Control of Substances Hazardous to Health (COSHH) Policy & Guidance

Transcription

1 Control of Substances Hazardous to Health (COSHH) Policy & Guidance Name of Author and job Title: Nina Goodwin Health and Safety Risk Manager Name of Review/development Body: Ratification Body: Health & Safety Committee Trust Board Date of Ratification/Effective from: March 2013 Review Date: February 2016 Reviewing Officer: Nina Goodwin Signed:. CEO or Chairperson of Ratifying Body If this document is required in an alternative language or format, such as Braille, CD, audio, please contact the PALS office.

2 VERSION CONTROL SHEET Date Nove mber Review Type (please tick) Minor amendment 1 Full Review Version No. Author of Review Title of Author 3 N Goodwin Health & Safety Risk Manager 2 N Goodwin Health & Safety Risk Manager Date Ratified Ratification Body Trust Board Trust Board Page Numbers (where amended) Line Numbers (where amended) Details of change Inserted Deleted N Goodwin Health & Safety Risk Manager Trust Board 1 Where there is a full review, amendment details are not required in the version control sheet.

3 Contents Page Number 1. Introduction/Background 4 2. Purpose and Objectives 4 3. Scope 4 4. Duties and Responsibilities Subject Matter Training Contact Numbers Implementation Monitoring Compliance with Effectiveness of This Policy Review, Approval and Archiving Dissemination and Publication Equality Analysis Associated Documents References 16 Appendices Appendix 1 - COSHH Symbols Appendix 2 - Managers Guide to COSHH Regulations Appendix 3 - COSHH Control Measures Appendix 4 - COSHH Risk Assessment Form and Action Plan Appendix 5 - Risk Grading Matrix Appendix 6 - COSHH Inventory Form 29 COSHH Policy March 2013 Version 3 Page 3 of 29

4 1. Introduction/Background The Trusts policy and guidance for substances hazardous to health has been written to satisfy legislative requirements and to set out the organisation and arrangements for managing risks relating to their use. This policy supersedes the previous version written in Purpose and Objectives The policy is required to demonstrate arrangements the Trust has in place to implement requirements of the Control of Substances Hazardous to Health (COSHH) Regulations (as amended) 2002, hereinafter referred to as the COSHH Regulations. The policy also takes account of recommendations made by the Health & Safety Executive (HSE) in 2011 following their inspection of the Trusts health and safety management system. The Trust has a duty to ensure, so far as is reasonably practicable, the health, safety and welfare of its employees and other persons who may be affected with regards to the use of hazardous substances. Where hazardous substances cannot be eliminated, exposure will be reduced or controlled, as far as is reasonably practicable, to prevent injury or ill health to employees, patients and members of the public. The aim of this policy is to prevent exposure to hazardous substances wherever possible, but where not possible, to adequately control exposure and minimise any harm which may be incurred as a result. This is to be achieved by implementing the following eight principles of good practice outlined within the COSHH Regulations: 1. Design and operate processes and activities to minimise emission, release and spread of substances hazardous to health 2. Take into account all relevant routes of exposure inhalation, skin and ingestion when developing control measures 3. Control exposure by measures that are proportionate to the health risk 4. Chose the most effective and reliable control options that minimise the escape and spread of substances to health 5. Where adequate control of exposure cannot be achieved by other means, provide, in combination with other control measures, suitable personal protective equipment 6. Check and review regularly all elements of control measures for their effectiveness 7. Inform and train relevant employees on the hazards and risks from substances with which they work, and the use of control measures developed to minimise risks 8. Ensure that the introduction of measures to control exposure does not increase the overall risk to health and safety 3. Scope This policy applies to employees of the Trust who may be required to use hazardous substances during the course of their work or who may be exposed to hazardous substance. It also applies to other staff including temporary staff (e.g. agency/ and Bank staff, contractors and students) and other people who may be affected by the Trust s activities. 3.1 Definitions Hazard The hazard presented by a substance is its potential to cause harm. COSHH Policy March 2013 Version 3 Page 4 of 29

5 Risk The risk from a substance is the likelihood that it will harm someone in the actual circumstance of use. The degree of risk depends upon the likelihood of harm occurring as well as the extent of the consequence. Hazardous Substance A substance hazardous to health is any substance, which presents a hazard to health. The substance may be in a solid, liquid, dust or gas form. Such substances include: 1) Substances defined in (the Chemical Hazard Information and Packaging for Supply (CHIP) Regulations 2009 as: Toxic Very toxic Harmful Corrosive Irritant 2) Biological agents, e.g. harmful micro-organisms or body fluids 3) Any dust in a substantial concentration in air 4) Any other substance creating a comparable hazard 5) Substances assigned a Workplace Exposure Limit (WEL) W.E.L A Workplace Exposure Limit (WEL) is the maximum concentration of a hazardous substance in air, averaged over a specified period to which employees may be exposed by inhalation. Health Surveillance Health surveillance is a way of protecting the health of people at work by identifying early symptoms in employees exposed to substances that could harm their health. Control Measures Control measures, also referred to as protective measures, are the arrangements made to remove, reduce or contain risks. Personal Protective Equipment (PPE) PPE is clothing or equipment provided to employees in order to protect them from the effects of hazardous substances which includes biological hazards such as micro-organisms. With regard to protection against hazardous substances, PPE includes gloves, aprons, eye and face protection, respiratory protection, etc. See Infection Control Personal Protective Equipment Policyfor further information on PPE in relation to micro-organisms (available on the TrustNet).. Routes of Entry of Hazardous Substances Hazardous substances can enter the body by: Inhalation (breathing in) Skin contact (through the skin or mucus membranes) Ingestion (through the mouth) Injection, cut or abrasion COSHH Policy March 2013 Version 3 Page 5 of 29

6 Exposure by breathing in: Once breathed in, some substances can attack the nose, throat or lungs while others get into the body through the lungs and harm other parts of the body, e.g. the liver. Exposure by skin contact Some substances damage skin, while others pass through it and damage other parts of the body. Skin gets contaminated: by direct contact with the substance, e.g. if you touch it or dip your hands in it; by splashing; by substances landing on the skin, e.g. airborne dust; by contact with contaminated surfaces this includes contact with contamination inside protective gloves. Exposure by swallowing People transfer chemicals from their hands to their mouths by eating, smoking etc., without washing first. Exposure to the eyes Some vapours, gases and dusts are irritating to eyes. Caustic fluid splashes can damage eyesight permanently. Exposure by skin puncture Risks from skin puncture such as cuts and needlestick injuries are rare, but can involve infections or very harmful substances, e.g. drugs. Materials Safety Data sheet (MSDS) A MSDS is a document provided by the substance or product manufacturer and is a statutory requirement. The MSDS provides the user with information about the hazardous properties of the substance, precautions to take, PPE which may be required, how to deal with spillages, first aid measures and waste disposal methods. A MSDS should be available in each ward or department where a hazardous substance in use and employees should have access to it. Copies of MSDS can be obtained directly from the manufacturer or supplier via the internet. 4.0 Duties and Responsibilities 4.1 Chief Executive (CEO) The CEO has overall responsibility for the health, safety and welfare of patients, employees and the visiting public. In practice, this responsibility is delegated to the Board Director responsible for risk. 4.2 Director of Organisational Transformation The Board member responsible for risk is the Director of Organisational Transformation. He is responsible for ensuring there are safe systems within the Trust for minimising risks associated with the use of hazardous substances. 4.3 Head of Non-Clinical Risk The Head of Non-Clinical Risk is responsible for ensuring risks associated with hazardous substances are entered on the Corporate Risk Register as appropriate and for reporting them to the Risk Management Strategy Group COSHH Policy March 2013 Version 3 Page 6 of 29

7 4.4 Health and Safety Risk Manager The Health & Safety Risk Manager is responsible for: Providing appropriate training for managers and employees in the safe management of hazardous substances Providing guidance with regard to the completion of COSHH risk assessments Ensuring appropriate revision of this policy on a regular basis Advising the Trust of changes in legislation or guidance from the HSE relating to COSHH and relevant implications Advising and supporting managers and employees regarding control measures and monitoring requirements. Assisting managers with investigating adverse incidents involving substances hazardous to health and making recommendations for safer practice 4.5 Occupational Health Manager It is the responsibility of the Occupational Health Manager to: Ensure appropriate health surveillance is carried out and records are maintained for 40 years from the date of the last entry Perform pre-employment/placement and on-going medical and health assessment for job applicants and employees respectively and advise on rehabilitation and the redeployment of symptomatic employees Provide an immunisation programme for relevant staff and ensure relevant national and local policies and guidelines are adhered to Maintain the register of all staff required to undergo health surveillance for hazardous substances Ensure an appropriate health surveillance programme is in place for relevant employees Inform relevant personnel of the outcome of health surveillance and provide a six monthly anonymsed report to the Health & Safety Committee Follow up and monitor employees who are suffering from health effects caused by hazardous substance used at work and ensure appropriate treatment is provided Inform the Health & Safety Risk Manager promptly of employees who have contacted an occupational disease (in accordance with the Reporting of Injuries, Diseases & Dangerous Occurrences Regulations (RIDDOR) 1995 and ensure the appropriate report is made to the HSE 4.6 Lead Infection Control Nurse The Lead Infection Control Nurse is responsible for: Ensuring policies and guidelines are in place to ensure safe practices are in place to reduce the risk and spread of pathogenic organisms Education and training of staff in clinical areas with regard to infection control policies, guidelines and procedures Providing advice regarding protection from microbiological agents. Detailed information is contained in the Infection Control Policy and Guideline folder(available on the TrustNet and in hard copy in clinical departments). Providing advice regarding personal protective clothing requirements with regard to biological hazards COSHH Policy March 2013 Version 3 Page 7 of 29

8 Providing training for relevant staff in the prevention of occupational dermatitis in relation to hand hygiene practices Support the provision of polices and guidelines in conjunction with the Occupational Health department relating to the safe use and handling of sharps In conjunction with Occupational Health, provide training to relevant staff in management of a sharps injury. Providing training to relevant staff in management of a sharps injury. 4.7 Estates Manager The Trust employs external contractors to maintain and repair its buildings and associated systems and sub-systems. It is the contractor s responsibility to maintain these items and assets under contract in accordance with statutory instruments and industry best practice. The maintenance contractors are managed by the Estates Services Manager. The Estates Services Manager is responsible for ensuring work carried out on Trust premises is safe and without risk to any persons who may be affected by hazardous substances. 4.8 Health & Safety Committee The Health & Safety Committee is responsible for: Monitoring compliance of this policy across the Trust Revising and updating the policy every two years Advising on recommendations for the improvement of health and safety measures in relation to the use of hazardous substances Highlighting concerns regarding the use of hazardous substances Monitoring reported adverse incidents involving hazardous substances and providing advice regarding preventative measures 4.9 Deputy Director of Operations (DDOS s) and DDM s, Specialty Managers and Matrons DDO s and DDM s, Speciality Managers and Matrons are responsible for ensuring ward sisters, charge nurses and Heads of Department complete COSHH risk assessments and inventories appropriately and implement preventative measures to protect employees and others from risks associated with the use of hazardous substances Heads of Department/Ward Sisters/Charge Nurses Heads of Department, Ward Sisters and Charge Nurses are responsible for: Ensuring all hazardous substances in use have an accompanying Materials Safety Data Sheet (MSDS) and that this is made available to relevant employees Completing a COSHH risk assessment for all hazardous substances and bringing them to the attention of relevant employees. Risk assessments must be kept in an easily accessible place within the ward or department Populating and maintaining a COSHH inventory for their area(s) Ensuring appropriate control measures are implemented to minimise risks to health and safety of people within their ward or department Bringing the COSHH policy to the attention of employees Ensuring relevant employees receive COSHH training appropriate to their role and that they implement the knowledge gained within their place of work. This may be via local induction or more formal, classroom training Attending relevant COSHH training courses (refer to section 9.6.2). COSHH Policy March 2013 Version 3 Page 8 of 29

9 4.11 Employees It is the duty of all employees to look after themselves and others at work and to co-operate with the employer in respect of statutory provisions and not misuse or interfere with safety measures (as laid down in Section 2 of Health and Safety at Work Act 1974). Duties under this policy specifically include: 5.0 Subject Matter Making themselves familiar with this policy Attending training sessions as provided, making use of information and knowledge gained and applying it to their work area Correctly using control measures as described within the risk assessment Correctly using personal protective equipment whenever required Attending appointments for health surveillance, if required Reporting any health concerns to their manager and to the Occupational Health department and completing an adverse incident form Reporting hazards, e.g. faulty equipment, PPE, spillages, etc Making themselves familiar with emergency procedures and first aid measures Reporting adverse incidents via the Trusts adverse incident reporting system 5.1 COSHH Risk Assessments and Inventories COSHH Risk Assessment Managers must not allow any work that is liable to expose an employee to a substance hazardous to health to be carried out unless a suitable and sufficient risk assessment has been made of the risk to health of employees, and other persons. The assessment must be made prior to exposure to any hazardous substance (refer to Appendix 1). The following factors must be taken into consideration when conducting a COSHH risk assessment for each substance (or group of substances): Possible harmful health effects (risks) Its form and quantity How it is stored and handled How it is used and transported Control measures to be implemented How it is disposed of Risks are evaluated using the Trust s risk grading matrix (see appendix 8) COSHH risk assessments should be reviewed on an annual basis or sooner if the assessment is deemed invalid (this is recommended by the Trust as good practice, however, in accordance with the Regulations assessments need only be reviewed and updated every five years unless there are any significant changes to work practices or the assessment becomes invalid). COSHH risk assessments must be communicated to employees and a copy of each assessment kept in the ward or department in an easily accessible location. A copy should be forwarded to the Health & Safety Risk Manager COSHH Policy March 2013 Version 3 Page 9 of 29

10 and to the Occupational Health Manager, where health surveillance may be indicated. When carrying out the COSHH risk assessment reference should be made to the list of symbols, abbreviations, risk and safety phrases described within the Chemicals (Hazard Information and Packaging for Supply) Regulations known as CHIP 4 or CHIP).This list can be found on the HSE website (refer to section 8.2 for link) and the TrustNet. COSHH Inventory An inventory of hazardous substances used in the ward or department must be kept and updated as necessary and at least annually (refer to Appendix 2). The COSHH inventory should be made available to employees and a copy kept in the ward or department. A copy should be forwarded to the Health & Safety Risk Manager, in order that the central record of all known hazardous substances in use across the Trust can be maintained. Guidance for completing COSHH risk assessments and inventories is available from the Health & Safety Risk Manager and Occupational Health Manager. COSHH training sessions are provided regularly (refer to section 9.6 and to the Risk Management & Clinical Governance annual training programme available on the TrustNet). 5.2 Control Measures (Risk Reduction) The department manager must ensure that the exposure of employees and others to substances hazardous to health is either prevented, or where this is not reasonably practicable, adequately controlled. Prevention of exposure must be attempted in the first place. This can be achieved by removing the substance, substituting it with a less hazardous one or using it in a less hazardous form. It also includes ensuring hazardous substances are securely stored and locked away when not in use (either in a locked cupboard or in a lockable room) Other control measures include enclosing the process, isolating employees, use of extract and ventilation equipment, general ventilation and the use of safe systems of work. Hazardous substances must be appropriately stored (refer to MSDS) and secure. Hazardous substances must be locked away at all times when not in use (either in a locked cupboard or in a room which is locked) Personal protective equipment (PPE) must be used in conjunction with other control measures: the use of PPE is an important secondary control measure. Control measures implemented by managers must be correctly used and maintained to ensure optimal control of hazards. This could include equipment, which requires regular testing, for example, local exhaust ventilation equipment should be tested at least every 14 months. Testing procedures and results should be recorded in writing and filed in the department. Guidance regarding control measures is available from the Health & Safety Risk Manager, Infection Control Lead Nurse and the Occupational Health Manager. COSHH Policy March 2013 Version 3 Page 10 of 29

11 5.3 Health Surveillance Department managers must ensure that employees who are exposed to substances hazardous to health are made known to the Occupational Health Department so a base line assessment can be carried out. The Occupational Health Adviser carries this outwhen the employee starts working for the Trust. Regular health surveillance will be arranged where appropriate. The Occupational Health Manager should be notified by the department manager when a new substance hazardous to health, which requires health surveillance, is introduced and the relevant MSDS and completed COSHH risk assessment provided to them. Health surveillance may involve tests such as lung peak flow, skin checks and blood tests, which are carried out at regular intervals to minimise the risk of potential ill health effects. The effects of some substances on the body cannot be measured by health surveillance and it is the manager and employee s responsibility to be aware of this and monitor potential side effects and report them promptly to the Occupational Health Department. Types of health surveillance include: Respiratory Skin Latex Sensitivity Biological Monitoring. Substances for which health surveillance is required: Lead Ionising Radiation Isocyanates Chemicals Wood dusts Biological Agents (blood & body fluids) Employees required to undergo a skin health surveillance programme (new programme following HSE Inspection): Those known to be working in an environment where exposure to occupational skin irritants/allergens could be possible; especially those with a history of atopic eczema or a past history of work-related skin disorder Records of health surveillance will be retained by the Occupational Health Manager for 40 years after the last entry. 5.4 Monitoring Monitoring is carried out to ensure adequate control of exposure of employees to substances hazardous to health and to comply with legislation. There are different types of monitoring processes: Environmental Monitoring Workplace monitoring may be required to check the level of certain substances in the atmosphere. This is not necessarily carried out in-house but where circumstances indicate the necessity for such monitoring this may be organised through the Health & Safety Risk Manager, who can instruct an appropriately qualified Occupational Hygienist or Environmental Consultant to undertake this function. Records of COSHH Policy March 2013 Version 3 Page 11 of 29

12 monitoring should be maintained by the department Manager, and must be available for inspection at any time. The Health & Safety Risk Manager will maintain records of environmental monitoring for 5 years. Personal Monitoring Personal monitoring of employees exposed to substances hazardous to health may be required: Where failure or deterioration of the control measures could result in a serious health effect To ensure that a Workplace Exposure limit (WEL) is not exceeded As an additional check on the effectiveness of any control measure The Occupational Health Manager will maintain records of any personal monitoring for 40 years after the last entry. 5.5 Spillage and Emergency Procedures Spillage As part of the information and training given to employees handling hazardous substances at work, spillage and emergency procedures for each substance must be included. Relevant information will be contained in the MSDS, which accompanies all substances covered by COSHH. These are available from the product manufacturer (by contacting them direct or accessing their website). Information may also be found on the container label. The manufacturer s instructions should be followed in all cases to ensure safe management of the spillage. The spillage of some hazardous substances will be via a specific spill kit, for example, mercury, cytotoxic agents, formaldehyde. The manager of the area where such substances are used must ensure they provide the correct type of spill kit appropriate to the substance. The spill kit must be stored in an easily identifiable location and must be easily accessible for use; appropriate information, instruction and training must be given to employee s o how to use the spill kit. Used spill kits must be adequately restocked after each use. All hazardous substances will require a specific procedure to be written; this will either be contained within the spill kit or in the Trusts; Safe Management of Healthcare Waste Policy or Infection Control Guidelines. Reference to these procedures will be found in the local Health and Safety Policy or in the blue Health and Safety file on every ward/department. The department manager must ensure adequate and suitable personal protective equipment (PPE) and/or clothing is available in the case of a spillage of a hazardous substance. Used items must be restocked immediately. Following a spillage of a hazardous substance, an adverse incident form should be completed following the Trust s procedure. The ward/department manager is responsible for carrying out an investigation following the incident and for completing the investigation report. Remedial action identified to prevent a recurrence must be implemented. Feedback should be given to employees regarding the outcome of incident investigations and remedial action. First Aid Appropriate first aid treatment must be administered when necessary following a spillage or contamination from a hazardous substance (details as stated on MSDS). Employees and other people can be treated in the Accident & Emergency Department on Level B; the MSDS should be made available where possible. People COSHH Policy March 2013 Version 3 Page 12 of 29

13 who require first aid treatment for eyes should go straight to the Eye Unit, on level B, where during normal working hours. Employees should document adverse incidents involving hazardous substances on an incident report form and contact the Occupational Health department as soon as possible. Some departments are required to have trained First Aiders and specific first aid equipment. Details are available in the Trust s First Aid Policy (available from the Health & Safety team) and should be described within in the local Health and Safety Policy addendum. Some departments have been identified in the First Aid Policy as requiring first aid equipment. Where relevant, the first aid box/equipment must be clearly marked and be in a prominent position in the department along with details of how to contact the trained First Aider or Appointed Person. 6.0 Training 6.1 Managers Ward Sisters/Charge Nurses and Department Managers where hazardous substances are in use must attend statutory and mandatory (SaM) COSHH training. This is provided by the Health & Safety team (refer to the Risk Management & Clinical Governance annual training programme available on the TrustNet and Trust s Learning & Development Directory). Refresher training is required every three years. Managers must ensure relevant employees are provided with suitable and sufficient training, instruction and information to enable them to carry out their work safely. This should be provided before work with hazardous substances commences, i.e. on induction to the ward or department. Managers must ensure adequate supervision is given to employees where indicated until a satisfactory level of competency is reached. Refresher training must be provided as required. Records of all training will be maintained on the Trust s central training database (OLM) but should also be kept locally. Some formal COSHH training will be provided locally, under the supervision of the health & safety team, for example, within Histopathology, the Clinical Laboratory and Pharmacy department. Named leads for cascade training have been provide with relevant training packages designed by the Health & Safety Risk Manager and are responsible for monitoring training (and refresher training) within their departments. Training will be entered onto the Trust s central training database. 6.2 Employees Employees required to use or handle hazardous substances at work must attend training provided and are responsible for applying knowledge to their area of work. Some training will be provided locally within departments. Managers in conjunction with the Health & Safety Manager and/or Occupational Health Manager are responsible for the provision of relevant information, instruction and training for employees which must include the following: The nature and degree of risks to health The reason for control measures and how to use them correctly Results of any relevant monitoring and health surveillance Employee s duties under the Regulations (refer to Section ). COSHH Policy March 2013 Version 3 Page 13 of 29

14 What precautions to take and when to take them (as described in the risk assessment) How to wear personal protective equipment/clothing correctly and of cleaning methods (where appropriate) or disposal methods (where single use items are used) and the importance of reporting any defects How to carry out correct cleaning, storage and disposal procedures The procedures to be followed in an emergency, i.e. spillage and first aid How to report adverse incidents involving hazardous substances SaM COSHH training is monitored by the Head of Learning & Development. Quarterly compliance reports are provided to the Health & Safety team as well as to all Head of departments. SaM training is also monitored on a monthly basis by subject via Specialty Business Unit (SBU) scorecards. 7.0 Contact Numbers: Health and Safety Department Ext 4547 Occupational Health Department Ext 4545 Infection Control Department Ext 4580 Head of Non-Clinical Risk Ext 4532 Estates Services Department Ext 4174 Waste Manager Ext 4174 Pharmacy Department Ext 4750 Purchasing & Supplies Department Ext Useful Sources of Information: Health & Safety Executive (HSE): Information Line Tel: Fax: hseinformationservices@natbrit.com HSE website: HSE Health & safety laboratory: 8.0 Implementation No action plan applicable as systems already in place. 9.0 Monitoring Compliance with Effectiveness of This Policy Minimum requirement that is to be monitored Monitoring Process e.g. review of incidents/ audit/ performance management Job title(s) of individual(s) responsible for the monitoring and for developing action plan Minimum frequency of the monitoring Name of committee that is responsible for review of the results and of the action plan Job title of individual(s)/ committee responsible for monitoring implementation of the action plan 1. Duties Audit Health and Safety Risk Manager Annually Health and Safety Committee Health and Safety Risk Manager COSHH Policy March 2013 Version 3 Page 14 of 29

15 Minimum requirement that is to be monitored Monitoring Process e.g. review of incidents/ audit/ performance management Job title(s) of individual(s) responsible for the monitoring and for developing action plan Minimum frequency of the monitoring Name of committee that is responsible for review of the results and of the action plan Job title of individual(s)/ committee responsible for monitoring implementation of the action plan (Section 4) Health and Safety Committee 2. How the organisation assesses risks associated with hazardous substances Audit Health and Safety Risk Manager Annually Health and Safety Committee Health and Safety Risk Manager Health and Safety Committee (Section 5.1) 3. How the organisation trains staff, in line with the training needs analysis (Section 6) Audit (To be sent to the Head of L&D to incorporate into a single annual risk management training report) Health and Safety Risk Manager supported by the Head of Learning and Development if necessary Annually Risk Management Strategy Group Health and Safety Risk Manager Risk Management Strategy Group 10.0 Review, Approval and Archiving The policy will be reviewed every 3 years or earlier if legislation, national policy or guidance changes are required to be considered. The review will then be subject to approval and re ratification. The author or Central Policy Officer is responsible for ensuring that archive copies of superseded working documents are retained in accordance with the Records Management: NHS Code of Practice, 2009, refer to Policy Development and Management: including policies, procedures, protocols, guidelines, pathways and other procedural documents. Persons requiring access to an archived policy must contact the central policy officer or the company secretary and provide them with the document title, name of author, ratification date and the version required. In addition, an electronic version of this is available on TrustNet under outdated policies Dissemination and Publication A copy of this policy will be uploaded to the Trust s Central Library (TrustNet) and to the health and safety folder on the shared (g) drive. The Head of Communications is responsible for Trust-wide notification of the revised policy. Clinical Directors, Associated Directors, Specialty Business Unit (SBU s) or supporting services management teams, Ward Managers and Heads of Department in areas where hazardous substances are in use, are responsible for distributing this policy and ensuring employees under their management (including temporary staff and volunteers) are aware of the policy. COSHH Policy March 2013 Version 3 Page 15 of 29

16 12.0 Equality Analysis The author of this policy has undertaken an equality and diversity impact assessment and has concluded there is no impact identified 13.0 Associated Documents 13.1 Trust Documents This policy should be read in conjunction with the following Trust policies/procedures: Trust Health & Safety Policy Local Health & Safety Policies (SBU/Clinical Service/Corporate Service) Incidents & Serious Incidents Management Policy Risk Management Strategy Personal Protective Equipment Policy Infection Control Policies and Guidelines The Safe Management of Healthcare Waste Policy First Aid Policy Latex Sensitisation Policy Dermatitis Policy Trust Fire Policy 13.2 Principal Legislation Health & Safety at Work, etc. Act 1974 Management of Health & Safety at Work Regulations 1999 Control of Substances Hazardous to Health Regulations 2002 (as amended). Hazard Information and Packaging for Supply (CHIP) Regulations 2009 Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995 Regulatory Reform (Fire Safety order) 2005, Article 16 Additional Emergency measures in Respect of Dangerous Substances 14.0 References Control of Substances Hazardous to Health Regulations 2002 (as amended). Hazard Information and Packaging for Supply (CHIP) Regulations 2009 HSE s Guidance Working with Substances Hazardous to health: a brief guide to COSHH ISBN: COSHH Policy March 2013 Version 3 Page 16 of 29

17 Appendix 1 COSHH Symbols International symbols replaced the old style symbols in 2009.Some of them are similar to the old ones, however, there is no single word describing the hazard. The most noticeable feature is the change in the labelling symbols: instead of the hazards symbols with black printing on orange/yellow rectangles, now 9 hazard pictograms with black symbols on a white background with red-rimmed rhombuses are used to provide warnings. The new symbols will eventually replace the old ones and there is a transition period as these will be phased in. The changes have to be completed by December 2010 for substances and by December 2015 for preparations. New International Symbols Hazardous to the Environment (Chemicals that may present an immediate or delayed danger to one or more components of the environment) Acute Toxicity, Fatal, Toxic Gasses Under Pressure Corrosive (Chemicals that may destroy living tissue on contact), Serious Eye Damage Explosives, Self Reactive, Organic Products COSHH Policy March 2013 Version 3 Page 17 of 29

18 Appendix 1 continued Flammable (Chemicals that may catch fire in contact with air, only need brief contact with an ignition source, have a very low flash point or evolve highly flammable gases in contact with water). Oxidising Gases, Liquids or Solids (Chemicals that react exothermically with other chemicals) Caution, Harmful Skim Irritation, Serious Eye Irritation Longer Term Health Hazards Symbols (old) Dangerous to the environment Explosive Substances Oxidising COSHH Policy March 2013 Version 3 Page 18 of 29

19 Appendix 1 continued Extremely Flammable Very toxic Corrosive(Chemicals that may destroy living tissue on contact) Irritant, Harmful or Sensitising(Irritant - Chemicals that may cause inflammation to the skin or other mucous membrane, Harmful - Chemicals that may cause damage to health and sensitising -. COSHH Policy March 2013 Version 3 Page 19 of 29

20 Appendix 2 Managers Guide to COSHH Regulations Step Regulation Requirement Section and Page Number 1 Assess the risks Assess the risks to health from hazardous substances used in or created by your workplace activities his means identifying all hazardous substances in your area, identifying who may be harmed by these substances and deciding what Section 5.1 Page 9 2 Decide what precautions are needed 3 Prevent or adequately control exposure 4 Ensure that control measures are used and maintained level of risk each substances poses. You must not carry out work which could expose your employees to hazardous substances without first considering the risks and the necessary precautions, and what else you need to do to comply with COSHH You must prevent your employees being exposed to hazardous substances. Where preventing exposure is not reasonably practicable, then you must adequately control it. The advice in this policy and information gained through COSHH training will help you to make correct assessments and to put the appropriate controls into place. Ensure that control measures are used and maintained properly and that safety procedures are followed. Managers are responsible for ensuring their staff follow control measures and must take appropriate action where they do don t co-operate. 5 Monitor the exposure Monitor the exposure of employees to hazardous substances, if necessary. Contact Occupational Health if this is indicated on the Materials Safety Section 5.2 Page 10 Section 5.2 Page 10 Section 5.2 Page 10 Section 5.3 Page 11 COSHH Policy March 2013 Version 3 Page 20 of 29

21 Data Sheet (MSDS) Step Regulation Requirement Page 6 Carry out appropriate health surveillance Carry out appropriate health surveillance where your assessment has shown this is necessary or where COSHH sets specific requirements.. Contact Occupational Health if this is indicated on the Materials Safety Data Sheet (MSDS) Number 7 Prepare plans and procedures to deal with with accidents, incidents and emergencies 8 Ensure employees are properly informed, trained and supervised Prepare plans and procedures to deal with accidents, incidents and emergencies involving hazardous substances, where necessary. This means you should have a documented spillage procedure and first aid procedure for hazardous sustances which are easlity accessible to all staff at all times. You should provide your employees with suitable and sufficient information, instruction and training. This should be recorded. Information, instruction and training should be repeated at regular intervals. COSHH Policy March 2013 Version 3 Page 21 of 29

22 Appendix 3 COSHH Control Measures In order of priority (hierarchy according to the COSHH Regulations): 1. Elimination: Eliminate the use of a harmful product or substance and use a safer one. 2. Substitution: Use a safer form of the product, e.g. paste rather than powder, more dilute format or reduce quantity used. 3. Safe Systems of Work: Change the process to emit less of the substance,.change the systems of work which, for instance: identify and define methods of work which: minimise emission, generation or release of substances hazardous to health reduce people s exposure time minimise the number of people exposed 4. Enclosure: Enclose the process and/or handing systems so that the product does not escape, limit the area contaminated if spillage or leakage occurs. 5. Ventilation: Extract emissions of the substance near the source (general or mechanical ventilation). 6. Employee Rotation: Have a minimal number of employees in the location where the hazardous substance is being used as possible or organise different employees to undertake tasks. 7. PPE/RPE: Provide personal protective equipment (PPE) such as gloves, apron, masks, face visor, etc. and respiratory protective equipment (RPE) such as half mask respirators where appropriate to control risk. 8. Facilities for washing, changing, eating and drinking: Facilities should be provided in order to ensure employees meet and maintain a standard of personal hygiene that is consistent with adequate control of exposure, they avoid the spread of substances hazardous to health; and to reduce the risk of ingestion of substances hazardous to health. NB If your control measures include 5, 6 and 7, make sure they all work together. Elimination The first control measure in the prevention of harm from hazardous substances is elimination of it, where possible. Can a safer alternative be sourced? Product manufacturers have a legal requirement to make their product as safe to human health as possible; they may have manufactured a similar product which is equally as effective but is less harmful. Substitution A safer form of the product may be available such as a paste rather than a powder. It may be possible to do things differently and still achieve the same result but using less of the substance. Consider diluting liquids or using less of a substance or using it in a different, less hazardous, way. Safe Systems of Work / Change the Process Managers need to ensure they have documented procedures or protocols which clearly identify systems of work to be followed by employees. The COSHH risk assessment will determine hazards and risks, routes of exposure, etc., which will be taken into consideration when procedures/protocols are written. Enclosure Can the process be enclosed so that the product does not escape and, thereby, affect other people in a neighbouring area? It may be possible to erect a physical barrier or carry out the process in a separate area which affects the least number of people possible. Ventilation Ventilation extracts emissions of the substance near the source; this only applies to substances giving off gasses, vapours, mists, etc. There are different types of ventilation: COSHH Policy March 2013 Version 3 Page 22 of 29

23 Appendix 3 continued General ventilation. This is provided either through opening external windows to allow fresh air to circulate or mechanical ventilation in the areas which provided a specific number of air changes per minute Local Exhaust Ventilation (LEV). LEV can be provided via laminar flow cabinets, scavenging systems or small extraction units which are placed directly adjacent to the process. If local exhaust ventilation is used to control exposure, it needs regular checking and thorough examination and testing at least once a year. Employee Rotation It may be appropriate to rotate employees who are exposed to the hazard thereby minimising duration of exposure to certain personnel. PPE/RPE Personal protective equipment (PPE) is often used as part of control measures. PPE can be disposable or reusable. Please refer to the Trust s PPE Policy for specific guidance. Where PPE is reusable it needs a visual check before each use and should be subject to regular maintenance because, if it fails, it no longer provides protection and exposes the wearer to danger. Where PPE is disposable staff must be advised how to dispose of it correctly. Disposable PPE is usually single use only. Respiratory protective equipment (RPE) may be required to ensure adequate protection of employee s to inhalation exposure. The manager must conduct a comprehensive risk assessment to determine the type of RPE required, taking into consideration the risks, different facial characteristics of the RPE wearers, comfort, and compatibility with other PPE, for example, safety goggles RPE must be CE -marked or HSE-approved; employees must be trained properly in its use and supervised; RPE should be cleaned and checked regularly to ensure that it remains effective. Managers should ensure that the selected face piece (tight and loose-fitting types) is of the right size and can correctly fit each wearer. For a tight-fitting face piece (filtering face pieces usually known as disposable masks, half and full-face masks) the initial selection should include fit testing to ensure the wearer has the correct device. Facilities for washing, changing, eating and drinking These should be sited in a convenient position but situated so that they do not themselves become contaminated. The facilities provided should relate to the type and level of exposure; Changing facilities. These should be provided when PPE/RPE is used or where outdoor clothing could be contaminated by substances hazardous to health. They should be located and designed to prevent the spread of contamination from protective clothing to personal clothing and from one facility to another, and to prevent contamination from getting on to the RPE from other equipment or protective clothing; Facilities for eating, drinking etc. Employees should not eat, chew, drink or smoke in places that are contaminated by substances hazardous to health. This will help reduce the risk of employees ingesting hazardous substances. If employers have to prohibit eating, drinking etc. in certain areas, they should set aside an uncontaminated area or areas where these activities can be carried out. The eating and/or smoking area should be accessible conveniently to the working area and to washing facilities. Managers should ensure that not only are the hygiene measures provided, but also that employees are made aware, through information, instruction and training of why, how and when they must be used. Managers should also ensure through appropriate supervision, that employees use the facilities in accordance with agreed procedures. COSHH Policy March 2013 Version 3 Page 23 of 29

24 Appendix 4 COSHH Risk Assessment Portfolio: SBU/ Service: Ward/Department: Substance Chemical Name: Trade Name(if applicable): Is the Materials Safety Data Sheet (MSDS) available? Yes (Please attach a copy of relevant MSDS) No (Obtain copy from manufacturer via website) Format Solid Liquid Gas Dust Classification Very toxic Harmful Other (describe): Toxic Carcinogenic Corrosive Flammable Irritant Corrosive What is the substance used for? Describe specific location(s) where substance is used Frequency of use/exposure Every day Once per day Several times per day Once a week Once a month or Less frequently Duration of use/exposure on each <1 min More than 1 hour at a time occasion 1-4 mins 1 hour 5-10 mins 15 mins 30 mins Approximate quantity used on each occasion Small (mg s/ml s/g s) Medium (kg s/litres) Large (tonnes) Route(s) of exposure Skin contact Eye Contact Skin absorption Inhalation Likely effects on the body from the substance Approximate number of personnel likely to be exposed to substance Current control measures Ingestion Skin Eyes Respiratory tract Other (describe): Approximate number: Type: Staff Patients Contractors Public Injection (sharps/puncture wound) PPE: Disposable gloves Other PPE (describe): Disposable apron Eye protection Face visor Transportation (describe): Signage Ventilation: General Mechanical Fume cupboard (Continued overleaf) COSHH Policy March 2013 Version 3 Page 24 of 29

25 Servicing of LEV/Fume cupboard (if applicable) Waste disposal-describe arrangements Emergency procedures: Risk evaluation (using Trusts standard risk assessment grading matrix attached) Is Health Surveillance required according to the MSDS Secure storage (locked cupboard/locked room) Segregation/Enclosure of the process Employee rotation Restricted access to area Other (describe): Frequency of servicing: Not applicable Date last serviced: Main drain Main drain but diluted appropriately Clinical waste stream Sharps container Return to Pharmacy or Stores Special/Hazardous waste (via contractor) Other (describe): Is there a documented spillage procedure? Yes No Where is it located? Is there a documented first aid procedure? Yes No Where is it located? Likelihood: Consequence: Overall risk grading: Low Moderate Significant Major (Complete action plan if risks can be further reduced) No Yes (Forward a copy of this risk assessment and the relevant MSDS to the Occupational Health Department) No Yes (Contact Health and Safety Risk Manager) Short-term: Not applicable Is environmental monitoring required according to the MSDS Workplace Exposure Limit (WEL) (if applicable) Long-term: Competency: Describe how relevant staff are made aware of health risks and safety precautions in your ward/department: This risk assessment has been brought to the attention of all relevant employee s? Yes Name of Assessor: Signature: Date: Name of Safety Rep (if appropriate): Signature: Date: Review Dates: 1st year: Manager s Name: Signature: Date: 2nd year: Manager s Name: Signature: Date: 3rd year: Manager s Name: Signature: Date: 4th year: Manager s Name: Signature: Date: This assessment should be reviewed annually or sooner if there is reason to believe it is no longer valid. A copy should be forwarded to the Occupational Health Department and Health and Safety Department For assistance on completing this form, please contact the Health & Safety Department on ext 4547 or the Occupational Health Department on ext 4545 COSHH Policy March 2013 Version 3 Page 25 of 29