kisii university iso 9001: 2008 internal quality audit report internal... · kisii university iso...

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KISII UNIVERSITY

ISO 9001: 2008

INTERNAL QUALITY AUDIT REPORT

KISII UNIVERSITY IS ISO 9001:2008 CERTIFIED

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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

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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

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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

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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.

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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.

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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


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:

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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.


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


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.

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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.


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


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.


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).

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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


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.


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.


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


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.


The following six (6) minor nonconformities were identified during the audit:

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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.


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


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.

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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).


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


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.


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.

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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.


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


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.


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)

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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


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.


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.

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4.12 Procurement Department

Contact Person: David Basweti


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.



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.


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


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).


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

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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.


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


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.



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.


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


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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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.


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


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.



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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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


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



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.


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


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


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


1. The department had established a vision and mission to guide in operations.

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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.


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


1. Quality Policy statement was strategically displayed in the department

2. The University vision and mission statements were strategically displayed in the department


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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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


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.



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


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.