Labour Standards Assurance System (LSAS Level 2)

The time scale for suppliers under the category of “Direct Textiles” to achieve LSAS Level 2 approval has been re-confirmed as the 30 September 2014, which is 18 months from the launch of the framework agreement. For companies who have already achieved LSAS Level 1 the first annual visit has been waived by NHS SC as long as suppliers are working towards the LSAS Level 2 and achieve this prior to the deadline.

There is no contractual requirement at present to go beyond LSAS Level 2, however, should a company decide to progress to level 3 or level 4 then this would be a demonstration that they have a robust system for managing labour standards in line with the International Labour Organisation (ILO) conventions.

The additional requirements and questions to think about, on top of the LSAS Level 1 requirements are as follows:

LSAS Level 2 –  Clause 1 (Policy) – Communication of the labour standards policy both internally and externally, in effect is it publicly available? Reviews against business objective and records to support this. Acknowledgment of receipt from suppliers. The policy to be a formal part of the documentation control system in terms of review, approval and updates.

LSAS Level 2 –  Clause 2 (Management Representative) – Training and experience the management representative has for this role. Minutes and other evidence of activity to demonstrate involvement and whether or not this is a dedicated role. Is does not have to be dedicated, especially for small companies the management representative would normally wear another “hat.”

LSAS Level 2 –  Clause 3 (Labour Standards Status Review) – Have desktop reviews taken place on supplier performance? How has the frequency of reviews been determined, for example has it been from the risk assessment that would have been formulated at Level 1? Have the audits been conducted by qualified and experienced auditors?

LSAS Level 2 – Clause 4 (Legal & Other Requirements) – Who has access to the information on legislation relating to Labour Standards, Contractors, Subcontractors and Suppliers?

LSAS Level 2 – Clause 5 (Objectives, Targets & Programmes) – Is there a plan of action in place and has it been  communicated internally and to all interested parties? Has the plan been discussed with the “facilities?”

LSAS Level 2 – Clause 6 (Roles & Responsibilities) – Is there a defined organisation structure relative to Labour Standards as well as defined roles and responsibilities?

LSAS Level 2, Clause 7 (Competence, Training & Awareness) – Has competence been assessed for personnel and training and development needs identified who are directly employed or working on behalf of the organisation in areas where there is contact with Labour Standards issues? Is evidence available to support the assessments?

LSAS Level 2, Clause 8 (Communications) – A procedure is required for this level which addressed internal communications and external communications with interested parties that deals with receipt, response and actions involved to deal with Labour Standards issues.

LSAS Level 2, Clause 9 (Documentation & Records) – There are no requirements within this clause for Level 1. For Level 2 the requirement is to have documents and records to demonstrate conformity with all clauses.

LSAS Level 2, Clause 10 (Operational Control) – The difference between Level 1 and Level 2 for this clause is that procedures are now required for operational control. What will be looked at here is whether the findings of the risk assessment as required at Level 1, under Clause 3 (Labour Standards Review) has been used.

LSAS Level 2, Clause 11 (Supply Chain Management) – This clause for Level 2 has the most additional requirements from those required for Level 1. Evidence that the policy has been communicated “beyond” directly contracted suppliers in the supply chain? Does the supply chain map as required for Level 1 identified Labour Standards risks “beyond” contracted supply, e.g. sub-suppliers, homeworkers, etc? In addition to communication of the policy how does the organisation know id the policy has been understood and the expectations that go with it? Does the organisation’s procedure address what should take place in instances where Labour Standards abuses have been identified within the supply chain?

LSAS Level 2, Clause 12 (Emergency Response) – The Organisation should have documented mitigation action plans in place that relate to significant Labour Standards risks as identified through the risk assessment as required by Level 1, Clause 3 (Labour Standards Review) or by other means. There should be evidence of review to ensure that the mitigation plans are robust, based upon findings and changing circumstances.

LSAS Level 2, Clause 13 (Performance Monitoring & Measurement) – There are no requirements within this clause for Level 1. For Level 2, has the company identified and defined data and performance indicators to monitor and measure performance against its stated objectives and targets, compliance with relevant legislation and any other requirements. Is there a process of internal audits to check conformance with planned arrangements that address critical control points and significant supply chain risks. Although as stated above there was no requirement for this clause at Level 1, this should have been partly addressed by Clause 3 (Labour Standards Review) and the risk assessment.

LSAS Level 2, Clause 14 (Corrective Action – There are no requirements within this clause for Level 1. For Level 2 a procedure is required and needs to address the identification, recording of non-conformities and potential non-conformities. That corrective actions as well as time scales for implementation are agreed and effectively implemented. That corrective and preventive actions are taken and reviewed and that root cause analysis has been undertaken. The requirements of Level 2 for this clause are almost the same as those defined within ISO 9001:2008.

LSAS Level 2, Clause 15 (Management Review) – This is one of the most important activities of any management system and often it is the weakest. For Level 1 there was only a requirement for policies, etc to be formally approved. For this Level there needs to be evidence that top management have reviewed the organisation’s labour standards assurance system at planned intervals to ensure its continuing suitability, adequacy and effectiveness. Records of such reviews would need to be available for the auditor(s).

The original time to achieve LSAS Level 1 was extended, however, the time scale of 18 months from the launch of the framework agreement remain unchanged, therefore, some organisations may not have that long to achieve LSAS Level 2. To assist with this Globalgroup shall be running a series of training courses and workshops throughout 2014. The dates will be published through the web site, in due course. Anyone interested in attending a training course or workshop on LSAS Level 2 should in the first instance send an email to

LSAS Level 1 (Labour Standards Assurance System) – The Requirements

Labour Standards Assurance System LSAS Level 1 – The Requirements. LSAS is a Management System Specification which has 4 levels: Foundation (Level 1) Implementation (Level 2), Established (Level 3) and Progressive (Level 4).

Within this blog I am only dealing with LSAS Level 1 Foundation requirements as these are the starting point and a requirement for suppliers within scope of supply to achieve at least LSAS Level 1 within 12 months of the contract award date.

In general LSAS Level 1, the Foundation level is about having a basic framework in place which deals with Labour Standards issues within the supply chain.

LSAS Level 1, Section 1, Policy – That the company have a policy in place which is documented, approved by “top” management and is appropriate to the size and scale of the company. Has a commitment for addressing compliance with legal and other standards. Defines a set of minimum labour standards and makes a commitment to continual improvement. Some of these requirements are similar to what you would find within other management system standards such as ISO 9001, however, instead of being aimed at product/service it is aimed at the workers within the supply chain. As with many management system standard the key is commitment so in order to demonstrate this commitment it would be normal for the policy to be endorsed by top management.

LSAS Level 1, Section 2, Management Representative – Again, the requirements of this section are very similar to those within ISO 9001 for example, whereby top management should appoint a representative who has responsibility and authority to establish, implement and maintain an effective labour standard assurance management system and report the results in terms of performance back to top management. A way of complying with this section would be to have an organisation chart identifying the management representative as well as a job description defining stating the responsibilities and authority level. This is just one suggestion there are other ways of meeting this requirement.

LSAS Level 1, Section 3, Labour Standards Status Review – This section requires the company to have conducted a risk assessment in relation to labour standards. The risk assessment should be reviewed to ensure it has addressed all labour standards risks within the scope of supply.

LSAS Level 1, Section 4, Legal & Other Requirements – The company should implemented a procedure which identifies information on relevant employment and human rights legislation in regard to its direct operations. All staff should have access to this information and understand how it applies in relation to their roles and responsibilities. For companies with more than one location the use of an intranet would be an effective way of communication as well as a centralised control on updates.

LSAS Level 1, Section 5, Objectives, Targets & Programmes – The company should establish, implement and maintain “documented” objectives and targets related to the assurance of labour standards. The objectives should be achievable and have targets for implementation.

LSAS Level 1, Section 6, Roles & Responsibilities – The roles, responsibilities and authorities should be documented and communicated in order to facilitate effective management of labour standards within the company’s direct operations and through its supply chain.

LSAS Level 1, Section 7, Competence, Training & Awareness – This section requires the company to ensure that training, experience and personnel criteria for those working within labour standards have been defined. Also that training and development plans have been created, where applicable. It is worth while noting the order in which the words appear in this section heading. Competence first, then Training and lastly Awareness.

LSAS Level 1, Section 8, Communications – There should be an effective system in place to communicate labour standards findings and issues to top management. Each company should chose a system that fits within the resources and technology that is available to them.

LSAS Level 1, Section 10, Operational Control – The company should identify the critical control points and risks associated to labour standards within its “direct” operations.

LSAS Level 1, Section 11, Supply Chain Management – There are a number of requirements within this section even for Level 1. There should be a “documented procedure” in place to address the management of supply chain labour standards risks and issues. The supply chain should be mapped and it should be clear the level it has been mapped to. Whether the policy of labour standards has been communicated to directly contracted suppliers and contractors.

LSAS Level 1, Section 12, Emergency Response – The company should have a basic plans in place to mitigate against adverse impacts in the event that significant labour standards risks manifest themselves. This would be in the form of a documented procedure for handling any significant risks or critical issues that may come to light.

LSAS Level 1, Section 15, Management Review – The company top management should review the organisation’s labour standards assurance system and performance, at planned intervals, to ensure continuing suitability, adequacy and effectiveness. This is almost the same as the requirements for management review within ISO 9001 with the exception of the words, “labour assurance.” A company who already has a quality management system, environmental management system and/or health and safety management system could quite easily integrate the requirements of the labour standards into other management reviews.

For LSAS Level 1, there are no requirements for Documentation & Records (Section 9), Performance Monitoring & Measurement (Section 13) and Corrective Action (Section 14).

For any company that thinking of starting or has started and would like some information or assistance on the interpretation of the requirements of LSAS Level 1, or any level then you can send an email directly to us at or create a posting through our Facebook Site or Twitter

Other Sources of information:

Labour Standards Assurance Scheme – LSAS

The Labour Standards Assurance Scheme – LSAS was designed by the National Health Service Supply Chain (NHS SC), in conjunction with the Departments of Health and Industry bodies and covers new ethical requirements for its suppliers. The objective of the LSAS scheme is to reduce the risk of labour standard abuses within the supply chain going on undetected and/or without resolution.

The scope of the scheme currently covers suppliers of surgical equipment and instruments, such as scissors, footwear, clothing, to name but a few. Although the scope of the scheme is limited, NHS SC are looking to expand compliance to other areas within the supply chain portfolio.

There are four levels of LSAS Maturity which are; Level 1* (Foundation), Level 2 (Implementation), Level 3 (Established) and Level 4 (Progressive)

*Suppliers must be audited to Level 1 as a minimum before NHS Trusts can purchase supplies through NHS SC.

In order to be approved to conduct these audits a certification body needs to be accredited by Social Accountability Accreditation Services (SAAS) against the requirements of SA 8000, Social Accountability Systems. Globalgroup are one of only a very small number of certification bodies authorised to carry out audits against the NHS Direct Labour Standards Assurance System, commonly known as LSAS.

The approach taken by competent GlobalGROUP lead auditors is one of working with clients in order to achieve objectives. This approach is quite different from other accredited management system schemes where the lead auditor is not allowed to be involved in the design of the corrective action.

For organisations who already hold an accredited certificate for another management system standard and where the requirements of LSAS have been integrated within the other management system(s) then it may be possible to make a discount on fee levels.

Should you wish to receive any additional information on the LSAS scheme or have a visit from one of our competent lead auditors please contact us by phone on 0845 548 9001 or by email at