APPENDIX 2 Health and Safety Control of Substances Hazardous to Health v2.0 Policy Manager Ian D Scott Policy Group OHSAS Policy Established March 2010 Last Updated March 2012 Policy Review Period/Expiry 2 years/march 2014 This policy does / does not apply to Medical/Dental Staff (delete as appropriate) UNCONTROLLED WHEN PRINTED 1
Version Control Version Number Purpose/Change Author Date 1.0 Version Control was introduced in July 2011 and the previous versions of this policy, prior to this date, are available in the Electronic Document Store. 2.0 Policy due for regular review. Minor amendments made to OHSAS responsibilities and contact details. Change to review period for existing assessments. Assessment form removed from policy document. Policy Approval and Rapid Impact Checklists updated. All assessment forms available on StaffNet or from OHSAS H&S Team. Previous versions of this policy available from OHSAS H&S Team Ian Scott Craig Webster April 2012 2
Contents Page number 1. Purpose and Scope 4 2. Statement of Policy 4 3. Responsibilities and Organisational Arrangements. 4 4. Organisational Structure 7 5. Key Contacts 8 6. Other Relevant Information 8 7. Policy Approval Checklist 9 8. Rapid Impact Assessment 10 3
1. Purpose and Scope NHS Tayside aims to comply with the legal requirements of the Management of Health and Safety at Work Regulations 1999 and therefore the purpose of this policy is to comply in particular with Regulation 3 Risk Assessment which stipulates that every employer shall make a suitable and sufficient assessment of the risks to the health and safety of his employee to which they are exposed whilst they are at work and to persons not in his employment but arising out of or in connection with the conduct by him of his undertaking. Specifically, this policy addresses the fulfilment of the above regulations through the implementation of the assessment requirements detailed in The Control of Substances Hazardous to Health Regulations (COSHH) 2002 as amended. 2. Statement of Policy NHS Tayside attaches the highest importance to the health, safety and welfare of its staff and in particular recognises the significance of COSHH assessment, corresponding control measures and robust record keeping. It is the aim of NHS Tayside that all persons that may have foreseeable exposure to any substance hazardous to health are fully aware of the risks posed and not exposed to unnecessary danger. This policy and associated Guidance have been produced in order to meet this aim. Line managers need to bring this guidance to the attention of those with specific responsibilities for hazardous substances in their work activities. 3. Responsibilities and Organisational Arrangements 3.1.1 CHIEF EXECUTIVE The Chief Executive has overall responsibility for COSHH assessment throughout NHS Tayside, for providing a safe place of work so far as is reasonably practicable, and for the provision of safe and suitable equipment. 3.1.2 DIRECTORS AND GENERAL MANAGERS The Director or General Manager is accountable to the Chief Executive for staff activities and areas under their control. They are required to provide a safe place of work, so far as is reasonably practicable, and to provide suitable and sufficient assessments within the terms of the Management of Health and Safety at Work Regulations 1999 and The Control of Substances Hazardous to Health Regulations (COSHH) 2002 (as amended). They are required to ensure that where applicable, suitable and sufficient COSHH assessments have been conducted for substances hazardous to health and that control measures are implemented and monitored to reduce any risk to as low as is reasonably practicable. 4
3.1.3 CLINICAL SERVICE MANAGERS OR EQUIVALENT The Clinical Service Managers or equivalent are accountable to their respective Directors for the implementation and management of this Policy. They are required to provide a safe place of work as far as is reasonably practicable. They must ensure that detailed COSHH assessments have been conducted for all tasks involving substances hazardous to health and that control measures are implemented, monitored and reviewed and information is communicated to all relevant individuals. 3.1.4 LINE MANAGERS AND SUPERVISORS The Line Managers and Supervisors are accountable to their respective managers for ensuring that the procedures and working conditions are managed to minimise risks to their staff. Line managers are directly responsible for ensuring that recommended control measures are implemented, monitored and reviewed where appropriate. 3.1.5 DEPARTMENTAL COSHH ASSESSORS Departmental COSHH Assessors act on behalf of NHS Tayside Managers. Their role, in conjunction with managers, is a proactive role in risk management. Trained COSHH assessors will undertake assessments and will present their findings to the appropriate line managers using the forms provided on StaffNet or a suitable approved equivalent. 3.1.6 HEALTH AND SAFETY REPRESENTATIVES The Health and Safety Representatives assist and support staff with the process of COSHH assessment and with the implementation of this policy. 3.1.7 ALL STAFF All Staff are responsible for their own safety. Staff must inform their manager if there is any task that they believe to be unsafe, or there is any reason why they may not be able to carry out the task safely. Staff must follow appropriate systems of work and make full and proper use of equipment provided for their safety. Staff must co-operate with the implementation of this policy. 3.1.8 OCCUPATIONAL HEALTH & SAFETY ADVISORY SERVICE(OHSAS) OHSAS will provide appropriate training and support to designated departmental COSHH assessors to enable them to conduct relevant assessments. OHSAS will also provide support to managers in relation to COSHH assessment. Additionally, OHSAS will also be responsible for providing suitable assessment paperwork and making it available through the NHST Docstore and StaffNet or equivalent means 5
3.2 ORGANISATIONAL ARRANGEMENTS 3.2.1 HAZARD IDENTIFICATION Line managers will ensure that adequate numbers of trained COSHH assessors are available to identify hazards, assess the risks and recommend appropriate control measures regarding substances hazardous to health. 3.2.2 RISK CONTROL MEASURES Line managers will ensure that COSHH assessments are reviewed at least every two years, or immediately in the event of a significant change or incident which suggests that it is no longer valid, and will decide what appropriate control measures should be implemented. Control measures may include information, instruction, training, supervision, ventilation equipment, personal protective equipment, policies, procedures, protocols, permits to work etc.. 3.2.3 RISK CONTROL PLANS Clinical Service Managers or equivalent will ensure that plans are established to implement, monitor and review adequate risk control measures. The CSM will forward such plans to the Delivery Unit Risk/Health and Safety management Group or equivalent committee on a yearly basis. 6
4. ORGANISATIONAL STRUCTURE OHSAS EXECUTIVE TEAM SAFETY, GOVERNANCE AND RISK RISK MANAGEMENT PATIENT SAFETY TRAINING AND EDUCATION PATIENT EXPERIENCE KNOWLEDGE MANAGEMENT CLINICAL TEAMS/GROUPS/PARTNERSHIP 7
5. KEY CONTACTS Occupational Health and Safety Advisory Service, T: 01382 346030 Wedderburn House, 1 Edward Street, DUNDEE, DD1 5NS Health and Safety Advisory Team T: 01382 346036 Wedderburn House, 1 Edward Street, DUNDEE, DD1 5NS 6. OTHER RELEVANT INFORMATION INTERNAL GUIDANCE AND ASSOCIATED DOCUMENTS COSHH assessment forms and supporting guidance can be found on the OHSAS pages on NHS Tayside StaffNet and DocStore. Homepage Safe & Effective Working OHSAS Risk Assessment LEGISLATION AND PROFESSIONAL GUIDANCE DOCUMENTS HSE Books (2000). Management of Health and Safety at Work Regulations 1999. Approved Code of Practice and guidance. L21 ISBN 0 7176 2488 9. HSE Books (2009) Working with substances hazardous to health What you need to know about COSHH. INDG136 (rev 4). ISBN 978 0 7176 6363 7 HSE Books (2011) Five Steps to risk Assessment INDG 163 (rev 3) A short guide to the Personal Protective Equipment at Work Regulations 1992 Leaflet INDG174(rev1) HSE Books 2005 (single copy free or priced packs of 15 ISBN 978 0 7176 6141 1) www.hse.gov.uk/pubns/indg174.pdf Clearing the air: A simple guide to buying and using local exhaust ventilation (LEV) Leaflet INDG408 HSE Books 2008 (single copy free or priced packs of 15 ISBN 978 0 7176 6301 9) EH40/2005 Workplace exposure limits: Containing the list of workplace exposure limits for use with the Control of Substances Hazardous to Health Regulations 2002 (as amended) Environmental Hygiene Guidance Note EH40 HSE Books 2005 ISBN 9780717664467 Preventing contact dermatitis at work Leaflet INDG233(rev1) HSE Books 2007 (single copy free or priced packs of 15 ISBN 978 0 7176 6183 1) www.hse.gov.uk/pubns/indg233.pdf Read the label: How to find out if chemicals are dangerous Leaflet INDG352 HSE Books 2002 (single copy free or priced packs of 15 ISBN 978 0 7176 2366 2) www.hse.gov.uk/pubns/indg352.pdf Respiratory sensitisers and COSHH: Breathe freely An employers leaflet on preventing occupational asthma Leaflet INDG95(rev2) HSE Books 1995 (single copy free or priced packs of 15 ISBN 978 0 7176 0914 7) www.hse.gov.uk/pubns/indg95.pdf 8
7. NHS TAYSIDE - POLICY/STRATEGY APPROVAL CHECKLIST This checklist must be completed and forwarded with policy to the appropriate forum/committee for approval. POLICY/STRATEGY AREA: (See Intranet Framework) Health and Safety POLICY/STRATEGY TITLE: Control of Substances Hazardous to Health LEAD OFFICER Ken Armstrong, Director of Operations Why has this policy/strategy been developed? Has the policy/strategy been developed in accordance with or related to legislation? Please give details of applicable legislation. Has a risk control plan been developed? Who is the owner of the risk? Who has been involved/consulted in the development of the policy/strategy? Has the policy/strategy been assessed for Equality and Diversity in relation to:- Race/Ethnicity Gender Age Religion/Faith Disability Sexual Orientation Please indicate /No for the following: To comply with the legal requirements of the Management of Health & Safety at Work Regulations 1999 and the Control of Substances Hazardous to Health Regulations 2002 (as amended) see above - See Management of Health & Safety Policy for details OHSAS H&S Advisors Has the policy/strategy been assessed For Equality and Diversity not to disadvantage the following groups:- Minority Ethnic Communities (includes Gypsy/Travellers, Refugees & Asylum Seekers) Women and Men Religious & Faith Groups Disabled People Children and Young People Lesbian, Gay, Bisexual & Transgender Community Please indicate /No for the following: Does the policy/strategy contain evidence of the Equality & Diversity Impact Assessment Process? Is there an implementation plan? Which officers are responsible for implementation? When will the policy/strategy take effect? Who must comply with the policy/strategy? How will they be informed of their responsibilities? Is any training required? If yes, has any been arranged? Are there any cost implications? If yes, please detail costs and note source of funding Who is responsible for auditing the implementation of the policy/strategy? What is the audit interval? Who will receive the audit reports? Members of Delivery Unit Risk/ Health & Safety Management Group Immediately All managers and staff dealing with hazardous substances Via local line management structures No N/A No N/A OHSAS by agreement with Delivery Unit Risk/ Health & Safety Management Group Annually Members of Delivery Unit Risk/ Health & Safety Management Group When will the policy/strategy be reviewed and by whom? (please give designation) Every two years by OHSAS H&S Team Name: Davina Clark, OHSS H&S Team Leader Date: March 2012 9
8. Rapid Impact Checklist (RIC) Each policy must include a completed and signed template of assessment Which groups of the population do you think will be affected by this proposal? minority ethnic people (incl. gypsy/travellers, refugees & asylum seekers) women and men people in religious/faith groups disabled people older people, children and young people lesbian, gay, bisexual and transgender people N.B. The word proposal is used below as shorthand for any policy, procedure, strategy or proposal that might be assessed. What impact will the proposal have on lifestyles? For example, will the changes affect: Diet and nutrition? Exercise and physical activity? Substance use: tobacco, alcohol or drugs? Risk taking behaviour? Education and learning, or skills? Will the proposal have any impact on the social environment? Things that might be affected include Social status Employment (paid or unpaid) Social/family support Stress Income Will the proposal have any impact on Discrimination? Equality of opportunity? Relations between groups? Will the proposal have an impact on the physical environment? For example, will there be impacts on: Living conditions? Working conditions? Accidental injuries or public safety? Transmission of infectious disease? Will the proposal affect access to and experience of services? For example, Health care Transport Social services Housing services Education people of low income Other Groups: people with mental health problems homeless people people involved in criminal justice system staff What positive and negative impacts do you think there may be Which groups will be affected by these impacts? No Impact on lifestyle No impact on social environment The proposal applies equally to all employees of NHS Tayside Potential positive impacts on working conditions, accidental injuries and public safety and Transmission of infectious diseases There will be no impact on access to services 10
Rapid Impact Checklist (RIC): Summary Sheet Each policy must include a completed and signed template of assessment 1. POSITIVE IMPACTS (Note the Groups Affected) Staff Members of public (patients and visitors) Secure, healthy and safe working environment 2. NEGATIVE IMPACTS (Note the Groups Affected) Staff Members of the public (patients & visitors) Health & safety risks, accidental injury 3. Additional Information and Evidence Required : Contained within policy 4. Recommendations Contained within policy 5. From the outcome of the RIC, have negative impacts been identified for race or other equality groups? Has a full EQIA process been recommended? If not, why not? No. Not relevant for this particular Occupational Health & Safety Policy. Manager s Signature: Date: 11