Health and Safety Practice Guidance Note Control of Substances Hazardous to Health (COSHH) Date issued Issue 1 Oct 12 Issue 2 Nov 15 Issue 3 Jul 16 Issue 4 Dec 16 Issue 5 Jun 17 Planned review Dec 2017 Responsible officer Tony Gray HS-PGN 03 Part of NTW(O)20 Health and Safety Policy Section Content Page No: 1 Control of substances hazardous to health (COSHH) 1 2 Aim 2 3 Responsibilities 2 4 Waste Products 4 5 Risk 4 6 Spillages 4 7 Transport/Vehicles 4 8 Incidents 5 9 Health Surveillance 5 10 Training and Education 5 12 Monitoring 5 13 Key References 5 Forms listed separate to practice guidance note 1 COSHH assessment guidance notes 2 COSHH Inventory 3 COSHH Assessment Form 4 COSHH Assessment Safe working procedure 1 CONTROL OF SUBSTANCES HAZARDOUS TO HEALTH (COSHH) 1.1 Many Substances we use within the care environment are hazardous and have the potential to cause health effects should they be absorbed into the body. Staff are also exposed to Infections or Bio hazards when dealing with direct patient/service user care and the contact with blood and bodily fluids which pose a risk of contracting strains of hepatitis and HIV. 1.2 The Chemical Hazard Information Packaging Regulations (CHIP) require those substances, including cleaning fluids and disinfectants which we use on a daily basis and are described as hazardous, to be provided with hazard data information. 1
1.3 Once a substance has been described as hazardous under the CHIP regulations and classified as Toxic, Harmful, Irritant, Corrosive or Infectious these substances should then be assessed under the COSHH regulations. 1.4 The transportation, use and disposal of substances hazardous to health within the Northumberland Tyne and Wear NHS Foundation Trust premises must be carried out in accordance with this Practice Guidance Note (PGN) and the Unit/Villa, department and community home working procedures. This PGN and procedures must comply with current Health, Safety and Environmental Regulations, and Health Service circulars. 2 AIM 2.1 The aim of this PGN is to provide the Trust with a clear, co-ordinated and safe approach to the handling, storage and disposal of substances hazardous to health. 2.2 The potential benefits of this approach are:- Eliminate the hazardous substance from the workplace Substitute the substance for a safer alternative Totally enclose the area of use to reduce number of persons exposed Partially enclose the area of use, e.g. by using local exhaust ventilation Ensure sufficient general ventilation Reduce exposure time of employees Provide Personal Protective Equipment (PPE) which is assessed and conforms to the appropriate British or European Safety Standard A reduction in the adverse incidents affecting patients/service users, staff, visitors and stakeholders Trust compliance with all relevant regulations/legislation therefore avoiding prosecution. Improved and safer working environment in all Trust premises A reduction in the cost of disposing of waste appropriately Facilitate the use of best practice and development of the service 2.3 This PGN is subject to an annual review, and/or where there has been any legislative change. 3 RESPONSIBILITIES Substances hazardous to health, including purchase, transportation, use and disposal, are ultimately the responsibility of the Chief Executive of the Trust. Responsibilities are cascaded down to each staff member. 2
Unit/Villa managers, departmental heads and team leaders are responsible for ensuring risk assessments are carried out in their area and ensuring their staff are aware of the protective and preventative measures. Unit/Villa managers, departmental heads and team leaders are responsible for ensuring adequate supplies of personal protective clothing and equipment are available and used. Individual members of staff have a responsibility for disposing of waste in accordance with procedures. The Pharmacy Manager is responsible for ensuring adequate systems are identified to remove pharmaceutical waste from Units/Villas and that it is stored safely until removed from site by a registered carrier for disposal. It is the responsibility of the Patient Safety Officers to ensure adequate controls and audits are in place. 3.1 Conducting Assessments 3.1.1 The assessor will require the following paper work to conduct the assessment COSHH Assessment guidance notes COSSH Inventory and assessment paperwork Safe working procedures - blank copy COSHH documentation file COSHH Hazard Data information sheets from the provider/manufacturer 3.2 Data Information 3.2.1 Data information sheets can be obtained from the supplier, Normanton stores, supermarket or manufacturer. It must be noted that many house hold substances such as bleaches and cleaning products have similar chemical ingredients. There fore the data sheets can be used from various manufacturers of a similar product, bleach is bleach is bleach. 3.3 Safe working procedures The procedure will identify what the substance is, A step by step process should be identified on how the substance is going to be used, including precautions to prevent volatile substances coming into contact which could liberate Toxic or noxious fumes. What to do in the event of an emergency spillage, How the substance can be disposed of i.e. through general waste flushed to foul sewerage or disposed of under special waste requirements, the Hazard data sheet will give direction. The procedure will also identify what to do in the event of an accident or exposure to a substance e.g. First aid and seeking medical attention. 3
3.4 COSHH DOCUMENT FILE 3.4.1 Once the assessment has been completed the paper work is added to the COSHH documentation file under Assessment. The Hazard data sheets are filed under Data information and the safe working procedures are added under procedures. All of these documents must be referenced so that the individual assessment is accompanied by the data information and a safe working procedure. 4 WASTE PRODUCTS Waste should be disposed of in a safe and efficient manner, guidance for the disposal of the specific waste items such as General household and Hazardous wastes are detailed in the Trust s Policy, NTW(O)24, Waste Management. The Facilities Management department will provide advice and assistance to managers on the safe disposal of waste material and substances.. 5 RISK ASSESSMENT Unit/Villa managers, departmental heads and team leaders must ensure risk assessments are carried out with regard to all substances which may be hazardous within their sphere of responsibility. The attached guidance note and assessment form should be used to conduct an assessment and then added to the COSHH document file under assessment. All staff must demonstrate competence in procedures that are derived from the risk assessment. The risk assessment will be reviewed on an annual basis or at any time as circumstances change or when a new substance is used within the area. 6 SPILLAGES 6.1 As part of local risk assessments, safe systems to clean spillages of substances hazardous to health will be identified. These assessments should include blood and body fluids, mercury, strong cleaning fluids and any other substances that may be used within the area. Blood Bodily Fluid Spillage kits are available from the supplies department through non stock ordering. Mercury Spill Kits are available from Hospital main receptions and domestic services. 7 TRANSPORT/VEHICLES Hazardous substances must be transported in a safe manner as detailed in the waste management policy and local risk assessments. Risk assessments must be carried out by the facilities management in respect of the transport of all substances. 4
Those substances classified under the Transport of Dangerous Goods Act such as fuel and fuel oils should be transported in suitable containers and have the correct UN labelling. 8 INCIDENTS 7.1 Any serious incident involving a Hazardous substances which has lead to bodily injury must be reported in the first instance by telephone during normal office hours to the Patient Safety Department or point of contact and formally reported as detailed in the Trust s Incident Reporting Procedure. 9 HEALTH SURVEILLANCE The Occupational Health Department provides a health surveillance service. Any request for the service should be forwarded to the Personnel Department in writing. The request should include a detailed report of the problem and all supporting information. 10 TRAINING AND EDUCATION 10.1 In order to fully comply with its responsibilities regarding the safe and efficient handling of waste without risk to health the Trust places great emphasis on the training and education of its entire staff involved in the processing of waste and in particular clinical waste. Line managers will ensure appropriate training and education is given to all waste handlers commensurate with their involvement. This will include regular updates/refresher training. All new staff must be made aware of this PGN as part of their induction. All new and re-deployed staff must be given a practicable demonstration in the handling, use, transportation and disposal of all substances as detailed within the local risk assessments. All staff must attend COSHH awareness training. 11 MONITORING The respective Group/Directorate Patient Safety Advisor will monitor risk assessments on an annual basis. Incident investigations and remedial action will be monitored by the head of the respective Group/Directorate. Training attendance will be monitored by the head of the Group/Directorate. 12 KEY REFERENCES 12.1 The following references should be used when deciding precautions within the risk assessment process: Health and Safety at Work Act 1974 Management of Health and Safety at Work Regulations 1992 5
Health and Safety Personal Protective Equipment Regulations 1992 Control of Substances Hazardous to Health Regulations 1999 Chemical Hazard and Information Packaging Regulations 1996, Environmental Protection Act 1990, NTW(O)24 - Waste Management Policy NTW(C)23 - Infection Prevention Control Policy V2 6