ISO/IEC 17025:2017 Quality Manual

6.1.2 Management – staff & specific dutiesTo demonstrate competence to work in accordance with the Quality Management System, records ofqualifications, training and experience of all staff shall be maintained by each member of staff involved intesting activities. This shall include, as a minimum, an up to date CV, job description, evidence ofappropriate education, qualifications, training (eg QA, trial specific training etc), relevant experience and anorganisational chart.Before commencement of testing, or any activity in support of testing which is included in the scope ofaccreditation, the Technical Manager (in liaison with the QAM) shall indicate which IMS SOPs each memberof the team should read and understand, and record in their training file, or SOP sign-off sheet (TMP-QA40). The Quality Management System Matrix (TMP-QA-44) indicates the component parts of the QMSwhich the various laboratory and support roles should be familiar with and may be used in place of the SOPsign-off sheet.6.1.2.1 Specific responsibilities6.1.2.2 Quality Assurance Manager (QAM)The QAM ensures that effective quality management is in place for all testing activity, manages the QualityManagement System (QMS) and oversee all auditing functions to demonstrate compliance. The QAMliaised directly with Senior Management regarding the performance of the QMS and identifiedimprovements. The QAM is also the main contact with the accreditation body.The QAM is also responsible for any third party assessments which may be necessary, and any archiving ofdocumentation, in liaison with the Named Archivist.All documentation which forms the QMS and all key trial documents must be controlled. The documentcontrol function is overseen by the QAM.6.1.2.3 Technical ManagerThe Technical Manager is responsible for the laboratory activities within the scope of testing, including thesupervision of all staff involved in testing. This shall include selection, determining and monitoring ofcompetence, training, supervision and authorisation.Also included is the development, modification, verification and validation of methods. This includes theanalysis of results, including QC and QA data (with the QAM) identification of any trends, and statements ofconformity. The Technical Manager is also responsible for reviewing, authorisation and reporting of results.6.1.3 Authorised DeputiesIn the absence of any of the above, any managerial and technical responsibilities shall be delegated toappropriate personnel. Such delegation shall be documented appropriately.6.1.4 Management – GeneralEach person within UoA is responsible for the quality of the work they do and at all times are required tobe familiar with the QMS relevant to their role and activities. Each individual shall be responsible forensuring they have a job description, which contains a brief summary of their key duties, and shall outlinethe extent and limitations of the job holder’s responsibility.Uncontrolled when printed.Please ensure that you are working on the most up to date version of this Quality Manual.QM-2 V1ISO/IEC 17025:2017 Quality ManualPage 7 of 14

6.1.5 ConfidentialityUoA shall ensure all information remains confidential and shall comply with the requirements of GeneralData Protection Regulations (GDPR) and the Data Protection Act (2018). All personnel shall keepconfidential all information obtained or created during the performance of laboratory activities, unlessrequired by law to release such information.The Quality Management System documentation is structured in five levels as follows:ISO/IEC 17025:2017UoA ISO/IEC 17025:2017 Quality StatementUoA ISO/IEC 17025:2017Quality ManualUoA IMS Standard Operating Procedures(COSHH, Risk Assessments and Environmental procedures)Technical or Group/Team specific Standard Operating Procedures & User GuidesForms, data, records and worksheets (eg templates, checklist, equipment log, QC data etc)Uncontrolled when printed.Please ensure that you are working on the most up to date version of this Quality Manual.QM-2 V1ISO/IEC 17025:2017 Quality ManualPage 8 of 14

Level 1 – Regulations and GuidelinesISO/IEC 17025:2017 (General requirements for the competence of testing and calibration laboratories) isthe international standard to which UoA adhere for all testing included on the scope of accreditation.Level 2- Quality Statement and Quality ManualThe Quality Manual (this document) details the outline structure of the QMS and serves as a reference forits implementation and maintenance. It is a policy document, incorporating UoA quality policies andobjectives, an outline structure of the organisation and the roles and responsibilities of key technical andmanagement personnel.The Quality Statement, signed by senior UoA management, demonstrates the organisations’ intent tocomply with and maintain quality assurance procedures. It shall list brief objectives and be reviewedregularly.Level 3 – UoA IMS Standard Operating Procedures (also COSHH, Risk Assessments and any EnvironmentalManagement procedures).The UoA IMS SOPs define the purpose and scope of activities necessary to meet the requirements ofISO/IEC 17025:2017. These procedures address the management requirements and technical requirementsof the standard and outline how such activities are conducted, controlled and recorded. These SOPs shallbe applicable to all UoA activities in support of testing which is included on the scope of accreditation.SOPs shall be allocated a review date of three years, although they shall be reviewed when there is anyreason to suspect they may no longer be valid (eg following a Deviation, Non-conformance, UKAS finding ora health and safety incident or near-miss), as significant new information becomes available, or when therehave been significant changes to working procedures. Such reviews are unplanned reviews and aretriggered by significant events or changes. Relevant new information may become available from varioussources (eg new staff with different expertise and experience, new manufacturers and suppliers of rawmaterials and equipment, or as a result of technological or scientific developments).COSHH (Control of Substances Hazardous to Health) and Risk Assessments shall be written and in placeacross UoA where appropriate. These are the responsibility of the UoA Health and Safety teams.Environmental procedures may be in place to comply with environmental legislation, policies orEnvironmental Standard, such as ISO 14001:2015. This is the responsibility of the respective UoAEnvironmental teams.Level 4 – Technical SOPs (Group or Team Specific SOPs) and User Guides.This level of documentation outlines methods of implementation for specific activities associated with theindividual groups and teams, and includes Technical SOP and User Guides.Generally Technical SOPs and Group Specific SOPs shall only be applicable in the area pertaining to thework, although other groups or teams may use a document from another group or team if it is appropriate.If minor changes are required to such a document (or location specific requirements) to make it applicableto another team or group, these can only be made with the prior approval of the document owner.Technical SOPs or Group Specific SOPs shall be controlled and reviewed in the same way as the UoA IMSSOPs but shall be managed by local management rather than the Quality Assurance Manager.Uncontrolled when printed.Please ensure that you are working on the most up to date version of this Quality Manual.QM-2 V1ISO/IEC 17025:2017 Quality ManualPage 9 of 14

User Guides are local controlled documents providing specific instructions, or further information, on aparticular task (eg how to operate a specific autoclave or analyser, sample handling, how to arrangearchiving of documentation etc). User Guides may be displayed on a wall (eg adjacent to the particularautoclave or analyser, where samples will be processed etc) and may not need to be reviewed on a regularbasis (eg valid for the lifetime of an item of equipment or until a local process changes).Level 5 – Forms, data and records.Documentation used for QA purposes in support of a project or activity (eg templates, checklist, logs,laboratory workbooks etc).Forms, data and records shall be controlled in the same way as SOPs and User Guides.Relevant email communications concerning testing activity shall be printed out and retained by theTechnical Manager as appropriate.6.1.6 ResponsibilityThe responsibility for the compilation, distribution, amendment and maintenance of the Quality Manualand SOPs lies with the QAM. The Master Copy of this Quality Manual and QMS SOPs, and all subsequentamendments, are held on file (Q-Pulse) by the QAM.Authors of Technical or Group Specific SOPs are responsible for their maintenance, although the QAM mayperform this task on their behalf (eg using Q-Pulse).6.2 Document ControlThe Document Control procedure is included in SOP-IMS-28 (Management of SOPs). All change requestsand controlled changes shall be made using the approved Change Control procedure (eg Q-Pulse) andinvolve the Technical Manager and QAM.6.3 Complaints and non-conformances (Deviations and Breaches)6.3.1 ProcessIt is UoA practice to ensure that all complaints and non-conformances identified within UoA remainconfidential, are investigated and resolved in a timely and effective manner, and that necessary Correctionand Corrective and/or Preventive Action (CAPA) are identified to prevent recurrence. See SOP-IMS-34(Internal Audit), SOP-IMS-35 (External Audit) and SOP-IMS-36 (Deviations).6.3.2 Non-conformances The QAM shall grade non-conformances as ‘serious’ or ‘non-serious’ and assesswhether non-conformances shall be reported immediately to the customer. Serious non-conformancesidentified through internal audit, shall be reported to the IMS Director and if necessary escalated to theHead of School.6.4 Improvement6.4.1 PracticeIt is UoA practice to ensure continual improvement of the effectiveness of the Quality Management Systemthrough the use of objectives, audit results, analysis of data, Corrections and Corrective Actions andPreventive Actions (CAPA).Uncontrolled when printed.Please ensure that you are working on the most up to date version of this Quality Manual.QM-2 V1ISO/IEC 17025:2017 Quality ManualPage 10 of 14

6.4.2 AuditUoA groups and facilities may be subject to audit and inspection by external parties, which may includeregulatory authorities (eg MHRA), accreditation bodies (eg UKAS) or certification bodies (eg LRQA orKPMG). All UoA staff are required to fully co-operate in such activities, under the direction of the QAM.Audit and inspection findings shall be dealt with by the appropriate staff and groups to provide a resolutionwithin previously agreed timescales. It is the responsibility of the Technical Manager to ensure Correctionsand any Corrective Action and/or Preventive Actions (CAPA) are implemented; failure to do so shall bereferred to senior management for appropriate action. See SOP-IMS-34 (Internal Audit) and SOP-IMS-35(External Audit).6.4.2.1 Auditing – a QA activity, conducted independent of the laboratory team, examining testing relatedactivities in accordance with the QMS and regulatory requirements.Audits shall only be conducted by competent and trained auditors. All audits shall be reported to theTechnical Manager and IMS Director, and CAPA shall be progressed, using Q-Pulse.6.4.2.2 Audit schedules shall be prepared by the QAM and Technical Manager and be based on risk; withincreased audit activity for those areas judged by the QAM and/or Technical Manager to be at increasedrisk. Additional audits may also occur in response to Deviations and may be unannounced.6.4.3 Correction, Corrective Action and Preventive Action (CAPA or CCAPA)Correction is any action to eliminate a non-conformance. Corrections shall also be implemented ifdeviations from the policies and procedures in the Quality Management System or technical operations areidentified. Corrective Actions are steps which are taken to remove the causes of an existing nonconformance. All CAPA shall be processed using Q-Pulse.6.4.4 Corrective ActionCorrective action is any action which is taken to eliminate the cause of a non-conformance and thereforeprevent a recurrence of the non-conformance.6.4.5 Preventive ActionPreventive actions is any action which is taken to eliminate the cause of a potential non-conformance, inorder to prevent their occurrence. Preventive actions may be noted as ‘Observations’ or ‘Opportunities forImprovement’ during audit.6.4.6 Continuous ImprovementIt is UoA policy to ensure that opportunities for improvement and potential sources of non-conformances,either technical or concerning the Quality Management System, are identified where required. ‘Stakeholder’feedback shall be regularly sought to identify any opportunities for improvement. This shall be managed by theQAM and reviewed at Management Review Meetings (see 6.7).6.5 Technical RecordsThe Technical Manager shall ensure that records of testing are retained which identify all factors whichcould affect results and enable recreation of the test if necessary. Such factors include: identification ofUncontrolled when printed.Please ensure that you are working on the most up to date version of this Quality Manual.QM-2 V1ISO/IEC 17025:2017 Quality ManualPage 11 of 14

operator(s); equipment, kit and reagent identifiers; dates and times; QC data; original observations;calculations and environmental factors.Procedures for control of records is included in SOP-IMS-31 (Control of Records). The QAM has ultimateresponsibility for all documents which form the Quality Management System.Records held electronically shall be suitably controlled, secure and backed-up, with appropriatelydocumented procedures. Software systems purchased ‘off the shelf’ may be considered suitably validatedbut any modified or bespoke software systems shall require validation before use. Any formulae orcalculations used in data handling require regular checks to ensure they are still fit for purpose; such checksshall be recorded.The Quality Manual, SOPs and User Guides shall be held, and controlled, using Q-Pulse.6.6 ContractsAny contracts or Service Level Agreements (SLAs) prepared for testing activities included in the scope ofaccreditation shall refer to ISO/IEC 17025:2017. Agreements with third party laboratories receiving samplesfor analysis shall document all relevant facts concerning the procedure, including who must receive resultsand data. The Technical Manager shall maintain oversight and regular communication with any thirdparties. The UoA Research & Innovation team may assist the Technical Manager in contractual matters.Any potential third party laboratory service providers or suppliers must be assessed by the QAM forsuitability prior to contracts being put in place. Only third parties which can demonstrate competence (egcertification or accreditation to a suitable quality standard) shall be used. A list of pre-approved thirdparties is maintained as an ‘approved supplier’ list by the QAM.6.7 Management ReviewsThis is a periodic (at least annual) review of the Quality Management System by senior Management, for itseffectiveness, any opportunities for improvement and its fitness for purpose. It includes a review offindings since the last Management Review and identifies any concerns. See SOP-IMS-39 (Managementreview).6.7.1 PracticeIt is UoA policy to ensure the continuing suitability and effectiveness of the Quality Management Systemand testing activities with regard to ISO/IEC 17025:2017, by performing a Management Review.6.7.2 GeneralManagement Reviews shall be held at least once per year. The objective of the review process is tocontinually develop and improve the performance of the Quality Management System and to identify andprogress any relevant preventive action and opportunities for improvement.The following agenda items may be discussed and reviewed: Any feedback from interested parties on the functioning of the QMS.Review of findings from any UKAS inspections.Review of non-conformances and observations raised during internal audits.Systematic findings and trends noted in audit.Uncontrolled when printed.Please ensure that you are working on the most up to date version of this Quality Manual.QM-2 V1ISO/IEC 17025:2017 Quality ManualPage 12 of 14

Effectiveness of CAPA.Possible areas of improvement and future development of the QMS.Review of Quality Manual for effectiveness.Review of Quality Statement for effectiveness.Staff training.Resource issues concerning the QMS.Review of feedback and satisfaction surveys.Planned assessment and regulatory inspections.Impartiality of activities.6.8 Human ResourcesAll staff involved in testing activities, or in support of such activities, must be trained to comply with therequirements of ISO/IEC 17025:2017. This training may be provided in-house by the QAM. All staff involvedin a testing must have documented training for equipment and procedures which form part of their duties,see SOP-IMS-30 (Training and Competence).6.9 Control of Customer Property (including samples)Customer property may be material or data supplied for analysis or intellectual property. UoA shall ensurethat any property supplied by the customer shall be stored and handled ethically and in such a manner as toprotect its integrity, security and confidentiality.Samples shall be uniquely identified and the identifier shall remain with the sample whilst under the controlof the laboratory.Upon receipt, an evaluation of sample suitability shall be undertaken and any deviation from specifiedconditions shall be noted and reported to the customer. Samples may be analysed when deviating fromspecified conditions if requested by the customer, but this shall be declared on the laboratory report.6.10 EquipmentAll critical equipment must be functioning correctly, be fit for purpose and be capable of achieving theaccuracy required. Only trained personnel shall use laboratory equipment, and procedures must be in placeto document the use, service and planned maintenance of all critical equipment. All critical equipment shallbe maintained and serviced according to manufacturers’ instructions. See SOP-IMS-33 (Critical Equipment).Each item of critical equipment shall be uniquely identified and intermediate checks shall be recordedappropriately to demonstrate confidence in the continued use of the equipment.The frequency of intermediate checks must be justified based on national guidelines and/or regulations.Any equipment that is used for a specific purpose/trial must be identified as such.Any equipment that is out of use must be identified as such to preclude its use.Uncontrolled when printed.Please ensure that you are working on the most up to date version of this Quality Manual.QM-2 V1ISO/IEC 17025:2017 Quality ManualPage 13 of 14

6.11 FacilitiesAll facilities must be fit for purpose with appropriate procedures in place to protect the integrity of samples,prevent cross-contamination between samples and prevent risk to staff or visitors. Procedures shall be inplace to ensure security, safety, hygiene and biosecurity.Appropriate measures shall be in place for Containment Level 2 and Containment level 3 laboratories andfacilities (there are no Containment Level 4 facilities in the UoA site). See SOP-IMS-32 (Accommodation andEnvironment).6.12 MethodsThe Technical Manager is responsible for ensuring methods are appropriate, current and documented (SOPsavailable at point of use). All standard methods must be verified before

Management Systems are managed by the joint UoA – NHSG Quality Assurance Manager (QAM). 5.1 Quality Manual This Quality Manual is the statement by UoA of its documented Quality Management System which conforms with ISO/IEC 17025:2017. Conformance with the requirements stated in the Quality Manual and in the UoA IMS Standard Operating