Audit of allergen controls and relevant open audit actions

Foreword

The Food Standards Agency (FSA) is the Competent Authority (CA) responsible for feed and food safety and standards legislation and for ensuring risk-based official controls are carried out at feed and food business establishments in Wales, England, and Northern Ireland. Feed and food official controls aimed at verifying food business compliance are fundamental to safeguarding public health and contribute to the FSA’s strategic outcome that ‘food is safe and what it says it is’.

Day-to-day monitoring and enforcement of feed and food business compliance is the responsibility of local authorities (LAs).

In Wales, the power to set standards and monitor LA feed and food law enforcement services was conferred on the FSA under Section 12 of the Food Standards Act 1999 and Regulation 7 of the Official Feed and Food Controls (Wales) Regulations 2009. The FSA is required to monitor and audit local authority feed and food law enforcement services under this legislation and the assimilated Official Controls Regulation (EU) 2017/625. In developing its audit arrangements, the FSA has taken account of the European Commission guidance on how such audits should be conducted.
In addition to assessing the delivery of official controls against legal requirements and statutory guidance, the audit process also provides the opportunity to identify and disseminate good practice and to provide information to inform FSA policy on the execution and enforcement of feed and food law.

FSA audit programmes assess local authorities’ conformance against the requirements of the assimilated Official Controls Regulation (EU) 2017/625 and the Feed and Food Law Enforcement Standard within the Framework Agreement on Official Feed and Food Controls by Local Authorities (Framework Agreement). Assessments were also made against the Food Law Code of Practice (Wales) 2021 (FLCoP) along with related centrally issued guidance including the Food Law Practice Guidance (Wales) 2021 (FLPG).

This report is available in hard copy from the FSA’s Regulatory Audit and Assurance Team, Asiantaeth Safonau Bwyd yng Nghymru / Food Standards Agency in Wales, Llawr 4 / 4th Floor, Adeilad Llywodraeth Cymru / Welsh Government Building, Parc Cathays Park, Caerdydd / Cardiff, CF10 3NQ, and electronically on the FSA’s website.

Table of Contents

1.0 Introduction (including Background and Scope of Audit Programme)

2.0 Executive Summary

3.0 Audit Methodology

4.0 Audit Findings

Annex A – Audit plan

Annex B – Allergen controls action plan

 

1.0 Introduction

Background

1.1 Audits of LA feed and food law enforcement services are part of the FSA arrangements to improve consumer protection and confidence in relation to feed and food. Implementing official controls in food businesses at appropriate frequencies based on risk is essential to protect public health and ensure the safety of food for consumers.

1.2 Following the Covid pandemic, from 1 April 2023, LAs should be planning to:

• Carry out due interventions for establishments that are back in the routine programme of interventions in accordance with the frequencies set out in the FLCoP.
• Work towards realigning with the provisions set out in the FLCoP from 1 April 2023, using the full range of flexibilities already offered by the FLCoP. These flexibilities including exemptions can be found in Chapter 4 of the FLCoP and Chapter 4 of the Food Law Practice Guidance (Wales).
• Continue to exercise a risk-based approach to the requirements set out in the FLCoP based on available resource.

1.3 A key part of the FSA’s remit in its role as a CA is to provide assurance for stakeholders and the public that food authorities, such as LAs, are correctly delivering and implementing any legislation, advice and guidance issued in relation to the services they provide. This audit programme, in tandem with the bi-annual performance surveys, provides
a key element of the FSA’s overall assurance framework.

1.4 In Wales, the power to set standards and monitor LA feed and food law enforcement services was conferred on the FSA under section 12 of the Food Standards Act 1999 and regulation 7 of the Official Feed and Food Controls (Wales) Regulations 2009.

1.5 The Framework Agreement on Local Authority Food Law Enforcement sets out the arrangements through which the FSA monitors and audits LA enforcement activities to help ensure that LAs are providing an effective service to protect public health.

Scope of Audit Programme

1.6 This programme consists of a series of audits across Wales to assess compliance with legislation relating to the provision of allergen information to consumers and the risk posed to hypersensitive consumers, as well as reviewing any relevant open audit actions following previous audits. The audits assess whether LAs are undertaking interventions involving allergen assessments based on a programme of interventions that is in accordance with the FLCoP.

1.7 The audit assessment considered:

• Food standards service planning, delivery and review,
• Resources available to the service and the risk-based prioritisation of activities, including the assessment of new food businesses.
• Authorisation and competence of officers
• Interventions (programmed and reactive) and Enforcement
• Sampling Policy, procedures and programme
• Internal monitoring
• Any other matters relating to allergen controls
• Open audit actions – review of any relevant open actions from previous audits and associated update of the LA audit action plan.

1.10 As part of the development of the audit programme the FSA engaged with relevant stakeholders and produced an audit plan. This is attached in Annex A.

2.0 Executive Summary

2.1 The audit examined Monmouthshire County Council’s arrangements for the delivery of allergen related official food controls. This included a reality check at a food establishment to assess the effectiveness of official controls and more specifically, the checks carried out by the authority’s officers, to verify food business operator (FBO) compliance with legislative requirements. The scope of the audit also included an assessment of the authority’s overall organisation and management, and the internal monitoring of food law enforcement activities.

2.2 The Strategic Director for Social Care and Health had overall responsibility for the delivery of food standards services within Public Protection Department. Day to day management was the responsibility of the Principal Environmental Health Officers.

2.3 The authority had service planning arrangements in place together with systems for reviewing performance. Service planning documents contained some but not all the information set out in the Service Planning Guidance including the requirements to reference a risk-based food standards sampling programme and thoroughly review the previous year’s work.

2.4 Arrangements were in place to ensure effective service delivery by appropriately authorised, competent officers who had been authorised in accordance with their qualifications, training and experience. The authority would benefit from providing a small amount of additional officer resources along with a formal system of identifying officer training needs based on individual training needs assessments.

2.5 Database checks confirmed that there was a small backlog of establishments overdue a food standards intervention, whilst a, now-resolved, administrative error had prevented the programme being fully delivered in accordance with the food standards risk rating. The authority had planned to address the backlog fully within the coming year’s programme.

2.6 Inspection records demonstrated a variable quality of assessments of business allergen controls compliance had taken place during food standards interventions. Insufficient information was available in some aspects of intervention records to demonstrate that a thorough assessment had been undertaken by officers, without notice, in accordance with the FLCoP. In general, risk rating, revisits and follow up action was being carried out as required.

2.7 In general, food standards reports would benefit from a review to ensure that they contain all the information required by the FLCoP.

2.8 Food and food establishment complaints had generally taken place in accordance with the FLCoP, however, no food standard samples had been undertaken and there was no risk-based food standards sampling plan in place.

2.9 The authority had used both informal and formal enforcement tools to secure improved business compliance with allergen control legislation. Where enforcement action had been taken it was, generally, appropriate, however, in some cases, additional action should have been undertaken in accordance with the Enforcement Policy & FLCoP.

2.10 There was evidence of some internal monitoring of food standards matters, including allergen controls and an area of good practice in relation to corporate monitoring. The amount of qualitative internal monitoring activity would benefit from being expanded to include larger sample sizes and additional areas of service delivery.

3.0 Audit Methodology

3.1 The LA received a pre-audit letter including a pre-visit questionnaire along with details of documents required to assess completion of previously outstanding recommendations.

3.2 The LA was also provided with a copy of any relevant audit reports /action plans and asked to provide evidence of their progress on outstanding actions.

3.3 This was followed by a structured on-site audit involving a reality visit to a local business and meetings with the Head of Service, LA lead officer and other relevant staff about current and future service delivery arrangements as well as an examination of a selection of food official controls records.

3.4 The audit took place from the 15th – 17th July 2025. The on-site element of the audit took 2½ working days.

3.5 The LA received this written audit report and an updated audit action plan, which will be published on the FSA website.

4.0 Audit Findings

4.1 Organisation and Management

4.1.1 Food law enforcement was overseen by the Cabinet Member for Social Care and Health. The authority’s Constitution set out its decision-making arrangements. Under the Constitution, decisions on most food-related operational matters had been delegated to the Strategic Director Social Care and Health.

4.1.2 A ‘Monmouthshire Food Team Service plan 2025/2026’ (‘the Service Plan’) had been developed by the authority. The Service Plan had yet to receive approval by the Cabinet Member.

4.1.3 The Service Plan contained most of the information set out in the Service Planning Guidance, including a profile of the authority, the scope of the service and organisational structure chart for the Public Protection department. The times of operation, service delivery points and aims and objectives of the service were clearly set out.

4.1.4 The service plan indicated that there were approximately 1516 food establishments in Monmouthshire. The profile of businesses was provided by establishment type, and the number of planned interventions due, by risk rating, had been provided.

4.1.5 The targets and priorities for food standards included a commitment to deliver all inspections / interventions due at high, medium and low risk establishments as required by the FLCoP or sooner, based on the food hygiene risk.

4.1.6 The expected number of revisits during the year, forms a required part of the intervention programme but was not included. This should be included in the service plan.

4.1.7 The authority’s priorities and intervention-targets as set out in the Service Plan, were based primarily on food hygiene risk. In some cases, where the food standards risk was higher, auditors were informed that food standards risk would be prioritised.

4.1.8 Information provided on food standards sampling lacked specificity and detail. It did not reference the current year’s food standards programme, nor did it include data on the number or types of samples to be collected, or the level of resource required to deliver the programme.

4.1.9 The resources available to deliver food law enforcement services were detailed in the Service Plan as 5.5 full time equivalent (FTE) officers for both food hygiene and food standards. A figure of 5.6 FTE was estimated as required to deliver the service indicating the need for a small amount of additional resources was required to fully deliver against requirements.

4.1.10 The plan did not include an estimate of the likely demand for the food enforcement service, based on previous years, nor were estimates provided for the resources required to meet the demand. Additionally, there was no overall assessment of the resources required to deliver the full range of food official controls against those currently available.

4.1.11 The Service Plan included general information on the authority’s Enforcement Policy and its approach to staff development. In addition, it emphasised the necessity to undertake programmed inspections out-of-hours.

4.1.12 Arrangements for internal monitoring or ‘quality assessment’ of the food standards service through quantitative reporting arrangements was referenced within the plan. However, the plan would also benefit from the inclusion of a brief description of the qualitative internal monitoring arrangements for the food standards service.

4.1.13 The overall costs of providing food law enforcement services, including a breakdown of some non-fixed costs such as staffing, equipment including investment in IT and travel and subsistence had not been provided in the Service Plan. Further, information with regards to the trend in growth or reduction of the budget, a reference to the departmental financial provision for legal action and the budget for sampling should also be provided in accordance with the Service Planning Guidance.

4.1.14 The Service Plan contained limited information following a review of delivering food official controls against the previous year’s plan. It was noted that the review did not cover all targets and would benefit from including much of the information reported internally through the quarterly and annual reporting system. This should include food standards interventions delivered in both rated and unrated / new businesses, number of revisits, timeliness of responses to service requests and number of samples against the food standards sampling programme.

4.1.15 Variations in achieving the targets set-out in the previous Service Plan were, similarly, only identified through the internal reporting system and these would benefit from being collated in a dedicated section as part of the service review within the service plan. Variances for the low-risk food standards interventions and unrated businesses had not been identified or explained as required by the service planning guidance.

4.1.16 The authority had incorporated a number of high-level areas for improvement in its Service Plan, but these did not specifically address areas where variances had occurred i.e. unrated and low risk food standards interventions.

Recommendations

4.1.17 The authority should:

• (i) Ensure future Service Plans for food standards are developed in accordance with the Service Planning Guidance. In particular, the details of their risk-based food standards sampling priorities and activities should be provided.
• (ii) Ensure the annual performance review includes all information on the previous year’s performance against the food service plan and any specified performance targets, standards and outcomes.
• (iii) Ensure all variances in meeting the food service plan is addressed in its subsequent plan.
• 
  [Articles 5(1)(a) & (e) of assimilated Regulation (EU) 2017/625; para 2.3.3 FLCoP]

4.2 Authorised Officers

4.2.1 The authority’s Scheme of Delegation of Powers to Officers, contained within the authority’s Constitution, provided the Strategic Director for Social Care and Health with delegated powers to execute almost all duties relating to food services. This includes the delegated authority to authorise other officers, however, the power to instigate legal action was given to the Chief Officer for Law and Governance.

4.2.2 A documented procedure had been developed for the authorisation of food standards officers based on their qualifications and experience and a lead officer for food standards had been appointed, who had the requisite qualifications, experience and was able to demonstrate appropriate knowledge.

4.2.3 The documented procedure for authorising officers was mostly comprehensive and accurate, including an assessment of competence. The procedure would benefit from a sole amendment in relation to listing the correct authorising officer.

4.2.4 The authority had identified, within its Service Plan, that the level of resources required to deliver food services was slightly higher than those available, a deficit of 0.1 FTE officers. Auditors were informed that the authority was able to deliver its obligations of conducting its intervention programmes and responding to service requests as they arose, with the available resources. However, the authority was carrying a small backlog of food standards interventions, was not currently planning to deliver a programme of food standards sampling and needed to improve the amount of qualitative internal monitoring being undertaken. The authority should, therefore, ensure that it increases its food service resources to ensure there are sufficient resources available going forward to fully deliver its obligations in law and under the FLCoP.

4.2.5 Provision of officer training was dependent on individual officers identifying their own needs. Whilst some relevant training had been provided to officers in recent years, the authority did not have a formal system in place to identify officer training needs including individual training needs assessments. The authority was providing a combination of in-house and externally provided training and making good use of the opportunities afforded by the FSA’s local authority training opportunities. All officers were required to achieve 10 hours of continual professional development (CPD) on core food matters in accordance with the FLCoP. The authority is able to fund training where a need has been demonstrated.

4.2.6 An examination of the qualification and training records of five officers involved in the delivery of official food standards controls was undertaken. Records were being maintained by the authority for officers in the Council’s computer file & folder system.

4.2.7 All officers had been authorised in accordance with evidence of their qualifications, training and experience. Authorisations had been signed by an officer with the delegated authority and included all of the key legislation required for the delivery of the range of official controls required for allergens.

4.2.8 Academic and other relevant qualifications were available for all officers and all had received the minimum 10 hours of CPD on core food matters required by the FLCoP and the authority’s own policies, in keeping with their duties. Further, all officers had received the necessary training to deliver the technical aspects of the work for which they are involved.

Recommendations

4.2.9 The authority should

• (i) Ensure it has a sufficient number of suitably qualified and experienced staff so that official controls and other
• official activities can be performed efficiently and effectively.
• (ii) Put in place a programme that ensures staff undertaking official controls and other official activities receive appropriate training based on their individual needs and the activities they are authorised to undertake.
• [Articles 5(1)(e) & 5(4) of assimilated Regulation (EU) 2017/625; para 3.8.1 FLCoP]

4.3 Food Premises Inspections, Records and Reports

4.3.1 The authority provided data prior to the audit which confirmed there were 1135 food businesses on the authority’s food standards establishment database. There were a total of 39 food establishments overdue a food standards intervention, of which, two were high risk, 20 were medium-risk and 17 were low-risk. Due to a, now resolved, administrative error a small number of the overdue premises, including both high risk premises, had become overdue without being noticed. However, this meant that the approach taken to managing the intervention programme had been based solely on the food hygiene risk rather than the food standards risk, as required. The correction put in place means that, where necessary, the approach to managing the intervention programme in the future will be based on the food standards risk instead of being solely reliant on the food hygiene risk.

4.3.2 Food interventions procedures have been developed largely in accordance with requirements. However, the procedures would benefit from additional clarity on when samples should be taken and when a revisit should be undertaken for food standards matters, particularly, those relating to allergen matters.

4.3.3 Food standards interventions were being undertaken as a combined intervention alongside food hygiene interventions in most cases, using joint inspection aide-memoire forms.

4.3.4 Five food standards interventions carried out in the two years prior to the audit were examined. Visits had been undertaken at the correct frequency in all but one case. However, in three cases, the identification of significant breaches during previous interventions should, in accordance with the FLCoP, have resulted in the business receiving further revisits to check compliance. In addition, the intervention rating should have increased to the highest category (A) and the future intervention frequency increased.

4.3.5 In all cases, officers’ observations had been documented on the Food Inspection Aide Memoire. Records relating to the latest inspection were retrievable, legible and officer’s observations had been documented, however, auditors were unable to determine that intervention visits had been unannounced. In all cases, auditors were able to establish the type of food activity undertaken by the business, although, in four of the cases, officers had not captured the size, scale and scope of the business or whether samples had been taken.

4.3.6 Assessments of compliance with traceability requirements had been undertaken in all cases, whilst assessments of composition, presentation, and labelling requirements had been partly documented in all but one case. However, there was an absence of information on business recall/ withdrawal procedures in all cases.

4.3.7 In all files evidence was available to demonstrate that officers had made an assessment of food safety management systems in relation to food standards. However, in three cases there was insufficient information available to demonstrate the findings of the officer.

4.3.8 Where previous interventions had indicated contraventions, assessments of these had taken place during the current intervention in all cases.

4.3.9 Advice on compliance with pre-packed for direct sale (PPDS) requirements had been provided to businesses, where appropriate. However, in three cases, records of assessments of compliance contained limited information, preventing the identification of appropriate follow up action. There was also evidence that a revisit and / or enforcement action could have been undertaken or escalated sooner in order to address the repeat of contraventions over several interventions. In addition, in two cases, where many products incorrectly labelled for PPDS were identified, it was not evident that considerations had been made as to whether this food was unsafe and should be removed from sale. In one case, a statutory notice was served for non-compliance with allergen controls, in 2025 despite non-conformities being recorded since the introduction of PPDS in October 2021 and auditors considered that enforcement action should have been escalated sooner.

4.3.10 Risk ratings applied were consistent with the officers findings and in accordance with the FLCoP in all cases.

4.3.11 The authority reported that it was not currently using an alternative enforcement strategy for lower risk establishments however there was a policy detailing when it would be implemented.

4.3.12 Reports of visit had been left with food business operators at the time of the inspection or emailed shortly thereafter in all but one case. In one case, there was a delay of over a month in providing the business with its report. Reports had been addressed to the correct trading name and address of the business. In one case, the report should have been sent to the head office of the limited company.

4.3.13 Food business records, including registration forms, inspection aide-memoires, post inspection visit report forms and correspondence were available electronically. Details of the date and types of intervention undertaken at food establishments, as well as the risk profiles and food standards ratings, were stored on an electronic food establishments database. In all cases, where relevant, information relating to the last three inspections were available. Food registration forms were available on file in four cases, however, on one file the registration form had been automatically deleted due to the authority’s data retention policy. However, the details were captured on the electronic database and the authority intended to send a new form to the FBO for completeness.

4.3.14 In general, inspection reports contained most of the required information. However, the following information was not consistently available in all cases, where carbon copy reports were being relied upon:

• Description of purpose of OCs
• Registered address if different
• Person seen/interviewed
• Specific food law under which inspection conducted
• Areas inspected
• Documents/other records examined
• Samples taken
• Key points discussed during the inspection including outcome of OCs & any non-compliances identified.
• Actions to be taken by the food authority
• Clear distinction between legal requirements and recommendations
• Timescales for addressing non-compliances
• Designation of inspecting officer
• Contact details of inspecting officer

4.3.15 In the three cases where contraventions were identified, reports did not contain sufficient details to clearly identify legal requirements and the action required to comply with requirements. Timescales for compliance had not been provided in any cases.

Recommendations

4.3.16 The authority should:

• (i) Ensure that food standards interventions/inspections are carried out at the minimum frequency specified by the FLCoP . [Articles 9(1) & (2) of assimilated Regulation (EU) 2017/625; 4.2, 4.3, 4.4.2 FLCoP]
• (ii) Amend the intervention procedure to include consideration of all methods and techniques to verify compliance, including whether a food sample should be taken. [Articles 5(1)(a), 9(1), 12 & 14 of assimilated Regulation (EU) 2017/625; 4.5 FLCoP & 4.2.2 FLPG]
• (iii) Ensure that official controls are performed without prior notice, except where such notice is necessary and duly justified for the official control to be carried out. [Article 9(4) of assimilated Regulation (EU) 2017/625, 4.2.1 FLCoP]
• (iv) Ensure that observations made and/or data obtained in the course of a food standards intervention/inspection includes the size and scope of the business and complete information for assessments of food standards management systems, composition, labelling, presentation, food withdrawal / recall systems, whether to take samples. [Articles 5(1)(a) & (b), 9(1), 12, 13 & 14 of assimilated Regulation (EU) 2017/625; 4.2.2, 4.2.3, 4.5 FLCoP & 2.13.3, 4.2.2, 4.3.3.3 FLPG]
• (v) Ensure that intervention report letters are correctly addressed, sent promptly to the business and contain all of the required information. [Article 13 of assimilated Regulation (EU) 2017/625; 4.2.3 FLCoP, 4.3.4 FLPG]

Verification Visit to Food Establishment

4.3.17 A verification visit was undertaken at a food establishment with the authorised officer of the authority who had carried out the most recent food standards inspection. The main objective of the visit was to consider the effectiveness of the authority’s assessment of the systems within the business for ensuring that food meets the requirements of food standards law.

4.3.18 The officer was able to demonstrate their knowledge of the business and provide auditors with an assurance that assessments of allergen controls had taken place as part of the inspection. However, the visit also confirmed the importance of fully recording detailed inspection observations on the appropriate aide memoire and the importance of capturing the nature and extent of the different products being offered for sale. It further confirmed the need to take appropriate follow up action including that of ensuring sufficiently detailed information is provided to the business and unsafe food is dealt with appropriately and that the business has its own procedures of withdrawal and recall.

4.4 Food Inspection and Sampling

4.4.1 The authority’s Service Plan contained limited information on food standards sampling suggesting potential participation in projects or surveys but did not address routine inspection-based sampling based on risk or sampling in response to matters arising. Auditors were provided with a sampling plan for this current financial year, however, the plan does not consider food standards sampling, including that for allergens.

4.4.2 A combined policy relating to food standards and food hygiene sampling activities had been developed by the authority. The authority had appointed a Public Analyst for carrying out analyses of food. The laboratory was on the recognised list of UK designated Official Laboratories.

4.4.3 The authority’s procedure for taking food samples outlined how to take samples as well as steps to take following receipt of results.

4.4.4 No food standards samples had been taken within the scope of the audit and therefore compliance checks on files were not undertaken as part of the audit.

Recommendations

4.4.5 The authority should:

• (i) Set up and carry out a programme of risk-based food standards sampling. [Articles 9(1), 14, 137 & 138 of assimilated Regulation (EU) 2017/625; 2.3 FLCoP & 2.6.2 FLPG]

4.5 Food and Food Premises Complaints

4.5.1 The authority has developed a procedure for undertaking food related complaints which outlined the criteria for investigations.

4.5.2 An examination of records relating to five complaints or service requests received by the authority were undertaken. Auditors were able to confirm that complaints had been investigated within a timely manner. The majority of the cases were found to have undergone a thorough investigation; however, one service request received via a referral from a neighbouring authority, received a partial investigation that did not include a visit to the establishment to check previously issued advice on allergen controls had been implemented. Further, the taking of a sample may have provided additional assurance.

4.5.3 Where appropriate, all complainants had been notified of the results of the investigation and appropriate action had been taken based on the findings of the investigations in four cases. In one case, no further action was taken despite there being evidence of allergen labelling non -compliance, along with a previous business history of non-compliance.

Recommendations

4.5.4 The authority should:

• (i) Ensure that food complaints or service requests are thoroughly investigated and appropriate action taken in relation to non-compliance. [Articles 5, 12, 137 & 138 of assimilated Regulation (EU) 2017/625; 6.4 FLCoP & 6.3.1 FLPG]

4.6 Enforcement

4.6.1 The authority had developed a Corporate Enforcement Policy which was supplemented by the Food Safety Enforcement Policy. There was no evidence of approval of either policy by the portfolio holder. The policies were available to the public and businesses upon request.

4.6.2 These documents advocated a graduated approach to enforcement and taken together, were generally in accordance with the FLCoP and other official guidance. They provided criteria for the taking of informal action, the service of various statutory notices, other formal actions, issuing simple cautions and taking prosecutions and made reference to the Primary Authority scheme.

4.6.3 The taking of action in establishments where the Council itself has an interest were addressed in the policies, such as schools and care homes, although this would benefit from amendment to include leisure centres.

4.6.4 The authority had developed an enforcement procedure which detailed the authority’s expectations with regards to certain enforcement actions; these included procedures for Food Information Regulation Improvement Notices (FIRINs), Remedial Action Notices (RANs), Voluntary Closure, Prohibition Notices and Orders, seizure, detention, certification and voluntary surrenders, simple cautions & prosecutions.

4.6.5 Auditors discussed the benefit of reviewing the procedure for enforcement to include local arrangements for the drafting and maintaining proof of service for notices.

4.6.6 The authority had provided documented procedures for the commencement of prosecutions and undertaking simple cautions. Whilst these considered most aspects of this work, they would benefit from further development to include detail on how to compile a case file, including local arrangements for the progression of a case, having regard to Criminal Procedures Investigation Act 1996 roles and responsibilities. Further, reference to final decisions on prosecution being made by the Principal EHO should be amended to align with the constitutional delegation of this role to the Chief Officer for Law and Governance.

4.6.7 Formal enforcement actions undertaken within scope of the audit included two FIRINs but no other notices had been served or voluntary actions taken place. No prosecution / simple caution cases relating to allergen controls had been escalated for decisions within the scope of this audit.

4.6.8 The Auditor reviewed two of the FIRIN files which detailed all the information required on the main body of the notice correctly. However, point 5 of the notice does refer to the FIRIN as a Hygiene Improvement Notice (HIN) indicating that the notice template would benefit from amendment. Further, the appeals information on both FIRINs was incorrect, referring to a Tribunal rather than the Magistrates Court. It was noted that the template notice contained within the procedure was correctly worded.

4.6.9 In the two FIRIN cases, evidence was available to demonstrate that the notices had been an appropriate course of action following a graduated enforcement approach, however, it was noted that there was no proof of service for either notice.

4.6.10 Compliance had yet to be checked as one had not yet expired and the other premises had ceased trading.

Recommendations

4.6.11 The authority should:

• (i) Review and amend its enforcement policies to include leisure centres where it holds an interest. Ensure both policies are approved by the appropriate member forum. [Articles 5(1a,b), 137 & 138 of assimilated Regulation (EU) 2017/625, FLCoP 2.1, 2.3.2, 2.6.2 & FLPG 2.4.2]
• (ii) Review and amend its enforcement procedures to include local arrangements for drafting and maintaining proof of service for statutory notices along with the process of compiling and approving files for decisions on prosecution / simple cautions. [Articles 5(1a,b), 12, 13, 137 & 138 of assimilated Regulation (EU) 2017/625, FLCoP 2.3 & FLPG 2.3.13]
• (iii) Ensure FIRIN notices contain the correct appeal information and that proof of service is recorded. [Articles 5(1a,b), 12, 13, & 138 of assimilated Regulation (EU) 2017/625, FLCoP 6.2, 6.3 & 6.4, FLPG 6.6.9.1, 6.6.10]
• (iv) Ensure appropriate enforcement action is undertaken to ensure non-compliance identified during interventions is remedied. [Article 138 of assimilated Regulation (EU) 2017/625, FLCoP 6.2, 6.3 & 6.4]

4.7 Internal Monitoring

4.7.1 Internal monitoring is important to ensure performance targets are met, services are being delivered in accordance with legislative requirements, centrally issued guidance and the authority’s procedures. It also ensures consistency in service delivery.

4.7.2 Key performance targets have been identified in line with the FLCoP and the authority has arrangements in place for both quarterly and annual quantitative internal monitoring across the food services. Performance was reported through the corporate performance monitoring system. Further monitoring of the progress of intervention programmes is monitored regularly by the lead officer.

Good Practice

The corporate performance monitoring system involved reporting against all risk categories within the FLCoP, including lower risk premises, as well as unrated establishments. Underachievement against required intervention frequencies was being reported in addition to achievement of intervention frequencies.

 

4.7.3 A documented internal monitoring procedure had been developed for the food services including accompanied visits and a sample of file checks across most official control activities. The procedure would benefit from improvement to specify an increased sample size of internal monitoring activity, a maximum interval for checking officer authorisations, inclusion of incident investigations and bulk database checks.

4.7.4 The Principal EHOs and lead officers were responsible for internal monitoring of the food enforcement services at an operational level.

4.7.5 Auditors were able to verify that some qualitative internal monitoring had been undertaken across the service including record checks.

4.7.6 Records maintained, in accordance with the procedure, were able to confirm the nature and extent of the monitoring activity. Auditors were able to verify that some qualitative monitoring has been undertaken across both services including accompanied inspections, intervention file record checks, and service requests.

4.7.7 The amount and extent of internal monitoring taking place in practice would benefit from expansion whilst also including periodic authorisation checks, bulk database checks and incident responses.

4.7.8 The records relating to internal monitoring that were available, were being maintained by managers for at least two years.

Recommendation

4.7.9 The authority should:

• (i) Revise its documented internal monitoring procedures to ensure all relevant activities are subject to proportionate monitoring. This should specify an increased sample size of internal monitoring activity, a maximum interval for checking officer authorisations, inclusion of incident investigations and bulk database checks. The amount and extent of internal monitoring taking place in practice should be expanded whilst also including periodic authorisation checks, bulk database checks and incident responses. [OCR Arts 5(1a&b) & 12, FLCoP 2.3 & FLPG 2.3.4]

4.8 Relevant Open Audit Actions

4.8.1 Relevant open audit actions from previous audit programmes were followed up. This includes those from the full audit programme of 2013 - 2017 and the Food Hygiene Rating Scheme focussed audit of 2017. An updated action plan has been published on the FSA website.

Auditors:

Craig Sewell
Joshua Jolliffe
Angela Phillips

Division:

Regulatory Audit and Assurance Team,
Asiantaeth Safonau Bwyd yng Nghymru / Food Standards Agency in Wales,
Llawr 4 / 4th Floor,
Adeilad Llywodraeth Cymru / Welsh Government Building,
Parc Cathays Park,
Caerdydd / Cardiff,
CF10 3NQ

Annex A: Audit Plan

Food Standards Agency in Wales

Local authority audit plan – Wales

April 2025 – March 2026

Programme Brief

 

Sarah Maddox
Head of Regulatory Audit and Assurance, FSA in Wales
Email Sarah.Maddox@food.gov.uk

Craig Sewell
Senior Audit Manager, FSA in Wales – Lead Auditor
Email wales.audit@food.gov.uk

 

Background

1. In Wales, the power to set standards and monitor local authority (LA) feed and food law enforcement services was conferred on the Food Standards Agency (FSA) under section 12 of the Food Standards Act 1999 (the Act) and regulation 7 of the Official Feed and Food Controls (Wales) Regulations 2009 (OFFC).

2. The Act provides the FSA with statutory powers to strengthen its influence over enforcement activity and to ensure national priorities and objectives will be delivered at a local level. It gives the FSA powers to carry out the following duties:

• set standards of performance in relation to enforcement of feed and food law
• monitor the performance of feed and food law enforcement authorities
• require information from LAs relating to food law enforcement and to inspect any records
• enter LA premises, to inspect records and take samples
• publish information on the performance of LAs
• make reports to individual LAs, including guidance on improving performance

3. Assimilated Regulation (EU) 2017/625 on official controls and other official activities performed to ensure the verification of compliance with feed or food law includes a requirement, under Article 6, for competent authorities to carry out internal audits or to have external audits carried out.

4. To fulfil this requirement the FSA provides assurance for stakeholders and the public that competent authorities (CAs) such as LAs, are correctly delivering and implementing any legislation, advice and guidance issued in relation to the services they provide. This audit programme, in tandem with the bi-annual performance surveys, provides a key element of the FSA’s overall assurance framework.

5. The audits in this audit programme will be a systematic and independent examination of the delivery of official controls by LAs in relation to food law in Wales.

Programme Objectives

6. The audit programme will look at official controls and official activities carried out from 01 April 2023. Management activities relating to the implementation of the legislation in the criteria before this date will also be included in the audit programme.

7. The audits will demonstrate whether the implementation of official food controls relating to allergens in Wales has been effective. Failure to secure compliance with food law which could detrimentally affect the health and welfare of people in Wales could result in reputational damage to LAs and the FSA, as well as loss of confidence in the food industry.

8. The focused audit programme will include an examination of the official controls, official activities and related results that are used by LAs to achieve the objectives of the Legislation below:

• The Food Safety Act 1990
• Assimilated Regulation (EU) No 1169/2011 on the provision of Food Information to Consumers
• The Food Information (Wales) Regulations 2014

9. The specific aims of this audit programme are to:

• provide assurance that the delivery of allergen labelling legislation that has been in operation since 2014 in Wales, has been effectively implemented by LAs; in that official controls are being delivered in accordance with the Food Law Code of Practice (Wales) (the Code), Food Law Practice Guidance (Wales), Framework Agreement and other centrally issued, official guidance and legislation*.
• evaluate LA activities in relation to food businesses providing products Pre-Packed for Direct Sale (PPDS) to consumers which came into force in October 2021.
• identify and disseminate any areas of good practice and innovation to other LAs to improve the effectiveness and efficiency of controls being delivered
• provide a means to identify under performance in the LAs food law enforcement systems
• provide information to aid the development of FSA policy.
• review LA progress in implementing any relevant outstanding recommendations from previous audits

* The Code used will be relevant to the timing of the delivery of relevant controls.

Scope of the Audit Programme

10. This programme will consist of a series of audits across Wales to assess the compliance with legislation relating to the provision of allergen information to consumers and the risk posed to hypersensitive consumers, as well as reviewing any relevant open audit actions following previous audits. The audits will assess whether LAs are undertaking interventions involving allergen assessments based on a programme of interventions that is in accordance with the Code.

11. The audit programme will focus on the risks associated with the following areas of official control: -

• Food standards service planning, delivery and review,
• Resources available to the service and the risk-based prioritisation of activities, including the assessment of new food businesses.
• Authorisation and competence of officers
• Interventions (programmed and reactive) and Enforcement
• Sampling Policy, procedures and programme
• Internal monitoring
• Any other matters relating to allergen controls

12. Open audit actions – review of any relevant open actions from previous audits and associated update of the LA audit action plan.

Assessment Approach

13. The audits will involve:

• a pre-audit questionnaire requesting copies of the LA service plans, planned/completed interventions and associated documentation
• the LA will also be provided with a copy of previous audit action plans and will be asked to provide evidence of their progress on any outstanding actions
• this will be followed by a structured on-site audit involving meetings with the Head of Service, LA lead officers and other relevant staff about current and future service delivery arrangements, a reality check visit and case file reviews.

Notification

14. Prior notification of 4 weeks for the submission of pre-audit material and at least 6 weeks of an audit visit, will be given for each audit carried out under this audit plan. This will aid transparency and facilitate the effectiveness of the audit process by allowing plenty of time for each LA to collate documents and ensure appropriate staff and facilities are available.

Timing

15. The audits will take place between May 2025 and February 2026. The on-site element of the audit, for each LA, should take 2 working days for assessment work followed by a closing meeting on a third day.

Assessment Report and Follow Up

16. All LAs in the programme will receive an individual report and an updated audit action plan, both of which will be published on the FSA website. An assessment of overall assurance for allergen controls will also be sent to each local authority but will not be published.

17. At the end of the programme an anonymised summary report will be produced which will contain findings from the audit programme. The summary report will include recommendations for LAs and the FSA to improve the delivery of official controls. The summary report will also highlight any common themes and emerging issues as well as any areas of good practice identified during the programme.

Planned Outcomes

Immediate Outcomes

Provide assurance regarding the arrangements in place for the delivery of LA official controls in managing the food safety risk relating to hypersensitive individuals posed by exposure to Allergens
Improvements and actions taken by LAs contribute to more effective local food law enforcement
Wider dissemination of identified good practice will contribute to improvements in quality and effectiveness of LA delivery of official food controls
Findings and recommendations will be fed back to relevant FSA teams to inform policy making
The audits will ensure that the FSA is fulfilling its’ statutory function.

Strategic Outcomes

The audits will raise the profile of the food service within LAs and help them maintain/enhance their resource allocation
Robust assurance on the LA implementation of Official Feed and Food Control (OFFC) requirements
Improved business compliance with food hygiene and standards contributes to improved public health and reduces the likelihood of foodborne illness, food incidents and food fraud
Contribute towards FSA strategic risk management and compliance with UK obligations under OFFC requirements & the Food Standards Act 1999

 

Annex B: Allergen controls audit action plan

Action Plan for Monmouthshire County Council
Audit Date: 15th — 17th July 2025

TO ADDRESS (RECOMMENDATION INCLUDING STANDARD PARAGRAPH)	BY (DATE)	PLANNED IMPROVEMENTS	ACTION TAKEN TO DATE
4.1.17 The authority should: (i) Ensure future Service Plans for food standards are developed in accordance with the Service Planning Guidance. In particular, the details of their risk-based food standards sampling priorities and activities should be provided.	30/11/25	We do have a budget for food standards sampling. We will develop a sampling plan for locally produced foods and contribute to regional and national food standards sampling initiatives, particularly when specific funding is provided.	We have discussed the sampling budget with our financial advisers. I have also made enquiries with the other Gwent LAs regarding their food standards sampling plans.
4.1.17 (ii) Ensure the annual performance review includes all information on the previous year’s performance against the food service plan and any specified performance targets, standards and outcomes.	30/11/25	The food service plan will be amended to include a reflection on the previous year’s performance.	Information is currently provided via the quarterly business improvements plans (BIPs) which collated into an annual performance review meeting which available to the public.
4.1.17(iii) Ensure all variances in meeting the food service plan is addressed in its subsequent plan.	30/11/25	Increased internal monitoring and use of the spreadsheet shared during the audit.
4.2.9 The authority should (i) Ensure it has a sufficient number of suitably qualified and experienced staff so that official controls and other official activities can be performed efficiently and effectively.	30/11/25	The shortfall identified as 0.1 FTE will be absorbed by reallocating tasks to other staff, in particular students and qualified staff transferred for the public protection team on a temporary basis. e.g. private water supply assessment, SRs, low risk food interventions, ESAG work and health and safety project work.
4.2.9 (ii) Put in place a programme that ensures staff undertaking official controls and other official activities receive appropriate training based on their individual needs and the activities they are authorised to undertake.	30/11/25	A more structured training plan is being developed to ensure staff receive sufficient and appropriate CPD.	Training needs have been discussed at team meeting and in one to one interviews with staff.
4.3.16 (i) The authority should: Ensure that food standards interventions/inspections are carried out at the minimum frequency specified by the FLCoP.	30/11/25	The spreadsheet provided during the audit will be used to check and monitor inspection frequencies.	The error made in calculating standards inspection frequencies has been addressed. The reason for the error was identified and support staff have been retrained. Businesses with a higher Q score with more complicated food standards issues will be inspected at a separate time for food standards and the risk frequency calculated independently which will reduce the risk of the F frequency being used in error.
4.3.16 (ii) The authority should: Amend the intervention procedure to include consideration of all methods and techniques to verify compliance, including whether a food sample should be taken.	30/11/25	Amend the intervention policy to include the consideration for sampling at visits.	A question on whether samples should be taken or arranged has been added to the inspection form. Currently any sampling deemed necessary at the time of a visit will be discussed with the sampling lead officer for inclusion in subsequent sampling runs.
4.3.16 (iii) The authority should: Ensure that official controls are performed without prior notice, except where such notice is necessary and duly justified for the official control to be carried out. [Article 9(4) of assimilated Regulation (EU) 2017/625, 4.2.1 FLCoP]	30/11/25	The current general hygiene and standards inspection form will be completely reviewed.	A question has also been added to the current inspection form on whether the inspection was done with or without prior notice, and if necessary, the justification for giving prior notice.
4.3.16 (iv) The authority should: Ensure that observations made and/or data obtained in the course of a food standards intervention/inspection includes the size and scope of the business and complete information for assessments of food standards management systems, composition, labelling, presentation, food withdrawal / recall systems, whether to take samples.	30/11/25	The current general hygiene and standards inspection form will be completely reviewed.	Questions have already been added to the current inspection form regarding the nature, scope and distribution of the food produced by a business. A question around withdrawal procedures has also been added. There was already a question on the form about traceability. A separate more detailed food standards inspection form has been adopted for more complicated food standards businesses, which will be used for doing standards only inspections.
4.3.16 (v) The authority should: Ensure that intervention report letters are correctly addressed, sent promptly to the business and contain all of the required information.	30/11/25	The handwritten carbonated report forms will be reviewed.	We have reviewed the handwritten report forms and the advice regarding the cost of a re-rating visit. Staff will also write the cost on the hand written report.
4.4.5 The authority should: (i) Set up and carry out a programme of risk-based food standards sampling.	30/11/25	To set up and carry out a programme of risk based food standards sampling.	Enquiries with other Gwent LAs as to ongoing standards sampling projects.
4.5.4 (i) The authority should: Ensure that food complaints or service requests are thoroughly investigated and appropriate action taken in relation to non-compliance.	Immediately	On going monitoring and review of SR performance.	The service request had been dealt with at an informal visit to the premises. We had informed the FBO of the complaint and she had assured us that she would investigate the matter – it was a very simple product (bread rolls). Unfortunately, the officer did not record that the advice had been given.
4.6.11 (i) The authority should: Review and amend its enforcement policies to include leisure centres where it is holds an interest. Ensure both policies are approved by the appropriate member forum.	30/11/25	Review the enforcement policies.	The intervention policy has been amended to include LA run food businesses.
4.6.11 (ii) Review and amend its enforcement procedures to include local arrangements for drafting and maintaining proof of service for statutory notices along with the process of compiling and approving files for decisions on prosecution / simple cautions.	30/11/25	Review of the enforcement procedure to include the new proof of service document that has been developed and how the document is to be stored. The enforcement policy will be reviewed to include how to decisions are made on simple cautions and prosecutions and the procedures will be amended to include the process for compiling case files.	A proof of service document has been developed, and a copy of the document is stored on the intervention record that resulted in the notice being served. We currently use am enforcement checklist (attached to email)
4.6.11 (iii) Ensure FIRIN notices contain the correct appeal information and that proof of service is recorded.	Immediately	Review the enforcement policy and emphasise using the Welsh FIRIN	Team members have been reminded to make sure that they use the Welsh FIRIN notices with the correct appeal information.
4.6.11 (iv) Ensure appropriate enforcement action is undertaken to ensure non-compliance identified during interventions is remedied.	30/11/25	Review the enforcement policy to reflect that after advice has been provided enforcement action will be taken if the advice is not implemented.	Discussed with the team, We intend to increase use of FIRINs to achieve compliance and not to rely on advice being implemented.
4.7.9 (i) The authority should: Revise its documented internal monitoring procedures to ensure all relevant activities are subject to proportionate monitoring. This should specify an increased sample size of internal monitoring activity, a maximum interval for checking officer authorisations, inclusion of incident investigations and bulk database checks. The amount and extent of internal monitoring taking place in practice should be expanded whilst also including periodic authorisation checks, bulk database checks and incident responses.	30/11/25	Review the internal monitoring procedure to reflect the increase in the frequency on qualitative checks. Checks will include reviews of interventions, service requests (including incidents), food complaints and record keeping. Officer authorisations will be checked on a regular basis and no longer than every 5 years. The spreadsheet shared with us during the audit will be used for checking and monitoring purposes.	Increased frequency of monitoring checks.