CONTROL OF SUBSTANCES HAZARDOUS TO HEALTH (COSHH) POLICY AND PROCEDURE

VERSION NUMBER REVIEW APPROVAL HISTORY Two December 2008 Central Health and Safety Committee 18th October 2005 Board 8th December 2005 DISTRIBUTION RELATED DOCUMENTS PCT-wide Transportation of Oxygen Spillage of Hazardous Chemicals or Substances (including Mercury) Lindsey Plumb, Health and Safety Advisor 01225 831877 lindsey.plumb@banes-pct.nhs.uk Version One; Control of Substances Hazardous to Health (COSHH) Policy and Procedure. The main changes are; The responsibility for identifying hazardous substances lies with the departmental manager who may choose to delegate the assessment role. The assessment tool is more structured to lead the assessors through the assessment process. The assessment is to be carried out for each substance and each work activity. All identified hazardous substances to be notified to the Health and Safety Advisor for inclusion on the PCT-wide COSHH database. A COSHH folder including all relevant Material Safety Data Sheets and risk assessments must be available for reference in each department. website address: www.coshh-essentials.org.uk

AUTHOR/FURTHER INFORMATION

THIS DOCUMENT REPLACES

OTHER NOTES IMPLEMENTATION PLAN

Local cascade by managers; Managers and nominated COSHH assessors to undertake the COSHH training provided by the PCT. All new staff receive COSHH awareness training at Core Induction. Ensure all staff are aware of Policy Review current practice in line with Policy Identify all potentially hazardous substances in the department carry out an initial risk assessment using the template Inform the Health and Safety Advisor of the substances and the assessments.

Page 1 of 16 Issue 2 / December 2005 Review: December 2008

H&S Manual Control of Substances Hazardous to Health (COSHH)

1 1.1 2 2.1 2.2 2.3 2.3.1 2.4 2.5 3 4 4.1 4.2 4.3 4.4 4.5 4.6 4.7 5

Introduction Statement of Commitment Responsibilities The Chief Executive and Board Responsibilities The Manager's Responsibilities The Employees Responsibilities Additional responsibilities for employees that purchase substances Health and Safety Advisor Responsibilities Non-PCT employees working on PCT sites Risk Assessment Control Measures Safe Systems of Work Maintenance Personal Protective Equipment Information, Instruction and Training Health Surveillance Storage and Signage Emergency Procedures References and Relevant Legislation Initial COSHH Assessment Guidance for completing the Initial COSHH Assessment

Page 2 of 16 Issue 2 / December 2005 Review: December 2008

H&S Manual Control of Substances Hazardous to Health (COSHH)

1.

Introduction

The Control of Substances Hazardous to Health (COSHH) Regulations 2002 (as amended) is intended to prevent workplace disease and illness resulting from exposure to hazardous substances. The Regulations introduce a control framework by requiring an adequate assessment of the risks to health arising from work activities associated with hazardous substances - the introduction of adequate control measures, maintenance of the measures and equipment associated with them, monitoring of the effectiveness of the measures and the health of employees. Using hazardous substances can put people's health at risk. COSHH requires employers to control exposure to hazardous substances to protect both employees and others who may be exposed from work activities. The Regulations apply to a wide range of substances and preparations with the potential to cause harm if they are inhaled, ingested, injected or absorbed through the skin. Substances hazardous to health occur in many forms: o o o o o o o o Dusts Liquids Vapours Gases Mists Fibres Solids Smoke

Any substance used, produced or that employees are exposed to in the workplace should be assessed under COSHH Regulations to determine whether there is a potential harmful effect. Substances that MUST be assessment under COSHH Regulations are; Any substance or mixtures of substances classified as dangerous and carry warning labels such as Toxic, Very Toxic, Harmful, Corrosive, Irritant, Sensitizing or Carcinogenic; Any substance with a Workplace Exposure Limit. Any biological agent (bacteria, blood and other micro-organisms); Radioactive materials Asbestos Lead and lead products Materials hazardous due to their flammability only Substances used for medical treatment (risk to patient is excluded but the risk to employee is included)

Certain materials are excluded from COSHH but are covered by their own Regulations:

1.1

Statement of Commitment

It is the intention of Bath and North East Somerset PCT (BANES PCT) to fulfill its statutory and mandatory obligations by complying with all relevant legislation and guidance. By doing so, BANES PCT aims to ensure so far as is reasonably practicable, the safety of all persons on its premises from the risks to their health from hazardous substances.

Page 3 of 16 Issue 2 / December 2005 Review: December 2008

H&S Manual Control of Substances Hazardous to Health (COSHH)

2. 2.1

Responsibilities The Chief Executive and Board Responsibilities

While ultimate responsibility is vested in the Trust Board, executive responsibility is delegated to the Chief Executive for managing health and safety. Compliance with this policy will be achieved by: Systematic identification and assessment of risk. Allocating appropriate resources to achieve reduction in risk, so far as is reasonable practicable. Implementation of effective control measures.

2.2

Manager's Responsibilities

Managers have the responsibility to ensure that All hazardous substances used, produced or that the department is exposed to have been identified, and that the Health and Safety Advisor is aware of these substances. Risk assessments have been carried out for each hazardous substance and work practice. Risk assessments are documented and are available, along with the Materials Safety Data Sheets (MSDS) for reference in the department. Control measures and safety procedures identified in the risk assessment are rigorously followed. To discipline if the risk assessment is not being followed. Health surveillance (i.e. occupational health referrals) is carried out when there is any unplanned exposure to hazardous substances. A PCT Adverse Event Reporting form is completed for any unplanned exposure to hazardous substances. All employees receive appropriate information, instruction, training and supervision as required so that they are aware of the risks to health created by their exposure to hazardous substances and the precautions that must be taken. Specific information on potentially hazardous substances should be included in the local induction of new staff. Managers who appoint contractors (including Facilities and Estates Department and IT Department) must ensure that this requirement is included in the specification document produced and disseminated to potential contractors as part of the tender/ selection process. The Employees Responsibilities

2.3

All employees have the general duty to co-operate with the PCT to ensure that it meets the legal responsibilities detailed in the Health and Safety at Work Act 1974 and the COSHH regulations. These duties are to ensure that: Employees must attend health and safety training as required by legislation and by PCT policies. Hazards and risks are reported to their manager. Including any health symptoms arising from their work with materials/substances. Control measures and safety procedures identified in risk assessments and safe systems of work are followed.

Page 4 of 16 Issue 2 / December 2005 Review: December 2008

H&S Manual Control of Substances Hazardous to Health (COSHH)

2.3.1

Additional responsibilities for employees that purchase substances

As well as the general employees responsibilities, employees that purchase substances have additional responsibilities. These are to ensure that: any substance that has not been purchased by the department previously is identified to the Health and Safety Advisor to be entered on the central COSHH database. The supplier of the substance provides a Material Safety Data Sheet (MSDS) for the substance.

2.4

Health and Safety Advisor Responsibilities

The PCT Health and Safety Advisor has the responsibility to ensure that: The PCT is compliant with the COSHH Regulations in that assessments have been undertaken for hazardous substances used, produced or that the employees of the PCT are exposed to. There is an investigation of all reported adverse events involving substances hazardous to health. Advice is given to all members of staff with COSHH responsibilities; COSHH awareness training is provided during PCT Core Induction for all staff. A central database of substances is kept up-to-date and that departmental managers have access to information required to carry out COSHH assessments.

2.5

Non-PCT employees working on PCT sites

There is a requirement for contractors to supply the PCT with information on the work they are carrying out. This must include informing the PCT of their intention to use any hazardous substances on PCT sites. Managers who appoint contractors must ensure that this requirement is included in the specification document produced and disseminated to potential contractors as part of the tender/ selection process. In such cases the contractor should supply a MSDS and up to date risk assessment for the task/process and include within this, where appropriate, where service users and staff are exposed to risk. Activities that may generate harmful substances, i.e. dust, fumes etc, shall likewise be fully assessed prior to commencement of work. Any service providers working in PCT sites, under Service Level Agreements must inform the PCT of their intention of using any hazardous substance in their activities prior to commencement of work. This information should be provided to the PCT Health and Safety Advisor and the Facilities and Estates Manager (if appropriate) before any works commence.

Page 5 of 16 Issue 2 / December 2005 Review: December 2008

H&S Manual Control of Substances Hazardous to Health (COSHH)

3.

Risk Assessment

The COSHH assessment must be undertaken by a competent person who is familiar with the systems of work within the area being assessed. It may be necessary to undertake more than one assessment for each area e.g. an assessment for nursing activities and another for housekeeping activities. It is the responsibility of managers of the PCT to ensure that a COSHH assessment is undertaken for their areas of responsibility and their assessment documentation is kept up-to-date. Where there are no substances hazardous to health within this area this must be clearly noted. The MSDS plays a vital role when completing COSHH risk assessment as it provides key information on the hazardous substance, which is used to help identify control measures required. It is important to understand that they are not a replacement for the risk assessment procedure. Assessment includes: Identification of all hazardous materials within the area. Identifying the level of risk these materials pose. To arrive at this conclusion with will be necessary to consider: How much of the substance is used; The nature of the hazardous substance; What the routes of entry are; The persons at risk of exposure; What the substances potential hazards are; What the substances potential ill health effects are; Emergency arrangements; Existing precautionary control measures; Further precautionary measure that may be required If there is no risk to health or the risk is trivial, no more action is needed. If there are health risks, then the manager must consider what else needs to be done to comply fully with COSHH requirements. Assessments must be undertaken when a new substance is used in the workplace that is classified as a substance hazardous to health. The original assessments state when a review should take place i.e. annually; there has been a change in the work procedure; the substance is used for a different task; the substance used is changed, i.e. manufacturer or concentration; the HSE issue guidance relating to the substance or work activity; Following any adverse event involving the substance or work activity.

Page 6 of 16 Issue 2 / December 2005 Review: December 2008

H&S Manual Control of Substances Hazardous to Health (COSHH)

4.

Control Measures

All control measures must perform as intended and continue to prevent or adequately control the exposure of employees to substances hazardous to health. This includes correcting as soon as possible any defects found in the controls which could result in reduced efficiency, effectiveness or levels of protection for employees. Department managers shall be responsible for implementing effective safety management systems for the prevention and control of exposure to hazardous substance in their work areas. The following is the preferred hierarchy of control measures which should be considered: Elimination Substitution Isolation Reduction (time of exposure / numbers of employees exposed) Enclosure (partial or fully) Safe Systems of work Housekeeping Information/Instruction Person Protective Equipment

Employees are required to make full use of all the control measures and to report any defects and managers must take all reasonable steps to ensure that they do so.

4.1

Safe Systems of Work

Safe Systems of Work shall be documented and implemented for all work activities and shall include good hygiene practice, safe handling and disposal procedures. Employees must be trained and supervised in the systems to maintain safety for themselves and others who may be affected by the work. All control measures must be followed and defects reported promptly to managers or Facilities Department.

4.2

Maintenance

All equipment used for the control of hazardous substances shall be tested and maintained in accordance with regulations and approved codes of practice and maintenance records are to be kept. Testing includes visual checks, inspections, servicing and remedial work and where appropriate, correction of working practices. Maintenance means any work carried out to sustain the efficiency of control measures, not just work carried out by maintenance workers. These documents must be recorded and copies maintained. For Local Exhaust Ventilation (LEV), including fume cupboards and ventilated endoscope washers, examinations must be made at least every 14 months and will normally be undertaken by arrangement with Facilities Department or a specialist contractor. Respirators must similarly be examined, kept clean and, where appropriate, tests carried out to demonstrate their effectiveness.
Page 7 of 16 Issue 2 / December 2005 Review: December 2008 H&S Manual Control of Substances Hazardous to Health (COSHH)

4.3

Personal Protective Equipment

Personal Protective Equipment shall be provided as a last resort measure following all other control options and shall be regularly inspected with records kept. Staff shall receive instruction and training in the correct usage, storage and maintenance of the personal protective equipment issued to them. Re-useable personal protective clothing must be allocated clean and safe storage space with personnel marking for hygiene reasons. Disposable or single use personal protective clothing should not be reused. Re-useable personal protective clothing should be kept clean and be inspected as required according to manufacturers guidelines. All personal protective clothing will be provided by the Trust free of charge. Personal protective clothing will be selected to ensure that it does not hinder the member of staff in carrying out tasks.

4.4

Information, Instruction and Training

Wherever employee are exposed to hazardous substances they must receive whatever information, instruction and training is required so that they are aware of the following: The risks to health created by their exposure; The precautions which should be taken; Control measures, their purpose and how to use them; How to use and store all personal protective equipment provided to them; The results of any exposure monitoring and health surveillance; The results of environmental monitoring carried out; Emergency procedures.

In conjunction with the completion of departmental risk assessments the need for information, instruction and training must be considered and appropriate arrangements made. All information, instruction and training should cover the principles of exposure, control measures to be used and the consequences of failure. A basic awareness of the principles of COSHH is covered in the PCT Core Induction program, PCT COSHH training is mandatory for some staff groups and should be updated as required on the PCT Training Matrix. Specific training and instruction for individuals should be updated as identified by the risk assessment. The training should cover the principles of exposure, the control measures to be used and the consequences of failure specific to the location. Advice can be sought from the Health and Safety Advisor. Where the employees of other departments or contractors may be affected, appropriate channels of communications must be established to ensure they are properly informed.

Page 8 of 16 Issue 2 / December 2005 Review: December 2008

H&S Manual Control of Substances Hazardous to Health (COSHH)

4.5

Health Surveillance

Routine surveillance of an individuals health must be undertaken when it is warranted by the degree of exposure and the nature of the effects. Health surveillance for those regularly using substances that pose a risk to health should be undertaken by the Occupational Health Department. Any health surveillance will be determined by the Risk Assessment and the responsible manager or supervisor should contact Occupational Health Department. Where there is substantial exposure to skin irritants, the regular checking of hands and forearms should be considered for early detection of dermatitis. Where health surveillance is provided, records shall be kept in a suitable form for at least 40 years, by the Occupational Health Department. Where employees are exposed to materials with possible long-term effects (such as sensitisers or carcinogens) a note of the fact should be attached to their personnel records. Where health surveillance is needed a health record must be established for each individual containing particulars approved by the Health and Safety Executive (HSE) and held for at least 40 years. Advice on all health surveillance matters should be sought from the appropriate Occupational Health Department: Royal United Hospital (01225 824064) and for staff working in the Specialist Learning Difficulties Service: Southmead Hospital (0117 9595499).

4.6

Storage and Signage

All substances identified as hazardous to health shall be stored in accordance with approved codes of practice or official guidance. Appropriate hazard signage shall be provided on all storage areas and containers where a risk has been identified.

4.7

Emergency Procedures

Emergency procedures shall be established for limiting the extent of health risks and to regain adequate control in the event of leakage, spill or uncontrolled release of any hazardous substances. The MSDS and manufacturers instruction provides appropriate information on the emergency procedures required for the substance and written arrangements should be in place which refers specifically to the departmental issues needing to be considered when an emergency occurs. All staff in the department must be aware of the measures to be taken in event of a spillage.

5.

References and Relevant Legislation

The Health and Safety at Work Act 1974 The Control of Substances Hazardous to Health 2002 and Approved Code of Practice The Management of Health and Safety at Work Regulations 2002 and Approved Code of Practice The Personal Protective Equipment at Work Regulations 1992 Chemicals (Hazard Information and Packaging Supply) Regulations 1996 (CHIP) EH40. Published by HSE.

Page 9 of 16 Issue 2 / December 2005 Review: December 2008

H&S Manual Control of Substances Hazardous to Health (COSHH)

This page is intentionally blank

Page 10 of 16 Issue 2 / December 2005 Review: December 2008

H&S Manual Control of Substances Hazardous to Health (COSHH)

Control of Substances Hazardous to Health - Procedure and Guidance

Step One Substance Inventory Managers and/or nominated COSHH Assessors identify all potentially hazardous substances in the work environment. Record on departmental substance inventory Step Two COSHH Assessment Carry out the COSHH Assessment for each substance and work activity identified in the substance inventory. Record the reference number from the substance inventory created in Step One to cross reference the assessments. The following should be considered when carrying out the COSHH Assessment: The Investigate alternative substances, could an alternative substance substance; be used? Has this substance been used before or elsewhere in the PCT? Request information on existing risk assessments from H&S Advisor Are there any fire risks associated with storage of the substance? i.e. Specific storage facilities, notification to fire advisors or specialist signage How would the substance have adverse effects on people? i.e. Asthma, dermatitis, watering eyes etc. The work How is the substance used? A COSHH Assessment should be activity undertaken for each work activity. Who would be affected and how many people would be affected during normal use of the substance? Control Investigate alternative substances, could an alternative substance Measures be used? General precautions and special precautions for the use of the substance i.e. ventilation of the area, minimizing people exposed, timing of work activity, personal protective equipment Control measures to be used in emergency situations i.e. spillages, contact with substance, fire, inappropriate use of substance, inappropriate person accessing substance Emergency What first aid provision is available? Where is the nearest point for Arrangements: first aid assistance? Consider specific risks associated with lone workers. Persons working on their own, but in busy departments i.e. Hotel Services Assistants as well as other lone workers i.e. Health Visitors Risk Scoring Using PCT Risk Scoring Matrix to identify the severity, probability and colour risk category for the substance and work activity. Record the allocated risk colour on the substance inventory. Step Three Communication Communicate the hazards, risks and control measures to the department. Ensure that the MSDS and the initial COSHH Assessment for each substance are available for reference in the department. Step Four Inclusion in PCT COSHH Database Forward copies of the initial COSHH Assessments to the Health and Safety Advisor for inclusion in the PCT COSHH database. Step Five Review the Assessment Review the assessments as identified in the initial COSHH Assessment and PCT Policy.
Page 11 of 16 Issue 2 / December 2005 Review: December 2008 H&S Manual Control of Substances Hazardous to Health (COSHH)

Step One - COSHH Substance Inventory Department

Ref Name of No. Substance Common Name
(If different)

Manufacturer
(where applicable)

Work Activity

Assessment undertaken?

Colour Risk Category

Page 13 of 16 Issue 2 / December 2005 Review: December 2008

H&S Manual Control of Substances Hazardous to Health (COSHH)

Page 14 of 16 Issue 2 / December 2005 Review: December 2008

H&S Manual Control of Substances Hazardous to Health (COSHH)

Substance Reference No.

Step Two - COSHH Assessment

This assessment is to be kept for reference in the department. A copy of the relevant Material Safety Data Sheet should be kept with this assessment (where applicable). Name of Date of Date of Assessor Assessment Review The Substance Name of Common Name (If different) Substance Manufacturer Catalogue Number
(where applicable) (where applicable)

Type of substance Size of container

Solid < 1litre/kg

Liquid 1-5 liters/kg Yes

Gas 6-10 liters/kg

Vapor >10 liters /kg

Other please specify Other please specify

Is the substance decanted? Hazard symbols on the container label.

No

Size of second container

Other please specify

Possible entry route

(tick all that apply)

Inhaled No

Ingested Yes

Absorbed by skin

Eyes

Other please specify

Alternative substance available? Describe the work activity

Alternative substance and reasons for not using

The Work Activity

Method of use People & no. of people who may be affected.

Page 15 of 16 Issue 2 / December 2005 Review: December 2008

Diluted Patients <5

Undiluted Staff 6-10

Other please specify Visitors 1115 16-20 Others > 20

H&S Manual Control of Substances Hazardous to Health (COSHH)

Storage Arrangements

Control Measures Max. stored in Max. stored on department site Special storage considerations i.e. well ventilated, secure

General Precautions

Wash hands before use Wear PPE (see

below)

Wash hands Two people after use present Other please specify

Well-ventilated area

Special Precautions

Personal Protective Equipment (PPE) for general use for use in emergency/spill situation

Gloves

Eye Protection

Dust Mask

Respirator

Safety Footwear

Apron

Lab coat

Gas Mask

Visor

Other please specify

Emergency Arrangements First Aid General Eyes Skin Ingestion Spillage

Disposal

Severity Probability Risk Category Entry onto Risk Register

Risk Scoring (using PCT Risk Scoring Matrix) Minor Moderate Major Catastrophic No Harm Low Moderate High Certain Unlikely Moderate Risk Significant Risk High Risk Low Risk (Yellow) (Orange) (Red) (Green) Yes Directorate Risk PCT Risk Register No Register
H&S Manual Control of Substances Hazardous to Health (COSHH)

Page 16 of 16 Issue 2 / December 2005 Review: December 2008