Standards › Standard 2B › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · FAC-SOP-001 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2B.6
At a glance
- Keep one facility risk register covering water, fire, equipment, cleaning, signage, power and other facility risks.
- Give every risk an owner, a rating and a review date.
- Review the register each month at the facilities meeting.
- Report the top risks to the governing body each quarter.
- Close a risk only when its controls are shown to work.
- Stop and get help straight away if: a high-risk item has no owner or no action, or a risk is tracked only on a separate checklist outside the register.
1. Purpose
To track all facility risks together, so the whole picture is visible and no risk falls between separate checklists [EC].
2. Scope
| Applies to | Facilities staff, service heads, and the risk manager |
| Locations | The whole facility |
| When | Continuously; reviewed monthly; reported quarterly |
| Does not apply to | Clinical risks, which are held in the clinical risk register (see the risk management policy) |
3. Definitions
| Term | Meaning |
|---|---|
| Facility risk | A condition or event in the buildings, systems or equipment that could cause harm, loss or service failure |
| Rating | A score from likelihood times impact, using the scale in the risk policy (EC) |
| Control | An action or barrier that reduces the rating |
4. Background
Water, fire, equipment, cleaning and signage risks are often managed in separate lists that no one reads together. An integrated register shows the total exposure and the priorities. Criterion 2B.6 requires one register, reviewed.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Facilities manager | Owns the register; runs the monthly review | Facilities risk management |
| Risk manager | Keeps the scoring method; reports to governing body | Risk management |
| Risk owners | Own each risk; deliver its controls | Competence for the area |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Integrated facility risk register (FAC-REG-001) | One register; current | Reviewed monthly |
| Risk scoring scale | Likelihood and impact scales from the risk policy (EC) | Current |
7. Safety
- A risk is not reduced by being recorded. Controls must be in place.
8. Before you start
- Gather the latest service, test and audit results for each area.
9. Procedure
Step 1. Enter every facility risk.
- Collect risks from water testing, fire checks, equipment service, cleaning audits, signage surveys and the failure log.
- Enter each on FAC-REG-001 with a short description and its source.
Key point: One list is only complete if every source feeds into it.
Step 2. Score and assign.
- Score each risk for likelihood and impact.
- Give each risk one owner.
- Write the current controls and the planned actions with dates.
Key point: Ownership is what makes a risk move.
Step 3. Review monthly.
- Review the register at the facilities meeting.
- Check each overdue action, and each risk whose rating has changed.
- Close risks only when their controls are shown to work by evidence.
Key point: A monthly review keeps the register alive.
Step 4. Report quarterly.
- Send the top risks, with actions and owners, to the governing body.
- Record the discussion and any decisions.
Key point: The governing body needs the total picture, not each list separately.
Step 5. Link to incidents and audits.
- Each incident, audit failure or failure log entry is checked for a new or changed risk.
- Add or update the risk in the register within 7 days.
Key point: Incidents show risks the register has missed.
10. Decision points
- If a high-rated risk has no control within 30 days, the risk manager escalates it to the chief executive.
11. Special situations
| Situation | Action |
|---|---|
| New building work or change of use | Enter the risks before the change, and review again after. |
12. Escalation
- High-rated risks go to the chief executive at once, and to the governing body at the next meeting.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Facility risks with owner and rating | 100% | Monthly | Facilities manager | Assign owner within 7 days |
| Overdue actions | 0 over 30 days | Monthly | Risk manager | Escalate to chief executive |
| Incidents checked against register within 7 days | 100% | Monthly | Risk manager | Review |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| FAC-REG-001 Integrated Facility Risk Register | Facilities and risk file | Current, plus history for the period set by the facility’s records policy years |
| Quarterly report to governing body | Governance file | the period set by the facility’s records policy years |
15. Training
- Risk owners are briefed on the register and their duties at appointment (EC).
16. Related documents
| ID | Title | Use |
|---|---|---|
| FAC-REG-001 | Integrated Facility Risk Register | The register itself |
| GOV-PLN-002 | Quality Improvement Plan | Actions feed the plan |
| SOP-N16 | Risk Management and Business Continuity Policy | Wider risk policy |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | ASF Expert Committee consensus. Scoring scale is an EC decision. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | Approved by the ASF Expert Committee |
| 1.1 | the date of approval | Internal quality review: corrected cross-references, status wording and document control | Approved by the ASF Expert Committee |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)