holds the Highfield Level 3 Award in Emergency First Aid at Work to 29/11/2028, so the second first aider the action called for is in place and evidenced, and first aid cover no longer rests on one person. RA_HO_16 was reissued at Issue 3 to match.
This report closes when Leanne Mason's renewed Fire Marshal certificate is on file, under the action 5 test.