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KISII UNIVERSITY
ISO 9001: 2008
INTERNAL QUALITY AUDIT REPORT
KISII UNIVERSITY IS ISO 9001:2008 CERTIFIED
Page 2 of 22
Table of Contents 1.0 INTRODUCTION .................................................................................................. 3
1.1 Audit Scope ..................................................................................................... 3
1.2 Audit Team ...................................................................................................... 3
2.0 AUDIT OBJECTIVES ............................................................................................... 4
3.0 PREVIOUS AUDIT FINDINGS ................................................................................ 4
4.0 CURRENT AUDIT FINDINGS .................................................................................. 5
4.1 General Summary ............................................................................................ 6
4.2 Administration Department ............................................................................... 6
4.3 Faculty of Agriculture & Natural Resource Management ...................................... 7
4.4 Transport and Maintenance Department ............................................................ 8
4.5 Academic Affairs .............................................................................................. 9
4.6 ICT Department ............................................................................................. 10
4.7 Faculty of Commerce ...................................................................................... 10
4.8 Examinations and Timetabling ........................................................................ 11
4.9 Farm Department ........................................................................................... 12
4.10 Faculty of Education ..................................................................................... 13
4.11 Faculty of Information Science & Technology ................................................. 14
4.12 Procurement Department ............................................................................. 15
4.13 Finance Department ..................................................................................... 15
4.14 Student Affairs ............................................................................................. 16
4.15 School of Pure and Applied Sciences.............................................................. 17
4.16 Research and Extension ................................................................................ 17
4.17 School of Health Science .............................................................................. 18
4.18 Medical Department ..................................................................................... 19
4.19 Library Department ...................................................................................... 20
4.20 Halls Department ......................................................................................... 20
4.21 Directorate of Academic Quality Assurance .................................................... 21
4.22 AIDS Control Unit ......................................................................................... 22
5.0 CONCLUSION ......................................................................................................22
Page 3 of 22
1.0 INTRODUCTION The ISO 9001: 2008 internal audit exercise was carried out between 25th and 27th November,
2015.
The criteria used during the audit were the ISO 9001:2008 International Standard, Kisii
University internal procedures (Standard Operating Procedures and General Operating
Procedures), the University Quality Manual, University policies and applicable statutory and
regulatory requirements.
The audit methods used were interviews, observation and review of documents and records.
This was geared at gathering objective evidence on conformance to specific requirements/
procedures laid down by the auditees.
The audit report outlines the commendable areas noted, nonconformities identified and
opportunities for improvement in the department/ faculties/ schools audited.
1.1 Audit Scope
The scope of the audit covered core processes (teaching & non-teaching) within the University
Main Campus.
1.2 Audit Team
The audit was carried out by:
1. Mr. Wilfred Ochieng‟ 2. Mr. Joseph Kamotho 3. Ms. Nancy Momanyi 4. Mr. Benjamin Ogata 5. Bro. Francis Kerongo 6. Ms. Rose Matundura 7. Mr. David Basweti 8. Ms. Charity Bett 9. Mr. Paul Gaitho 10. Dr. Pamela Wadende 11. Mr. Ishmael Nyabuti 12. Ms. Irene Nyakweba 13. Ms. Kate Makworo 14. Mr. Warren Lekaram 15. Mr. M.E.D. Mong‟are 16. Ms. Teresa Abuya 17. Mr. Polycarp Oluoch 18. Mr. Joshua Omondi
Page 4 of 22
2.0 AUDIT OBJECTIVES The objectives of the audit were:
To confirm that the Quality Management System conforms with all requirements of the ISO
9001:2008 International Standard;
To confirm that the University‟s quality management system is effectively implemented and
maintained; and
3.0 PREVIOUS AUDIT FINDINGS
During the audit, the results of the previous ISO 9001: 2008 internal audit conducted between
28th and 30th April, 2015 and 3rd and 4th June 2015 were reviewed to confirm whether
appropriate correction and corrective action had been undertaken to address the
nonconformities raised.
It was observed that some of the nonconformities identified had not been adequately addressed
in the following departments/ faculties/ schools audited as illustrated in Table 1 below:
Table 1: Pending proposed corrective actions
Department / faculty
Nonconformity raised
Academic Affairs There was no objective evidence of monitoring of Quality Objectives and thus taking appropriate action when planned results are not achieved.
Some records e.g. record reference number KSU/R.AA/058 were not in the Master List of Records to ensure ease of retrieval of records as required by procedure on Control of Records( KSU/SOP/COR/02).
There was no evidence to indicate whether some of the sampled students were registered within the 4 weeks as outlined in the department‟s Quality Objective number Four.
It was observed that sampled records e.g. student‟s personal files and requests for IDs were not well stored to protect them from damage as required by procedure KSU/SOP/COR/02; clause 3.3
Farm The department did not have both the Master List of Internal and External Documents as well as the Document Distribution Record Sheet as required by the procedure on Control of Documents (KSU/SOP/COD/02)
The department‟s quality objectives had not been approved by the HOD. There was also no objective evidence to demonstrate that the same were being monitored and reviewed as required by the Quality manual (KSU/QMA/02).
SPASS There was no evidence to show that the CODs held departmental meetings for course allocation prior to the start of the semester as required by the procedure KSU/GOP/SPASS/01; clause 4.1 (a)
Examinations and Timetabling
There was no objective evidence to show that a Timetabling Committee was operationalized as required in the department‟s GOP (KSU/GOP/EXM/02) to handle matters of teaching and examinations timetable
Page 5 of 22
Department / faculty
Nonconformity raised
Medical
Although food handlers had been examined as required by procedure, KSU/GOP/MED/02, it had not been demonstrated that a memo was issued in September, 2014 by PHO asking relevant offices of food handling to undergo medical examinations as per clause 4.3. (a).
School of Health Science
There was no objective evidence to indicate that students had signed class attendance registers for the sampled course DPHA 0214 to monitor class attendance as required by the procedure KSU/GOP/SHS/01; clause 4.1 (g)
Records are required to be easily retrievable and identified as per the procedure on Control of Records. However this was not demonstrated for sampled records e.g. minutes of course allocation, class attendance registers, lecturer‟s attendance sheets and the examinations records (KSU/SHS/33).
Commerce It was established that course appraisal forms developed for evaluating effectiveness of teaching had not been included in the general operating procedures.
There were no records to show that the dean had convened a stakeholders meeting to discuss curriculum development and review as per process 4.4
Education There was no evidence to demonstrate that lecturer‟s teaching is monitored to ensure that teaching timetable(or planned)are followed as per KSU/GOP/EDU/02 clause 4.1(b).
There was no objective evidence to show that responsibility and authority had been clearly defined and communicated to all the staff in the faculty as required by procedure KSU/QMA/02,Clause 5.5.1.
ICT It was not demonstrated that mechanisms have been put in place to monitor the Quality Objectives established in the department as required by the procedure KSU/QMA/02; clause 5.4.1
It was not demonstrated that there were mechanisms in place to communicate to staff in the department on the Quality Objectives including communication on the progress made towards achieving the Quality Objectives as required by the procedure KSU/QMA/02; clause 5.5.3. Additionally, it was observed members of staff in the department were not aware of the University‟s Quality Policy.
Transport and Maintenance
There was no objective evidence to show that implementation of the quality objectives was being monitored as required by the procedure KSU/QMA/02; clause 5.4.1.
4.0 CURRENT AUDIT FINDINGS A total of sixty (60) minor nonconformities were identified during the audit.
Page 6 of 22
4.1 General Summary
In most of the departments/ faculties audited, the auditors found that:
Internal Communication on the Quality Management System: It was observed that
majority of the auditees did not have mechanisms in place to discuss progress on the
implementation of the QMS in the Department/ Faculty/ School for effective implementation of
the QMS e.g. holding regular meetings to discuss implementation of the QMS, induction of new
staff on the QMS etc.
Monitoring of Quality Objectives: Most of the Departments/ faculties/ schools had
established Quality Objectives as required; however there was no evidence that clear
mechanisms had been put in place to regularly monitor the established Quality Objectives in
order to assess progress made towards achieving the set targets.
Handling Customer Complaints: It was observed that the Complaints Registers established
in most of the Departments/ Faculties/ Schools were not being fully utilized to record customer
complaints received either verbally/ recorded by the customers.
Control of Documents (Distribution of Records): Most of the Departments/ Faculties/
Schools audited did not control distribution of records using both the Internal and External
Document Distribution Sheets as outlined in the procedure on Control of Documents.
Additionally, most of the auditees were not conversant with the requirements outlined in the
Standard Operating Procedure on Control of Documents.
Control of Records: It was observed that most of the staff handling records in the
Departments/ Faculties/ Schools did not have the necessary competency and skills to perform
their work effectively.
4.2 Administration Department
Contact Person: Christopher M. Nyenze
4.2.1 Positive Findings
1. It was observed that the Department had established measurable Quality Objectives for the
Financial Year 2015/2016
2. The Department had established a Training Calendar for the Financial Year 2015/2016
outlining various trainings to be conducted for different cadres of staff.
4.2.2 Nonconformities identified
The following six (6) minor nonconformities were
1. There was no objective to show that members of staff had been effectively communicated
to on the effectiveness of implementation of the ISO QMS in the department as required by
clause 5.5.3 of the Quality Manual.
2. It was found that members of the department were not well versed with the University‟s
Quality Policy as required by the University‟s Quality Manual clause 5.3.d.
Page 7 of 22
3. It was established that not all documents were duly updated and included in both the
Master List of Internal and External documents respectively as required by the SOP on
Control of Documents KSU/SOP/COD/02. e.g the 2015/16 Performance Contract for the
Registrar (A) was not in the Master List of Internal Documents.
4. There was no objective evidence to show that complaints raised in the department‟s
complaints register on 6/8/2015, 5/8/2015 and 6/1/2016, had been reviewed by the HOD
and appropriate action taken as required by the procedure on Corrective Action clause
3.8.b.
5. It was not demonstrable that the quality objectives established in the department were
monitored to assess progress in achievement of the set targets.
6. There was no objective evidence to show that the payroll system had been subjected to
internal audit in the last 1 year. The Quality Manual, KSU/QMA/02, states that KSU shall
establish suitable methods for monitoring and, where applicable, measurement of the QMS
processes to demonstrate the ability of the process achieve planned results.
4.2.3 Opportunities for Improvement
1. There is need to develop a staff induction profile or handbook to ensure the exercise is done
holistically and effectively. Reports of the induction exercises conducted also need to be
documented in form of detailed reports alongside list of staff inducted.
2. All registers in use at the department and all its sections need to have reference numbers. It
was found that the following registers in use at the Central Registry office lacked reference
numbers: Incoming Mails Register, Incoming Letters/Memos register.
3. There is need to develop a comprehensive records management policy for the university.
4. There is need to ensure that all staff handling records , that is in the Central Registry,
Faculties and other departments have the necessary competency and skill in records
management.
4.3 Faculty of Agriculture & Natural Resource Management
Contact Person: Dr. Evans Basweti
4.3.1 Positive Findings
1. The two (2) minor non-conformities raised during the last audit held on 29th April, 2015,
were all closed satisfactorily.
2. The auditees were co-operative and seemed quite informed of their systems and procedures
during the audit session.
3. The quality objectives were reviewed, documented and signed on 5th May, 2015 by the
Dean, Faculty of Agriculture.
4. There was evidence that the Faculty project co-ordinator convenes a panel of examiners for
students defence, as per clause 4.8 (e).
5. Attendance of all members of staff for the audit was a sign of team work.
4.3.2 Non-Conformities Identified
During the audit, the following five (5) minor nonconformities were identified:
Page 8 of 22
1. It is required that documents of external origin are identified and their distribution
controlled. However there was no evidence of distribution and control of the same e.g the
Egerton University Catalogue.
2. There was no evidence that the Dean submits the course allocation list to the HR within one
month after commencement of the semester as outlined in the Faculty GOP ; clause 4.1
process.
3. There was no evidence that the Faculty Quality Objective no. 3 (To submit the examination
drafts within two weeks after the start of the semester) was attainable within the two week
time frame.
4. There was no evidence that the Dean forwards the approved results to the Senate within
two weeks after the Faculty Board as required in procedure 4.2 (i) of the Faculty GOP.
5. The Faculty GOP clause 4.6 (c) requires that the COD reports in writing to the Dean of
Faculty attaching evidence after the exam session. This was not evident during the audit
process.
4.3.3 Opportunities for Improvement
1. The Faculty should consider ways of monitoring the attainment of the quality objectives in
place e.g by coming up with a monitoring tool.
2. Staff involved in record keeping should follow the proper flow whereby all records i.e copies
of memos/letters originating from the Faculty are well filed in the Faculty file for future
reference.
4.4 Transport and Maintenance Department
CONTACT PERSON: Eng. Fredrick Onkware
4.4.1 Positive Findings
1. It was observed that the Quality objectives established in the department were measurable as required by the University Quality Manual ; clause 5.4.1
4.4.2 Nonconformities Identified
The following five (5) minor nonconformities were identified during the audit:
1. There was no objective evidence to prove reliability of monitoring fuel consumption. Fuel
consumption data of the tractor KBW 103V sampled showed inconsistencies and
inaccuracies e.g. on 20/03/2015 the tractor went to Lolgorian at 12.00pm and returned at
5.00pm as per the work ticket. That translates to 4.5 hours but according to the fuel
consumption analysis records, the tractor was recorded to have consumed 42.1 hours.
2. Not all Transport Request Forms were recorded in the Transport Request Register as
sampled. The Incoming Register KSU/MTT/R05 had also not been updated since
16/08/2013 contrary to ISO 9001:2008 clause 4.2.4.
3. There was no objective evidence to show that feedback was being made to applicants for
transport requests on approval, availability or non-availability of transport requests contrary
to the requirement stated in ISO 9001:2008 clause 7.2.3.
Page 9 of 22
4. There was no objective evidence to show that the monthly fuel consumption analysis
records had ever been discussed by the University Management as stated in the GOP clause
4.4.b.
5. There was no objective evidence to show that staff responsibilities in all sections had been
determined and the same communicated to the staff to enhance their productivity as
outlined in ISO 9001:2008 clause 5.5.1.
4.4.3 Opportunities for Improvement
1. During the audit, it was established that the department had competent staff that carried
out vehicle diagnosis but actual servicing and repair for most vehicles was being done
externally. However, according to the department‟s GOP, only vehicles under warranty are
to be serviced by dealers or their recommended agents. There is need to review the process
on vehicle repair and servicing in line with the set standards as laid out in the GOP i.e.
external versus internal repair and servicing of vehicles to be clearly laid out to improve on
efficiency.
2. Some documents had been filed but had no folio numbers. Some files also lacked a folio
register. There is need to ensure the laid down record control procedure is followed at all
times.
3. Drivers who have been issued with fuel cards need to sign for them formally upon receipt
for accountability purposes.
4.5 Academic Affairs
Contact Person: Prof. Philip Owino
4.5.1 Positive Findings
1. It was noted that the customer complaint book was well displayed for all.
2. It was also noted that most of the staff are eager to learn and apply the laid down
procedures in their service delivery.
4.5.2 Nonconformities Identified
The following four (4) minor nonconformities were identified during the audit:
1. It was noted that staff in the Department were not fully aware of the Quality Policy and
QMS related processes
2. There was no evidence to justify closing of the previously identified nonconformities during
the last audit as required by the Quality Manual
3. It was not demonstrated that the Department had established a Master List of Internal and
External Documents as required by the procedure on Control of Documents;
KSU/SOP/COD/02
4. There was no evidence to show that the Registrar (AA) had convened a meeting with
officers that participated in the registration exercise as required by the departments GOP;
clause 4.3.1 (b).
Page 10 of 22
4.5.3 Opportunities for Improvement
1. There is need for the Department to develop a tool for monitoring the attainment of the
quality objectives as well as service delivery charter.
2. Due to internal transfers there is need for refresher training on the University‟s Quality
Management System for the new staff in the Department.
3. The department needs to review their GOP so as to align it with the current situation.
4.6 ICT Department
Contact Person: Gordon Ouma
4.6.1 Positive Findings
1. The department had designated a member of staff to be in charge of coordinating
implementation of the QMS.
2. Files used to keep records were well referenced for ease of retrieval.
3. Quality policy statement was strategically displayed in the office.
4.6.2 Nonconformities Identified
The following one (1) minor nonconformity was identified during the audit:
1. It was not demonstrated that the ICT Maintenance Schedule had been communicated to
HODs and Deans as per method 4.1 (a) of the department‟s procedure.
4.6.2 Opportunities for Improvement
1. The department needs to review its GOP to conform to its current status. It was observed
that although there is a substantive ICT Manager, this has not been reflected in the
department‟s GOP.
2. The department should continuously update and monitor its quality objectives.
4.7 Faculty of Commerce
Contact Person: Dr. Christopher Ngacho
4.7.1 Positive Findings
1. There was objective evidence to demonstrate that examination malpractice was being
addressed by the faculty. This is demonstrated by one case whereby a Bachelor of
commerce student Registration number CBP12/10058/14 was caught cheating on
29/07/2015 between 3.30-5.30Pm.The student faced disciplinary committee on 11/8/2015
and the ruling was that the student be discontinued.
4.7.2 Nonconformities Identified
The following six (6) minor nonconformities were identified during the audit:
Page 11 of 22
1. There were no records to show that the Dean had convened a stakeholders meeting to
discuss curriculum development and review. A case in point is Bachelor of Secretarial
management and diploma in secretarial management which were developed in academic
year 2015. This is contrary to KSU/GOP/COMM/02 ;clause 4.4
2. It was noted that processing examinations within 2 months after the end of academic year
was not done as indicated in KSU/GOP/COMM/02; clause 4.2(f)
3. There was no evidence to demonstrate that student transcripts were issued on time as
required in the Faculty‟s GOP ( KSU/GOP/COMM/02 ); clause 4.2(g)
4. There was no objective evidence to show that students were supervised at postgraduate
level. There was no record showing supervisors and students assigned to them. There were
no minutes supporting defenses held for proposal and final presentations. This is contrary to
KSU/GOP/COMM/02 clause 4.7(c),(i)
5. There was no objective evidence to demonstrate how teaching is monitored by the faculty
to ensure that teaching time-table or planned arrangements are followed as required by the
procedure KSU/GOP/COMM/02 clause 4.1(b)
6. In the Faculty‟s Performance contract for the financial year 2015/2016, the faculty had
proposed to post results on the website to improve service delivery. However, this was not
demonstrated at the time of audit.
4.7.3 Opportunities for Improvement
1. There is need for all new staff in the Faculty to be inducted into the Faculty‟s functions and
procedures. It was noted that a new member who was put to be in-charge of ISO and
Performance Contracting was not oriented on how to perform his duties and what it entails.
He was not able to trace files and other relevant documents.
2. It was observed that CODs were not in the audit meeting yet they coordinate teaching in
their faculty. There is need for all key persons who coordinate the Faculty‟s processes to be
available in all audits.
4.8 Examinations and Timetabling
Contact person: Kenneth Basil Onyango
4.8.1 Positive Findings
1. It was demonstrated that the Directorate had developed and communicated the
Examination Calendar- KSU/E&TT/CODs/051(99) for the September- December 2015
semester, clearly indicating dates for exam drafts submission, proof reading of typed
examination papers, examination dates etc.
2. It was observed that the Examination Issuance records were well maintained. Additionally
sampled examination papers BENS 211, BPSM 403 and BCOM/BBAM 270 for the August
2015 examinations had been issued to the relevant authority as outlined in the Directorates
GOP; clause 4.3 (e).
3. The Quality Objectives in place had been approved by the Director as required by the
Procedure on Control of Documents.
Page 12 of 22
4.8.2 Nonconformities Identified
The following two (2) minor nonconformities were identified during the audit: 1. There was no objective evidence to indicate that the Timetabling Committee meeting had
been convened to approve the teaching timetable for the September-December 2015
semester as required by the Procedure KSU.GOP/EXM/02; clause 4.1 (b).
2. It was observed that the Examination Policy in use had not been approved by the relevant
authority prior to use and issue to process owners as required by procedure
KSU/SOP/COD/02; clause 3.2 (b).
4.8.3 Opportunities for Improvement
1. There is need for the Director to specify timelines for release of both the final teaching and
final examination timetable in order to avoid extreme delays in their release to both the
students and Faculties.
2. The Master List of Records in use needs to be updated to include all records currently in
use.
3. The Director had clearly defined responsibilities for staff in the Directorate; however the
same had not been officially communicated to the respective staff.
4. There is need therefore for the Director to convene regular meetings to discuss progress in
implementation of the Quality Management Procedure as this was not demonstrated during
the audit.
5. It was observed that there is need for adequate storage space for records in the office of
the Coordinator Timetabling to ensure that they are adequately protected.
6. It was noted that although lecturer‟s had been notified in time to proof read the typed
examination papers, some lecturer‟s did not turn up to proof read the examinations. There
is need therefore for the Director to liaise with the Faculties/ Schools and put in place
measures to ensure that all typed examination papers are proof read.
4.9 Farm Department
Contact Person: Charles Ayaga
4.9.1 Positive Findings
1. Milk production and animal production records were up to date. They however need to be
properly labeled as they did not have reference numbers on them.
2. The HOD had communicated to all staff on their duties and responsibilities as required.
4.9.2 Nonconformities Identified
The following two (2) minor nonconformities were identified during the audit:
1. Some files in the department containing record (eg. Bin cards file sampled) lacked reference
numbers on them hence making it difficult to identify and retrieve as envisaged in
procedure of control of records as well as in ISO 9001:2008 clause 4.2.4.
Page 13 of 22
2. The department did not have both the Master List of Internal and External Documents as
well as the Document Distribution Record Sheet as required by the procedure on Control of
Documents (KSU/SOP/COD/02).
3. It was not demonstrated that the department had established quality objectives to guide
their operations for the current year. According to ISO 9001:2008 clause 5.4.1, “ the
organization shall ensure that quality objectives….. are established at relevant function and
level…” Hence without Quality objective it is difficult for the department to measure
progress.
4.9.3 Opportunities for Improvement
1. Both master lists of internal and external documents had not yet been developed. The same
had been raised as a nonconformity in the previous audit held on 29th April 2015 (CAR 002).
Hence the nonconformity needs to be closed.
2. Some documents had been filed but had no folio numbers. Some files also lacked a folio
register.
3. Receipts and vouchers need to be filed in an orderly manner for easy analysis. Currently all
receipts and vouchers are lumped together in a single file without any order.
4.10 Faculty of Education
Contact Person: Dr. Peter Nyakan
4.10.1 Positive Findings
1. The Course allocation forms are now identified
2. There was objective evidence to show that there was a faculty meeting held on 12th
November, 2015.
3. There was evidence to show that a COD‟s meeting was held on 19/10/2015 at the Dean‟s
office.
4.10.2 Nonconformities Identified
The following four (4) minor nonconformities were identified during the audit:
1. There was no objective evidence to demonstrate that stakeholders participated in review of
curriculums and development of new curricular such as PhD in ECDE, PhD in EAPE, PhD in
education psychology, guidance & counseling, PhD in education management ,Planning and
economics .There were also no minutes to support the review sessions.
2. There was no objective evidence to demonstrate how teaching is monitored by the faculty
to ensure that teaching time-table or planned arrangements are followed as required by the
procedure KSU/GOP/EDU/02 ; clause 4.1(b)
3. There was no evidence to demonstrate that student transcripts were issued on time as
required in the Faculty‟s GOP KSU/GOP/EDU/02 ; clause 4.2(g)
4. There was no objective evidence to show how students were supervised at postgraduate
level. There was no record showing supervisors and students assigned to them. There were
no minutes supporting defenses held for proposal and final presentations. This is contrary to
KSU/GOP/EDU/02; clause 4.7(c),(i)
Page 14 of 22
4.10.3 Opportunities for Improvement
1. It was observed that the Faculty‟s Quality Objectives were for the FY 2014/2015, there is
need for the Faculty to review the Quality objectives.
2. There was no objective evidence to show curriculums which were reviewed. However some
of PhD curriculums were still under review.
3. The CODs were not available during the audit. They could have given valuable information
concerning coordination of teaching.
4.11 Faculty of Information Science & Technology
Contact Person: Dr. Kibiwott Kurgat
4.11.1 Positive Findings
1. It was observed that the Department was conforming, to a great extent, to the
requirements of ISO 9001:2008 International Standard. For instance the staff members
were well vast with their GOPs and other requirements of the Standard such quality policy
and quality objectives.
2. There was objective evidence of an established filling system and other requirements such
as Master Lists of Records and Documents.
4.11.2Nonconformities Identified
The following three (3) minor nonconformities were identified during the audit:
1. There was evidence of difficulty in retrieval of records and documents e.g General Operating
Procedures (G.O.P) for the Faculty and the curriculum review minutes file reference number
KSU/FIST/042 and KSU/FIST/052. The standard at clause 4.2.4 requires that records should
be readily identifiable and retrievable.
2. There was no evidence that the Industrial Attachment Coordinator had requested students
to indicate their preferred institutions of attachment contrary to the procedure clause 4.3(a)
of the Faculty‟s G.O.P.
3. It was established that the Faculty was not following procedure 4.5(c) of the G.O.P that
requires that the administrative assistant generates a list of registered students during the
registration process.
4.11.2 Opportunities for Improvement
1. The Faculty had provided a customer complains register but had not displayed to customers
the customer complaints handling procedure. The Faculty should therefore develop and
display clearly to its customers the customer complaints handling procedure.
Page 15 of 22
4.12 Procurement Department
Contact Person: David Basweti
4.12.1 Positive Findings
1. The HOD convenes a meeting with staff in the department every morning before start of
work day to discuss progress of activities assigned to staff in the Department.
2. It was observed that files in the Department were well labeled and arranged which ensured
ease of retrieval.
4.12.2 Nonconformities Identified
The following one (1) minor nonconformity was identified during the audit:
1. At the time of the audit the sampled staffs were not aware of the University‟s Quality Policy
statement. The procedure KSU/QMA/02; clause 5.3 (d) requires that staff are
communicated to on the Quality Policy Statement.
4.12.3 Opportunities for Improvement
1. Some sampled records had no folio .Updating the folio system would help the unit avoid any future confusion that would result from such an oversight.
4.13 Finance Department
Contact Person: Johnson Mwaura
4.13.1 Positive Findings
1. It was demonstrated that disbursement of payment was done as per the
Department‟s General Operating Procedure.
2. The process on receiving of cheques /cash was done as per the Department‟s
General Operating Procedure. Records on the same were well maintained.
4.13.2 Nonconformities Identified The following one (1) minor nonconformity was identified during the audit:
1. It was not demonstrated that the ADHOC committee for the budget met to discuss
the budget prosposals as outlined in the Proceudre KSU/GOP/FIN/02; clause 4.3.1
(b).
4.13.3 Opportunities for Improvement
1. There is need to establish measuring tools for the Quality Objectives to assess
progress in implementation.
2. It was not clear who should have the GOPS and standard operating procedures
Page 16 of 22
3. It was noted that Quality objectives 7 & 8 were not measurable. There is need for
the Department to ensure that all Quality objectives are measurable as required.
4. It was observed that the asset register was not dully filled with all the requisite
information.
5. There is need for the department to maintain clear records on imprest taken by
members of staff in the University.
4.14 Student Affairs
Contact Person: Gladys Osoro 4.14.1 Positive Findings
1. The auditees were cooperative and open during the audit
2. The Department had established Quality Objectives for the FY 2015/2016 and the same had
been approved by the Head of Department and subsequently convened a departmental
meeting - 18/07/2015; to discuss the Quality Objectives developed with all the staff.
3. It was observed that majority of the Quality Objectives developed had been included in the
Department‟s Performance Contract; this made it possible to track progress in achievement
through the Quarterly Progress reports submitted to the DVC (ASA).
4. It was noted that the Department had developed a number of channels to help in recording
customer complaints, that is, through the complaints box, Client Attendance Sheet and the
Complaints Register.
5. It was demonstrated that most of the sampled processes e.g. First Year orientation for the
September intake, registration of clubs and societies, counselling services were conducted
as per the requirements outlined the Department‟s GOP.
4.14.2 Nonconformities Identified
No nonconformities were identified during the audit. 4.14.3 Opportunities for Improvement
1. The New Student Registration Forms, Peer Counseling records and records in the Sports
Section need to be well maintained to ensure ease of retrieval and identification.
2. The Master list of Records in use needs to updated to ensure that all records in use are
captured e.g. student affairs departmental meeting and Consent Records, Confidential
Progress Records including other records used in the Counseling Section.
3. It was observed that recently recruited Sports Officers and Games Attendant were not
included in the Administrative Structure, there is need therefore for the Administrative
structure in the GOP to be reviewed.
4. It was demonstrated that the Department had amended the steps followed in taking teams
for external fixtures; clause 4.13.2. There is need therefore for the GOP to be revised to
reflect these changes using the „Change Request Form‟.
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4.15 School of Pure and Applied Sciences
Contact Person: Dr. Joash Kerongo
4.15.1 Positive Findings
1. It was noted that the complaints raised had been handled to the client satisfaction. It was
also noted that the school has up to date quality objectives.
4.15.2 Nonconformities Identified
The following three (2) minor nonconformities were identified during the audit:
1. There was no evidence to show that specific duties and responsibilities had been allocated
to staff as required by the Quality Manual; clause 5.5.1
2. There was no evidence to demonstrate that a meeting had been convened to sensitise staff
on the Quality Management System as required by the Quality Manual ; clause 5.5.3
3. There was no evidence of corrective action on nonconformities identified during the last
audit as required by ISO 9001 International Standard; clause 8.2.2.
4.15.3 Opportunities for Improvement
1. The quality objectives need to be reviewed to be SMART and a measuring tool developed to
evaluate their achievement.
2. A complaint handling procedure for the school needs to be developed and publicized for all
clients to see.
3. There is need to review the school‟s GOPs so as to bring them in tandem with the actual
practice and add such processes as are currently missing yet are important for the school.
4. It was observed that the work environment and infrastructure at the School was not
conducive to allow for efficient service delivery to clients. Some of the major ones include
limited space thus congestion; limited or lack of hardware including computers and printers;
a very small staff size; too much noise and commotion by students dealing with the fee
collection office; and laboratory equipment required by academic programs not installed.
4.16 Research and Extension
Contact Person: Prof. Anakalo Shitandi
4.16.1 Positive Findings
1. There was objective evidence to show that quality objectives had been reviewed and their
achievement was being monitored.
2. It was demonstrated that staff duties and responsibilities were clearly defined and the same
communicated to the staff.
3. The department demonstrated that regular departmental meetings were held to assess
achievement of targets set for staff as well as to review effectiveness in implementation of
the QMS.
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4.16.2 Nonconformities Identified
The following one (1) minor nonconformity was identified during the audit:
1. There was no objective evidence to show that a research committee was constituted under
the university statutes XXXlll. There was a memo to the DVC ASA dated 20th March 2015,
however the meeting never took place as there were no minutes for the same.
4.16.3 Opportunities for Improvement
1. More measures still need to be undertaken to unsure proper records are kept as some of
the files were not easily retrievable.
4.17 School of Health Science
Contact Person: Dr. Wycliff Mogoa
4.17.1 Positive Findings
1. The auditees were cooperative and open during the audit
2. It was demonstrated that the Dean had convened a School Board Meeting on 22/10/2015 to
discuss examination results for the August 2015 examinations before forwarding them to
the Senate as per the Schools GOP; clause 4.4 (d)
3. It was demonstrated that the examination drafts for the examinations scheduled for
December 2015 had been internally moderated as required.
4. It was observed that the Examination draft submission records for the Department of
Nursing were well maintained.
4.17.2 Nonconformities Identified
The following five (5) minor nonconformities were identified during the audit:
1. There was no objective evidence to show that class attendance registers for sampled units
COMH0122, COMH0222 and COMH0212 for the September –December 2015 semester were
filled as required by the procedure KSU/GOP/SHS/01; clause 4.1 (i).
2. Records are required to be easily retrievable and identifiable as per the procedure
KSU/SOP/COR/02 clause 3.1 (d); however this was not demonstrated for sampled records
e.g. class attendance registers, lecturer‟s applications, minutes of Faculty Board meetings
etc.
3. There was no objective evidence to show that examination drafts for the September –
December 2015 semester examinations had been moderated by the external examiners as
required by the procedure KSU/GOP/SHS/01; clause 4.2 (e)
4. There was no objective evidence to indicate that the School had put in place mechanisms to
monitor progress in achievement of the quality objectives established.
5. The School had not established a Master List of Records in the prescribed format as
required by the procedure KSU/SOP/COR/02; clause 3.1 (b).
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4.17.3 Opportunities for Improvement
1. There is need for the Dean to ensure that all the part time lecturers‟ records have the
requisite documents attached, that is, CVs, certified academic certificates and official
application letters.
2. The teaching timetable in use for the September-December 2015 semester had not been
approved prior to use. There is need therefore for the School to identify the responsible
authority for approving the teaching and examination timetables.
3. It was noted that the Complaints Register in use needs to be in the prescribed format. The
current Register in use was missing some of the details as outlined in the Procedure on
Corrective Action, that is, responsible person for handling the complaint and date complaint
was resolved
4. It was observed that the School‟s Examination Coordinator was responsible for preparing
the teaching and examination timetable. There is need therefore for the process on
preparation of the teaching timetable to be included in the School‟s General Operating
Procedure.
5. There is need for the Dean to officially communicate the specific duties and responsibilities
assigned to the staff
4.18 Medical Department
Contact Person: Dr. Jackline Nyaanga
4.18.1 Positive Findings
1. It was demonstrated that the department convenes regular meetings aimed at monitoring
its performance.
2. It was observed that the Quality Policy statement was strategically displayed in the
department
3. It was observed that the University vision and mission statements were strategically
displayed in the department
4.18.2 Nonconformities Identified
The following one (1) minor nonconformity was identified during the audit:
1. There was no objective evidence to demonstrate that memos were issued after every 3
months by Public Health Officer asking relevant offices concerned with food handling to
undergo medical examinations.
4.18.3 Opportunities for Improvement
1. The department needs to review its GOP to conform to its current status. It was observed
that although there is a substantive Medical Officer, this has not been reflected in the
department‟s GOP.
2. The department should continuously update and monitor quality objectives.
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3. Some members of staff were not aware of the key QMS documents. There is need to
continuously sensitize members of staff on QMS.
4.19 Library Department
Contact Person: Irene Nyakweba
4.19.1 Positive Findings
1. It was noted that the quality objectives were up to date and approved by the HOD as
required.
2. The accession register used in the department was also up to date thus helping track books
catalogued.
3. The customer complaints register was strategically placed to allow ease of access by clients.
It was also noted that the complaints raised were filled in the CAR forms.
Nonconformities Identified
The following one (1) minor nonconformity was identified during the audit:
1. It was not demonstrated that the Department had established mechanisms to monitor and
to track progress made in achievement of the Quality objectives established.
Opportunities for Improvement
1. That the Master List of Records had titles that do not tally with those in files. In one case,
there were two different records with one reference number KSU/LD/LO/023 (for Annual
Work Plan and Performance Contract).
2. There is need to ensure that the Library Police in use is approved while the obsolete
documents e.g. GOPs be controlled as required by the procedure on Control of Documents.
3. There is need to do proper communication of the duty allocations to individual members of
staff.
4. There is need to amend the title in GOP clause 4.1 (a) from application form to Student
Library Record Card so as to tally with the actual record.
5. There is need to update the Master List of Internal Documents to include the up to date
documents and not obsolete ones e.g. Library Annual Work Plan 2014/2015 and Library
Procurement Plan 2014/2015.
4.20 Halls Department
Contact Person: M.E.D. Mongare
4.20.1 Positive Findings
1. The department had established a vision and mission to guide in operations.
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4.20.2 Nonconformities Identified
The following five (5) minor nonconformities were identified during the audit:
1. The Quality Objectives established were not measurable as required in ISO 9001:2008
clause 5.4.1.
2. The Tenancy Agreement Form was not being used during students „check-in‟ contrary to
what the department‟s GOP process 4.1.
3. There was no objective evidence to show that a standard way of making requests for use of
meeting rooms and conference facility which is contrary to ISO 9001:2008 clause 7.3.1 on
design and development planning in line with planned arrangements.
4. There was no objective evidence to show that staff had been formally issued with their job
descriptions/duties and responsibilities as required by the Quality Manual clause 5.5.1.
5. It was not demonstrable that the department had put in place effective monitoring and
supervision measures to ensure quality work performance. Lecture hall 6, 7 and 8 sampled
were found to be very dirty and seemed not to have been cleaned for a long while. This was
contrary to the ISO 9001:2008 clause 8.1.
4.20.3 Opportunities for Improvement
1. There is need to review the monitoring mechanisms to ensure effective cleaning of facilities
in terms of quality and frequency.
2. It was observed that all registers should have reference numbers for ease of identification
and retrieval.
3. There is need to improve on the processes and timelines of acquiring cleaning materials to
avoid delays.
4.21 Directorate of Academic Quality Assurance
Contact Person: Dr. Kennedy Getange
4.21.1 Positive Findings
1. Quality Policy statement was strategically displayed in the department
2. The University vision and mission statements were strategically displayed in the department
4.21.2 Nonconformities Identified
The following two (2) minor nonconformities were identified during the audit:
1. It was not demonstrated that the Directorate had established measurable quality objectives
as per clause 5.4.1 of the Quality Manual.
2. There was no objective evidence to demonstrate that the Directorate had convened
quarterly Academic Quality Assurance Board meetings as per clause 4.1 of the Directorate‟s
procedure as well as Statute XXXII (7) the Kisii University Statutes, 2013.
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4.21.3 Opportunities for Improvement
1. It was observed that some members of staff were not aware of the key QMS documents.
There is need to continuously sensitize members of staff on the QMS.
4.22 AIDS Control Unit
Contact Person: Prof. Benjamin Ondigi
4.22.1 Positive Findings
1. The auditees were cooperative, open and
2. The Unit had developed operating procedures clearly outlining the steps followed in
executing their activities.
3. It was demonstrated that all staff had clear roles outlined for them and the same
communicated to them by the HOD.
4.22.2 Nonconformities Identified
The following three (3) minor nonconformities were identified during the audit:
1. It was not demonstrated that the Director had held meetings for the ACU Board every
quarter as outlined in the Kisii University Statutes, 2013.
2. The Quality Manual clause 5.5.3 requires that …..”Communication takes place regarding the
quality management system.” It was however established that members of staff in the
Directorate were not aware of the Directorate‟s General Operating Procedure.
3. It was observed that some of the quality objectives established , that is, quality objectives 5
and 6 were not measurable to facilitate tracking of the progress in achievement as required
by the procedure KSU/QMA/02; CLAUSE 5.4.2
4.22.3 Opportunities for Improvement
1. The Master Lists of external documents was note in the prescribed format as outlined in the
procedure for Control of Documents. There is need to ensure compliance to all the
requirements outlined in the procedure for Control of Documents.
2. There is need for the Unit to establish a Master List of Records clearly indicating the records
generated from the processes including their retention periods and disposition methods.
5.0 CONCLUSION
Based on the processes that were sampled, it was established that there has been significant
improvement in the implementation of the University‟s QMS and areas of improvement that
have been identified will make it possible for continual improvement when the corrective and
preventive actions have been implemented as appropriate.
Additionally, nonconformities identified should be addressed by undertaking timely and
appropriate corrective action which should be based on the root cause analysis to avoid
recurrence of the issues raised. All responsible Deans/ HODs shall be required to maintain
appropriate records on actions undertaken for verification and review by the auditors and MR
respectively.