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Audit of allergen controls and relevant open audit actions
Wales specific
Neath Port Talbot County Borough Council, 2nd - 4th December 2025
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). A new Code of Practice and Practice Guidance has been published and will be applied to ongoing recommendations where applicable.
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
Background
Scope of Audit Programme
2.0 Executive Summary
3.0 Audit Methodolodgy
4.0 Audit Findings
Organisation and Management
Authorised Officers
Food Premises Inspections, Records & Reports
Food Inspection and Sampling
Food and Food Premises Complaints
Enforcement
Internal Monitoring
Relevant Open Audit Actions
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 FLPG.
- 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 Neath Port Talbot County Borough Council’s arrangements for the delivery of allergen related official food controls, a major part of the authority’s food standards function. 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 standards activities.
2.2 The Director of Environment and Regeneration, the Head of Planning and Public Protection and the Trading Standards & Food & Health Protection Manager had overall responsibility for the delivery of food standards services within the Planning and Public Protection Department. Day to day management was the responsibility of the Trading Standards Team Leader and Senior Trading Standards Officer.
2.3 The authority had service planning arrangements in place together with systems for reviewing performance. Service planning documents contained most, but not all of the information set out in the Service Planning Guidance, including the commitment to deliver Council’s full obligations, the requirement to review all elements of the previous year’s work and address all delivery shortfalls in the next plan.
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. There was, however, a shortage of 3.2 full time equivalent officers required to deliver the authority’s intervention numbers with current practices. However, the challenges of completing thorough records of interventions, and consistently following up non-compliances requires further additional resources to ensure the authority’s full obligations in relation to allergen controls are being met. Whilst the authority had put in place some plans to ensure long term resources were maintained, there was no plan in place to fully address the shortage in officer resources, preventing the authority from meeting its obligations.
2.5 Database checks confirmed that approximately half of the food standards premises interventions were missing following a problematic database migration. High risk interventions had not all been undertaken on time, and an unknown number of establishments were able to be identified as overdue a food standards intervention due to the missing data. Of the premises that were identifiable as overdue, a large proportion of the overdue medium (59%) and low risk premises (95%) were likely to carry allergen risks and many of the low-risk premises belong in a higher risk band. There was no plan in place to fully re-align its intervention frequencies with the FLCoP, preventing the authority from meeting its obligations.
2.6 Intervention records showed that assessment records of business allergen control compliance during food standards interventions were not of the required standard. Insufficient information was available to demonstrate that a thorough assessment had been undertaken by officers. It was not always possible to identify whether follow up action was needed but where it was, follow up action was not always being carried out effectively to remove unsafe food from the market or to prevent a recurrence of the problems.
2.7 Food standards intervention reports to businesses were not of the required standard.
2.8 Whilst food and food establishment complaints and food standards sampling had generally been undertaken as required, there was evidence that thorough investigation of complaints and appropriate follow up action was not always undertaken.
2.9 The authority had mostly used informal enforcement tools to try and secure improved business compliance with allergen control legislation. Where enforcement action had been taken it was, generally, appropriate up to a point, however, follow up action was not always being carried out effectively to remove unsafe food from the market or to prevent a recurrence of the problems.
2.10 There was evidence of some internal monitoring of food standards matters, including allergen controls. The internal monitoring activity would benefit from improvement to ensure better recording, better analysis, bulk database checks and the re-instatement of intervention programme delivery monitoring, once the database migration issues have been resolved.
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 2nd - 4th December 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 Director of Environment and Regeneration, the Head of Planning and Public Protection and the Trading Standards & Food & Health Protection Manager. The authority’s Constitution set out its decision-making arrangements. Under the Constitution, decisions on food-related operational matters had been delegated to the above officers.
4.1.2 A ‘Food & Feed Law Enforcement Service Delivery Plan for 2025/2026’ (‘the Service Plan’) had been developed by the authority. Evidence of the approval of the Service Plan had not been provided.
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 1322 food establishments in Neath Port Talbot. The profile of businesses was provided by establishment type. The number of planned interventions due, by risk rating, had also been provided including those that were overdue.
4.1.5 The targets and priorities for food standards included a commitment to deliver all inspections / interventions due at high-risk and unrated establishments as required by the FLCoP but there was no commitment for the delivery of all medium and low risk establishments in accordance with the law and the FLCoP. The number of visits in the intervention programme table was short of that required.
4.1.6 The expected number of revisits during the year, forms a required part of the intervention programme and an estimate of a small number of revisits was included in the intervention programme table. There was, however, no commitment to revisit establishments for food standards in accordance with the requirements of the law and the FLCoP.
4.1.7 The authority’s priorities and intervention-targets as set out in the Service Plan, based primarily on delivering interventions in high-risk and unrated establishments was not fully risk based.
4.1.8 The plan included an estimate of the likely demand for the food interventions programme, including the likely demand, based on previous years, for the reactive work required to be undertaken.
4.1.9 Information was provided on the food standards sampling programme and included the resources allocated to undertake this work. However this did not include reference to risk-based sampling undertaken during inspections.
4.1.10 The resources available to deliver food law enforcement services were detailed in the Service Plan as 2.8 full time equivalent (FTE) officers for food standards. A figure of 6.0 FTE was estimated as being required to deliver the service, indicating the need for more than double of the current available resources (an additional 3.2 FTE) to fully deliver against requirements.
4.1.11 The Service Plan included information on the authority’s Enforcement Policy and its approach to staff development.
4.1.12 Arrangements for internal monitoring or ‘quality assessment’ of the food standards service through quantitative reporting arrangements was referenced within the plan along with a brief description of the qualitative internal monitoring arrangements for the service.
4.1.13 The Service Plan was supplemented by a separate “Review of Food and Feed Law Enforcement Performance 2024 / 2025”. Together, they contained information following a review of delivering food official controls against the previous year’s plan. However, it was noted that whilst the review covered most areas of work, it did not cover all targets. The review should include the number of samples taken against the food standards sampling programme and the amount of reactive cases responded to within target times.
4.1.14 Following the review, variances in achieving the targets set out in the previous Service Plan had been identified in relation to the backlog of medium (category B) and low-risk food standards (category C) interventions and unrated businesses. The limited resources available was given as the explanation for these variances.
4.1.15 The authority had incorporated a number of areas for improvement in its Service Plan, however, this did not include addressing the variances in Category B, C and unrated establishment interventions in order to ensure re-alignment with the requirements of the law and the FLCoP.
Recommendations
4.1.16 The authority should:
- (i) Ensure future Service Plans for food standards are developed in accordance with the Service Planning Guidance. In particular, a commitment and plan to deliver all due and overdue Category unrated, B & C category interventions and revisits, based on the requirements of the FLCoP and the inclusion of planned intervention based samples within the sampling programme, should all 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 are addressed in its subsequent plan.
[Articles 5(1)(a) & (e) of assimilated Regulation (EU) 2017/625; FLCoP 2.3.3, FLPG 2.3.18.2, 2.3.18.3 & Annex 1]
4.2 Authorised Officers
4.2.1 The authority’s Scheme of Delegation of Powers to Officers, contained within its written Constitution, provided the Director of Environment and Regeneration, the Head of Planning and Public Protection and the Trading Standards & Food & Health Protection Manager with delegated powers to execute all duties relating to food services. This includes the delegated authority to authorise other officers and the power to instigate prosecutions.
4.2.2 A documented procedure had been developed for the authorisation of food standards officers based on their qualifications and experience. The documented procedure was a high-level document that did not fully capture the process of authorising officers. The procedure would benefit from amendments to identify responsibilities and include the full process of authorisation based on officer competence as well as the documentation required to be completed.
4.2.3 The authority had appointed a suitably qualified and competent lead officer for food standards in accordance with the requirements of the FLCoP.
4.2.4 The authority had identified, within its Service Plan, that the level of resources required to deliver food services was significantly higher than those available, a deficit of 3.2 FTE officers. The authority was unable to deliver its obligations of conducting its intervention programmes, fully recording inspection observations, undertaking revisits and taking the necessary enforcement action with the available resources. The authority was carrying a significant backlog of food standards interventions and was not currently planning to re-align with the FLCoP due to an absence of sufficient resources. The authority had taken steps to ensure the development of future authorised officers through local development opportunities and long-term succession planning, which should cover expected losses through future staff retirements. However, there is a need for additional substantial support for the short to medium term in order to address the current backlog, improve work processes and keep pace with new businesses arising. 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 a formal training needs assessment. 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.
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 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 but one 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 but one officer had received the necessary training to deliver the technical aspects of the work relating to allergen controls, which they were involved in.
Recommendations
4.2.9 The authority should:
- (i) Amend its authorisation procedure to document the full procedure for the authorisation of officers based on competence.
[Articles 5(1)(a)&(g) of assimilated Regulation (EU) 2017/625; FLCoP 2.3.1] - (ii) 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.
[Articles 5(1)(e) of assimilated Regulation (EU) 2017/625; FLCoP 3.2]
4.3 Food Premises Inspections, Records and Reports
4.3.1 The authority provided information in its service plan which confirmed there were 1322 rated food businesses on the authority’s food standards establishment database at the start of the year. Also, according to the service plan, at the start of this planning year, there were 182 unrated premises and 289 rated premises overdue a food standards intervention. These included 0 high risk (cat A), 99 medium risk (cat B) and 190 low risk (cat C) establishments. At the time of the audit, there were an unknown number of overdue and unrated establishments due to a problematic database migration carried out earlier this year, although it was known that one of the high-risk interventions had not been delivered on time. Approximately half of the premises that should be included on the database were not appearing as premises rated for food standards. Whilst the authority was working with its database provider to try and address the migration problems, the issues prevented the measurement of the delivery of the food standards intervention programme. From the partial database provided for the audit, a significant proportion of the overdue medium (59%) and low risk (95%) premises carried allergen risks and evidence from premises type data indicated that many of the low-risk premises were likely to belong in a higher risk band. With neither plans to address this backlog of overdue interventions, nor the resources to implement such a plan, the number of uninspected premises carrying allergen risks is likely to rise, increasing the likelihood of public health impacts emerging.
4.3.2 Food standards intervention procedures had been developed and were largely in accordance with requirements. The procedures would benefit from additional information on how new businesses are prioritised. Food standards interventions were being undertaken by a stand-alone food standards service and whilst an aide-memoir had been developed for undertaking interventions, it was not in use. Instead, officers were using an inspection summary sheet which did not capture all required information. Auditors were provided with a draft procedure during the audit for advising officers on allergen contraventions.
4.3.3 Five food standards interventions carried out in the two years prior to the audit were examined. It was noted that all files contained relevant food registration details, and all observations were legible and retrievable, in all cases. Visits had been undertaken at the correct frequency in all but one case.
4.3.4 Auditors were able to establish that, in all but one case, officers had incorrectly used the inspection summary sheet as an aide-memoir and auditors were therefore unable to determine that all relevant information had been assessed. This included whether the visits had been unannounced, the nature & extent of food activities, whether the business had a food safety management system, including all control measures in place for allergens. The use of the inspection summary sheet meant officers were, for the most part, reporting findings by exception and only recording contraventions. Whilst the authority had already identified this, auditors were informed that the summary sheet sometimes continued to be incorrectly used.
4.3.5 Information on whether any samples were taken or considered during the intervention was only available in two of the five files.
4.3.6 Auditors were able to establish that assessment of incoming traceability requirements in relation to allergens including details of suppliers, other businesses that produce or import for the business and ingredient specifications, were available in three out of five cases.
4.3.7 Compliance with composition and presentation requirements had been thoroughly assessed in only one out of five cases. Whilst compliance with allergen labelling requirements had been assessed in two out of five files. Insufficient information was available on the remaining files to be able to determine what assessments had been undertaken.
4.3.8 Auditors were able to determine that, as part of outgoing traceability, assessment of customer information product recall / withdrawal arrangements had only been examined in one out of five cases.
4.3.9 Auditors were able to determine that risk ratings were consistent in all cases. However, in one case the scoring relating to business activities differed between two inspections with no apparent reasons documented.
4.3.10 Auditors were able to determine that reports were sent to correct business address in a prompt manner to Food Business Operator / left on site in all cases where appropriate.
4.3.11 However in two out of five cases, where relevant, the reports did not contain:
- Description of purpose of official controls
- Control methods applied
- Trading name and address of the business, and registered address if different
- Name of the food/feed business operator.
- Type of business
- Person seen/interviewed
- Date and time of inspection
- Specific food law under which inspection conducted
- Areas inspected
- Documents/other records examined
- Samples taken
- Key points discussed during the inspection including outcome of official controls & any non-compliances identified.
- Actions to be taken by the food authority
- Clear distinction between legal requirements and recommendations
- Timescales for addressing non-compliances
- Signed by officer
- Officer’s name
- Designation of inspecting officer
- Contact details of inspecting officer
- Contact details of senior officer
- Date of report
- Authority name and address
4.3.12 In three out of five cases, auditors were able to determine that appropriate follow-up action had not been taken in light of inspection findings. Revisits were not undertaken in two cases where it was deemed necessary. Considerations as to the removal of unsafe food from sale were not adequately explored or recorded where concerns were raised in relation to composition, labelling and allergen control requirements.
4.3.13 The authority reported that it was not currently using an alternative enforcement strategy for lower risk establishments, however there was a procedure covering this activity.
Recommendations
4.3.14 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; FLCoP 4.2, 4.2.2, 4.2.4 & 4.2.5]
- (ii) Ensure that observations made and/or data obtained in the course of a food standards intervention/inspection is captured on the correct aide memoire and that it includes complete information on:
• Whether intervention was unannounced/ announced
• nature & extent of food activities,
• assessments of food standards management systems, including all control measures in place for allergens,
• assessments of labelling, composition and presentation
• incoming traceability requirements in relation to allergens including details of suppliers, other businesses that produce or import for the business and ingredient specifications
• product recall / withdrawal arrangements
• the consideration of whether to take samples/ what samples taken.
[Articles 5(1)(a) & (b), 9(1), 12, 13 & 14 of assimilated Regulation (EU) 2017/625; FLCoP 4.3.2, 4.3.3.1, 4.4, 4.6; FLPG 4.3.4.2, 4.3.4.3, 4.6]
(iii) Ensure that the establishment database & any information management system is capable of retrieving all food establishment information and providing the information requested by the FSA. Ensure that intervention report letters/ post inspection forms contain all of the required information.
[Articles 5(1)(f) & 13 of assimilated Regulation (EU) 2017/625; FLCoP 2.6, 2.6.3, 4.6; FLPG 4.3.4.3, 4.6]
Verification Visit to Food Establishment
4.3.15 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 in relation to allergen controls.
4.3.16 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.
4.4 Food Inspection and Sampling
4.4.1 The authority’s Service Plan contained information on food standards sampling indicating participation in projects or surveys, and sampling in response to matters arising. Auditors were provided with a sampling plan for this current financial year, that considered food standards sampling, including that for allergens. The plan would benefit from detailing samples to be taken on the basis of risk, during routine inspections.
4.4.2 The authority has developed a procedure for taking food samples which outlined how to take samples as well as steps to take following receipt of results.
4.4.3 Auditors were provided with a draft procedure during the audit for advising officers on Allergen contraventions, including a flowchart for taking action in relation to unsatisfactory samples.
4.4.4 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.
4.4.5 Five food standards samples carried out in the two years prior to the audit were examined. All samples had been taken by appropriately trained and authorised officers and sample results were available on file. Auditors were able to confirm that, all food business operators had been informed of the results and where appropriate, the Primary Authority had also been notified.
Recommendations
4.4.6 The authority should:
- (i) Include in the sampling plan a programme of risk and intervention based food standards sampling. [Articles 9(1), 14, 137 & 138 of assimilated Regulation (EU) 2017/625; FLCoP 2.3.1, 4.2, 4.3, 4.3.3.1 & 4.4]
4.5 Food and Food Premises Complaints
4.5.1 The authority had developed a procedure for undertaking food and food premises related complaints which outlined the criteria for investigations which was in accordance with the requirements. Auditors were provided with a draft procedure during the audit for advising officers on Allergen contraventions.
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 in all but one case.
4.5.3 In four cases, auditors were able to determine that the cases had been appropriately investigated and where appropriate complainants had been notified of the results of the investigation.
4.5.4 In one case, auditors were unable to determine that the case had been appropriately investigated as there was no information on file relating to the complaint.
Recommendations
4.5.5 The authority should:
- (i) Ensure that food complaints or service request records are retained, retrievable and they are thoroughly investigated and appropriate action is taken in relation to non-compliance. [Articles 5, 12, 137 & 138 of assimilated Regulation (EU) 2017/625; FLCoP 2.6, 4.4, 4.6, 6.3 & 6.4 FLPG 2.3.2.4, 4.6]
4.6 Enforcement
4.6.1 The authority had developed an Environmental Health and Trading Standards – Enforcement Policy which was appropriately approved. The Policy advocated a graduated approach to enforcement and was generally in accordance with Food Law Code of Practice and other official guidance. The Policy provided criteria for the taking of all enforcement actions and made reference to the Primary Authority scheme and included information to direct action in establishments where the Council itself has an interest, such as schools, care homes, and leisure centres.
4.6.2 The food standards department did not have specific enforcement procedures relating to improvement notices, prohibition notices, seizure and detention and certification of food. Procedures should be developed to ensure that up-to date information is readily available to enable authorised officers to carry out their duties.
4.6.3 One Food Information Regulation Improvement Notice {FIRIN) had been served within the scope of the audit and the file relating to this notice was reviewed. The notice was fully compliant with requirements.
4.6.4 No detention, seizure, certification or voluntary surrenders relating to allergens had been undertaken within the scope of the audit and were therefore not assessed.
4.6.5 The authority had invested in an online resource tool, the Enforcement and Legal Process manual which provides documented guidance including the full process for the commencement of prosecutions and undertaking simple cautions. These considered all aspects of this work, including information on how officers access template documents for compiling a case file and arrangements for the progression of a case, having regard to CPIA roles and responsibilities.
Best practice
4.6.6 Auditors reviewed one case file relating to allergen controls that had been escalated for a decision by the Prosecuting Officer within the scope of this audit. That case resulted in a decision to issue a Simple Caution, which was appropriate. However, auditors determined that the case file did not contain all the relevant information including statements, disclosure schedules and a record as to whether the decision was in accordance with the Enforcement Policy and the Code for Crown Prosecutors. Auditors also determined that there was an unexplained delay of 5 months in completing the investigation.
Recommendations
4.6.7 The authority should:
- (i) Review and amend its enforcement procedures to include food standards procedures covering improvement notices, prohibition notices, seizure and detention and certification of food.
[Articles 5(1 (a) & (b), 12, 13, 137 & 138 of assimilated Regulation (EU) 2017/625, FLCoP 2.3, 2.3.1 & FLPG 2.3.10] - (ii) Ensure appropriate enforcement action is undertaken to ensure non-compliance identified during interventions is remedied and does not recur. This should include following relevant procedures relating to prosecution / Simple Caution decision, making and ensuring there is no undue delay in progression that may jeopardise the success of a case. [Articles 5(1 (a) & 138 of assimilated Regulation (EU) 2017/625; FLCoP 6.3 & 6.4, FLPG 6.9]
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. However, due to the problematic database migration, it was not currently possible to report accurate information on food standards intervention programme delivery, meaning that measurement of progress in addressing the interventions backlog was not possible at this time.
4.7.3 A documented internal monitoring procedure had been developed for the food standards service including officer responsibilities, accompanied visits and a sample of file checks relating to interventions. The procedure was high-level and would benefit from the inclusion of detail relating to sample sizes and monitoring of reactive work including service requests / complaints, adverse sample follow ups, incident investigations and a bulk database checks.
4.7.4 The Trading Standards Team Leader and Senior Trading Standards Officer 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 Where internal monitoring had taken place, evidence was available in the form of partial records, for the nature and extent of that monitoring, covering the matters that required feedback to officers, however, the full nature and extent of monitoring undertaken had not been recorded. Furthermore, the monitoring would benefit from the use of a method of analysing trends in any persistent matters arising along with bulk database checks, once the database migration issues have been resolved.
4.7.7 The records relating to internal monitoring that were available, were being maintained by managers for at least two years.
Recommendations
4.7.8 The authority should:
- (i) Revise its documented internal monitoring procedures to ensure all relevant activities are subject to proportionate monitoring. This should include detail relating to sample sizes and monitoring of reactive work including service requests / complaints, adverse sample follow ups, incident investigations and a bulk database checks.
- (ii) The internal monitoring taking place in practice should include recording the full nature and extent of monitoring, the use of a method of analysing trends in any persistent matters arising, along with a re-instatement of intervention programme delivery and bulk database checks, once the database migration issues have been resolved.
[OCR Arts 5(1a&b) & 12, FLCoP 2.3.1 & FLPG 2.3.2]
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.
4.8.2 An updated action plan has been published on the FSA website.
Auditors
Craig Sewell
Josh 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 the 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 Neath Port Talbot County Borough Council
Audit Date: 2nd - 4th December 2025
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TO ADDRESS (RECOMMENDATION INCLUDING STANDARD PARAGRAPH) |
BY (DATE) |
PLANNED IMPROVEMENTS
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ACTION TAKEN TO DATE |
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4.1.16 The authority should: (i) Ensure future Service Plans for food standards are developed in accordance with the Service Planning Guidance. In particular, a commitment and plan to deliver all due and overdue Category unrated, B & C category interventions and revisits, based on the requirements of the FLCoP and the inclusion of planned intervention based samples within the sampling programme, should all be provided.
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May/ June 2026
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Service plan to be developed in accordance with the guidance to include recommendations.
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Reviewed current service plan and identified improvements and amendments for 2026/27.
The 2026 / 27 plan will include a specific commitment and plan to address the backlogs for B,C and unrated categories. In addition, a sampling programme will now include planned intervention-based samples.
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4.1.16 (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.
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Performance Reviews will reflect the recommendation |
The Performance Reviews format will assess achievement of service plans and identified improvements and be amendments for 2026/27 |
Performance Reviews will reflect the recommendation |
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4.1.16 (iii) Ensure all variances in meeting the food service plan are addressed in its subsequent plan. |
May / June 2026 |
Future food service plans (2026/27 onwards) will include all variances |
Reviewed current plan and identified amendments for 2026/27 |
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4.2.9 (i) Amend its authorisation procedure to document the full procedure for the authorisation of officers based on competence.
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August 2026 |
Bring authorisation procedure in line with recommendations and internal monitoring procedure |
Procedure currently under review to link with competence of Officers |
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4.2.9 The authority should (ii) 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.
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March / April 2026
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Explore options / opportunities to increase in number of staff to meet legal minimum requirements to fulfil FSA framework agreement and audit recommendations
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Referred to Head of Service, business case being developed for additional resources.
Meeting with Director / Chief Executive planned to discuss FSA Audit Report and resource issues. |
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4.3.14 (i) Ensure that food standards interventions/inspections are carried out at the minimum frequency specified by the FLCoP.
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March 2027
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Explore options/opportunities to increase numbers of resources and increase time spent on monitoring to ensure targets are met.
An improvement in numbers of interventions outstanding by the end of the financial year 2026/27. |
Issues discussed with team at audit feedback meeting.
Planned meeting with Director / Chief Executive to discuss performance and resource issues.
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4.3.14 (ii) Ensure that observations made and/or data obtained in the course of a food standards intervention/inspection is captured on the correct aide memoire and that it includes complete information on: • Whether intervention was unannounced/ announced • nature & extent of food activities, • assessments of food standards management systems, including all control measures in place for allergens, • assessments of labelling, composition and presentation • incoming traceability requirements in relation to allergens including details of suppliers, other businesses that produce or import for the business and ingredient specifications • product recall / withdrawal arrangements • the consideration of whether to take samples/ what samples taken.
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Jan 2026
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Continue focus on quality of data recording and monitor via supervisions and Team meetings
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Issue was identified in Sept 2025; staff were advised accordingly since then aide memoires have been in place and there is a focus on the content of the aide memoires.
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4.3.14 (iii) Ensure that the establishment database & any information management system is capable of retrieving all food establishment information and providing the information requested by the FSA. Ensure that intervention report letters/ post inspection forms contain all of the required information.
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March 2026 |
Database (Idox) will be fully functioning and data will be properly configured and mapped to enable the service to effectively manage food safety function.
Qualitative monitoring of report letters and post inspection reports will be undertaken in accordance with the updated internal monitoring procedure |
Various Data management issues identified since migration on 1/4/2025, from previous Database (Flare) , plus additional issues have been identified and we have been working with Idox suppliers continuously to rectify the issues.
Post audit meeting raised the issues with staff and focussed on quality of reports / forms and of the ongoing internal monitoring requirements on the required information.
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4.4.6 (i) Include in the sampling plan a programme of risk and intervention based food standards sampling. |
April 2026 |
Business have been identified and integrated as part of the service plan for 2026/27. |
Addressed as part of the audit feedback session with staff and integrated into the project planning process for 2026/27.
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4.5.5 (i) Ensure that food complaint or service request records are retained, retrievable and they are thoroughly investigated and appropriate action is taken in relation to non-compliance.
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January 2026 |
Internal monitoring procedure to be tightened and feedback given at supervisions/ team meetings |
Addressed as part of the audit feedback session with staff and integrated into the project planning process for 2026/27. |
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4.6.7 (i) Review and amend its enforcement procedures to include food standards procedures covering improvement notices, prohibition notices, seizure and detention and certification of food.
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November 2026 |
Draft, Implement and communicate procedure as per recommendations. |
Draft of improvement notice procedure sent to FSA in December 2025. Discussed at Feedback meeting in January 2026. |
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4.6.7 (iii) Ensure appropriate enforcement action is undertaken to ensure non-compliance identified during interventions is remedied and does not recur. This should include following relevant procedures relating to prosecution / Simple Caution decision, making and ensuring there is no undue delay in progression that may jeopardise the success of a case.
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January 2026 |
Internal monitoring procedure to be tightened and feedback given at supervisions/ team meetings. Case meeting to be held where appropriate between Senior Officers and Case Officers. |
Addressed as part of the audit feedback session with staff. |
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4.7.8 (i) Revise its documented internal monitoring procedures to ensure all relevant activities are subject to proportionate monitoring. This should include detail relating to sample sizes and monitoring of reactive work including service requests / complaints, adverse sample follow ups, incident investigations and a bulk database checks. |
January 2026
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Finalise internal monitoring procedure to satisfy recommendations.
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4.7.8 (ii) The internal monitoring taking place in practice should include recording the full nature and extent of monitoring, the use of a method of analysing trends in any persistent matters arising, along with a re-instatement of intervention programme delivery and bulk database checks, once the database migration issues have been resolved. |
April 2026 |
Internal monitoring procedure to be tightened and feedback given at supervisions/ team meetings. Develop methods of analysing trends. |
Addressed as part of the audit feedback session with staff. Neighbouring authorities have been consulted for database reporting advice. |