Control of Substances Hazardous to Health (COSHH) Operating Standards

Control of Substances Hazardous to Health (COSHH) Operating Standards

CONTENTS 1. Background... 3 2. Aim... 3 3. Definitions... 3 4. Details... 4 4.1 Management of COSHH... 4 4.1.1 Risk Register.... 4 4.1.2 Record of assessments... 4 4.1.3 Risk Assessments... 5 4.1.4 Reasonable Adjustments... 5 4.1.5 Controls... 5 5.1.6 Storage and Signage... 5 5.1.7 Spillage & Disposal... 6 5.1.8 Training... 6 5.1.9 Arrangements for Securing the Health and Safety of Workers... 6 5.1.10 Procedures for Dealing with Health and Safety Issues... 6 5. Support and Additional Contacts... 7 6. Responsibilities... 7 7. Appendix 1 COSHH Risk Assessment... 8 Appendix 2 COSHH Risk Assessment Flow Chart... 12 Appendix 3 Hierarchy of Control Measures... 13

These Operating Standards are mandatory for all staff and managers to follow. 1. BACKGROUND The Health and Safety at Work etc Act 1974 and the Control of Substances Hazardous to Health (COSHH) Regulations 2002 (as amended) impose obligations upon Derbyshire Community Health Services NHS Foundation Trust (Trust) to ensure the health, safety and welfare of patients, service users, employees, visitors, contractors, members of the public and any person who may be affected by the organisation s activities. These Operating Standards do not cover Lead (Control of Lead at Work Regulations 1998) Ionising Radiation Regulations 1999 Ionising Radiation (Ionising Radiation (Medical Exposure) Regulations 2000 Asbestos (Control of Asbestos at Work Regulations 2006) Any substance that is a risk to the health of a person to whom the substance is administered in the course of a medical treatment by a registered medical practitioner, registered dentist or appropriate practitioner under section 58 of the Medicines Act. 2. AIM The purpose of these Operating Standards is to ensure that all employees and other persons affected by the Trusts activities are protected where reasonably practicable from exposure to any substance within the workplace that may be hazardous to health or ensure it is adequately controlled. 3. DEFINITIONS The definition of a substance hazardous to health is given in Regulation 2 of the COSHH regulations and covers virtually all substances capable of causing adverse effects or disease arising out of work activities. These are classified below: a) chemicals classified under CHIP 4 which is the name for the Chemicals (Hazard, Information and Packing for Supply) Regulations 2009 as very toxic, toxic, harmful, corrosive, irritant, sensitising, carcinogenic, mutagenic or toxic to reproduction b) substances for which the Health and Safety Executive has assigned a Workplace Exposure Limit (WEL), in line with the European Commission s third Directive on Indicative Occupational Exposure Limit Values (2009/161/EU)1 c) a biological agent, which includes micro-organisms, bacteria, viruses, parasites and microscopic infectious forms of larger parasites d) any dust at a substantial concentration in the air e) any substance not in any of the above but has a comparable hazard to health. Biological agents are substances for the purposes of COSHH if: a) there is a deliberate intention too work with the agent eg in a laboratory b) exposure arises out of a work activity eg body fluid spillage or needle stick. 3

4. DETAILS 4.1 Management of COSHH The Trust will ensure that a record of the Assessment and a copy of the Material Safety Data Sheet is kept at the location where the substances are being stored or used. 4.1.1 Risk Register Once completed the master copy of the COSHH assessments must be kept on file within the area where the substance is being used. The Staff Health & Safety Team must be informed of any High or Extreme Risks as soon as possible. 4.1.2 Record of assessments The COSHH regulations are specific in what records need to be kept and for how long, that an assessment of all substances are carried out prior to use, using the Trust s COSHH Risk Assessment From, (Appendix 1) following the assessment Flow chart, (Appendix 2) and the Hierarchy of Controls, (Appendix 3). The Trust acknowledges that under the provisions of COSHH, the following formal documentation should be kept: a) inventory of hazardous substances b) assessments of risk and exposure levels c) any control measures that have been provided d) methods of use of control measures, and defect/fault reporting e) examination, testing and repairing of any Personal Protective Equipment (PPE) or equipment provided as a control measure. Either the record itself or a summary must be kept for a minimum of five years. Refer to PPE Guidance. f) background exposure and control proving record, must be kept for a minimum of five years and for 40 years if a record of exposure of an identifiable member of staff g) individual health record or incident report, of exposure or potential exposure, must be kept for 40 years from date of last entry h) training given to members of staff. Although COSHH specifically requires records of e, f and g above, other items (a, b, c, d and h above) will also be needed to demonstrate full compliance. 4

4.1.3 Risk Assessments COSHH Risk assessments will be carried out in accordance with the Trust s Health & Safety Risk Assessment Policy, using the Trusts COSHH Risk Assessment From, (Appendix 1) following the assessment Flow chart, (Appendix 2). COSHH risk assessments will be undertaken on a departmental basis and executed by a trained risk assessor. Any other employee or other person who, by virtue of their specialised skills or particular competence, may contribute to the suitability and sufficiency of the assessments and any Safety Representative who represents the employees within the department or area of work where an assessment is being undertaken. 4.1.4 Reasonable Adjustments It may be necessary to ensure the safety of persons with Protected Characteristics that reasonable adjustments need to be made to the working practices. In making reasonable adjustments priority must be given to the safety of the employee and where necessary the employee must be moved to a safer working environment. 4.1.5 Controls Other types of hazards such as dust, fume, vapour, mist and spray are also subject to control under COSHH. The Trust will ensure that reasonably practicable Control Measures are implemented to reduce contamination levels in the employees breathing zone ie local exhaust ventilation (LEV) Where LEV is used there will be a procedure to ensure correct maintenance and compliance with manufacturers recommendations are adhered to. For dusts and a wide range of specified substances, limits to exposure known as Workplace Exposure Limits (WELs) have been established. Where a substance has been assigned a WEL and the exposure level is being exceeded the organisation will identify the reason and take the necessary action to rectify the problem. When considering control measures, we must demonstrate that the Hierarchy of Controls have been considered, (Appendix 3). 4.1.6 Storage and Signage All substances identified as hazardous to health shall be stored in accordance with manufacturer s Materials Safety Data Sheet (MSDS). Appropriate hazard signage shall be provided on all storage areas and containers where a risk has been identified in the COSHH Assessment. 5

4.1.7 Spillage & Disposal All substances identified as hazardous to health shall have spillage procedures identified in the COSHH Assessment. Appropriate equipment shall be provided in all areas, where a risk has been identified, to deal with spillages according to the manufacturer s instructions. All substances will be disposed of in accordance with the manufacturers recommendations and correct procedures stated on the COSHH assessment sheet. 4.1.8 Training The Trust will give sufficient information, instruction, training and supervision to all employees to ensure a full understanding of any hazards associated with the substances and the necessary control measures to prevent any risks to health and safety, prior to the use of substances. Information will also be given to others who may be affected such as contractors, temporary staff and volunteers as appropriate. Managers and supervisors should ensure that employees within their department are aware of procedures in the event of an accidental spillage, eg blood, bodily fluids, chemicals. First Aiders will be instructed on how to use the MSDS in line with COSHH assessments and use of the information when applying first aid treatment. 4.1.9 Arrangements for Securing the Health and Safety of Workers The Trust will, in consultation with members of staff and their representatives, implement the following: competent persons will be appointed to carry out risk assessments of the exposure to substances hazardous to health and advise on their control. health surveillance, of members of staff where indentified by the assessment, will be carried out by qualified professionals. occupational health records of staff will be kept of all exposures to substances hazardous to health for a minimum of 40 years. all changes to control measures and changes of PPE will be properly assessed and no new substance will be introduced into the workplace without prior assessment. contractors and visitors will be asked to provide copies of assessments for the products being used on Trust premises The Trust will provide copies of assessments to contractors and visitors who may be exposed whilst working on Trust premises. 4.1.10 Procedures for Dealing with Health and Safety Issues Where a member of staff raises a point related to the use of substances hazardous to health the Trust will: - ensure that the hazard associated with the substance has been correctly identified - ensure that the assessment of the use of the substance is correct and up to date 6

- ensure that the controls in place are adequate - correct any observed deficiencies in the control of the hazards - inform the member of staff, and his or her representative where appropriate, of the results of the investigation and actions taken. If an identified exposure, which exceeds the WEL has taken place, those affected, and the managers and representatives, will be informed immediately. Possible health effects will, in addition, be communicated to the Trust s Occupational Health Department who will advise the member of staff accordingly. 5. SUPPORT AND ADDITIONAL CONTACTS Further advice can be obtained from the Staff Health & Safety Team: ian.cromarty@nhs.net, kathy.hoult@nhs.net, tsanders@nhs.net 6. RESPONSIBILITIES Refer to the Trust Health and Safety Policy for additional responsibilities on the intranet. 7. Appendices Appendix 1 COSHH Assessment Form Appendix 2 COSHH Risk Assessment Flow Chart Appendix 3 Hierarchy of Control Measures 7

Appendix 1 (COSHH) ASSESSMENT FORM) COSHH Assessment Ref: CONTROL OF SUBSTANCES HAZARDOUS TO HEALTH 2005 (AS AMENDED) No:. Organisation: DCHS Hospital /Clinic Premise: Ward/Department/Area: Name and Position of Assessor(s): Date of Assessment: IS THE MANUFACTURERS SAFETY DATA SHEET (MSDS) ATTACHED? MSDS or a copy should be attached YES/NO Product name: (As per MSDS or product label) SYNONYMS: Other names used Physical state of substance (Tick appropriate description) (MSDS Section 9 ) Liquid Powder/ Dust HOW DUSTY IS THE SOLID? Vapour/Mist Gas Solid High Medium Low Hazard Category. Tick appropriate symbol(s) (Section 3 & 15 MSDS ) Oxidising Corrosive Toxic Very Toxic Irritant Harmful Explosive Dangerous for the Environment Highly Flammable Oxidising Corrosive Acute Toxicity Acute Toxicity Health Hazard Health Hazard Explosive Hazardous to the Environment Flammable The orange symbols above reflect the classification from the Chemical Hazards, information and Packaging Regulations (CHIP) which have now been revoked. The red triangle symbols reflect the introduction of the updated Classification Labelling and Packaging Regulation (CLP) as from June 2015. This will run con-currently until 1 st June 2017 by which time CHIP will no longer exist. Mutagenic/Toxic for Carcinogenic Reproduction 8

Workplace Exposure Limit ((WEL) Refer to MSDS) The Exposure Limit is: First Aid Measures ( Section 4 MSDS ) General Medical Effects: Ingestion/Swallowed Skin Contact Eye Contact Inhalation Emergency Procedures/First Aid: Ingestion/Swallowed Skin Contact Eye Contact Inhalation Persons at Risk: tick appropriate group(s) Staff Patient/Client/ Resident The Public Visitors Other Volunteer/ Student etc. New Expectant Mothers: Does this activity constitute an unacceptable risk for new or expectant mothers? YES/NO ( Refer to Hazard Category ) If YES state what action is required: Storage & Handling (Section 7 MSDS) Storage: Work environment where used: Quantity Used: Packaging Size: Work Practice Information, e.g. Substance Use/Task/Method, Normal use Frequency and Duration of Use, e.g (tick appropriate) Less than 15 mins ½ hour ½-2 hours 2-4 hours 4-8 hours Over 8 hours All day/ night 9

Accidental Spillage: Please state what action needs to be taken in the event of a spillage including disposal considerations, using information in Section 6 & 13 on the MSDS. Fire Fighting Measures (Section 5 on MSDS ) Existing Control Measures: State what existing control measures are in place including (training, instruction, information and supervision.)these must follow the Hierarchy of Controls non compliance with each control should be justified. Personal Protective Equipment (PPE) to be used. (From Section 8 & 15 on the MSDS. This will be used as a last resort only.) 10

RISK ASSESSMENT Refer to Organisation Risk Assessment Matrix COSHH Assessments are required to be kept for 40 years. RISK RATING Tick one box in the column for table A and one box in the column for table B. These values will then be used in table C to assign a risk rating. TABLE A: LIKELIHOOD TABLE B: CONSEQUENCE Likelihood of exposure exceeding the Workplace Exposure Limit occurring ALMOST CERTAIN LIKELY POSSIBLE UNLIKELY RARE Will occur / recur, possibly frequently on most occasions, a persistent issue. Value (tick one) Scale of Severity 5 Catastrophic Will probably occur / recur, but is not a persistent issue. 4 Major May occur / recur occasionally. 3 Moderate Do not expect this to occur / recur, but it is possible. 2 Highly unlikely to occur. Would only occur / recur in very extreme circumstances Risk Rating with controls: Minor 1 Insignificant Worst Case Injury that will occur from exposure. Death or major injury / illness Permanent or serious incapacity Litigation potential greater than 1m Serious Injury / illness (requiring prolonged absence from work, specialist medical intervention/treatment Major loss in confidence in the PCT Litigation potential 500k to 1m Moderate injury/illness (requiring up to 3 days absence from work and/or moderate medical or nursing intervention/treatment e.g. severe chemical burn) Semi-permanent harm (up to 1 year) including known or suspected health care associated infection which may result in non permanent harm Litigation potential > 50k to 500k No permanent harm (up to 1 month) including known or suspected health care associated infection, which may result in no permanent harm Injury/illness (requiring first aid only) Litigation less than 50k No obvious harm No/negligible injury (requiring no treatment) Minimal Impact No/negligible loss/effect/change Value (tick one) 5 4 3 2 1 Likelihood x Consequence = Rating Manager/Head of Department/Assistant Director Authorisation Risk Grade Authoriser Signature Job Title Date Green (Low) Risk Manager / Matron No Risks greater than 5 should be accepted for COSHH Head of Dept or Service 11

Appendix 2 COSHH RISK ASSESSMENT FLOW CHART Identify the Hazard Can the Hazard be Removed YES Stop Assessment NO Establish what is the risk NO YES Have the Control Measures Created a New Hazard Evaluate Risk Is the Level of Risk Acceptable NO Introduce Control Measures YES Review Periodically or When Changes Occur 12

Appendix 3 Heirarchy of Control Measures A list of control measures, ordered according to effectiveness at reducing risks, is given below. Within the COSHH Regulations this hierarchy is absolute and you must be able to show that you have considered each option before moving to the next one. The best approach to deciding which are the best control measures to use for each particular risk, is to begin by considering the first measure, and then move down the list to consider the next option, only if the more effective option cannot be implemented i.e. do not go straight to PPE. 1.0 Eliminate The best way to reduce a risk is to remove the hazard altogether. For example using a trolley instead of lifting and carrying eliminates a manual handling hazard. 2.0 Substitute The second most effective measure is to substitute the hazard for something less risky. For example cleaning products with bleach are covered by the COSHH requirements - an alternative product without bleach might do the same job. 3.0 Contain Preventing access or containing a hazard is usually done by means of barriers - for example a guard over a sharp blade or keeping hazardous chemicals in a locked cupboard. This is an important measure where removing the hazard altogether is not feasible. 4.0 Reduce exposure Reducing exposure to a hazard means you are reducing the likelihood of harm occurring, and therefore reducing the risk. For example VDU users can lower the risk of Work Related Upper Limb Disorders (formerly Repetitive Strain Injury) by doing other tasks every so often. 5.0 Training and supervision Information, instruction, training and supervision are to make sure people follow correct procedures and are aware of the risks when working with hazards. This reduces the likelihood of harm occurring, although these measures are usually only effective in conjunction with other controls that tackle the risks at source. 6.0 Personal Protective Equipment The law requires that PPE is supplied and used at work wherever there are risks to health and safety that cannot be adequately controlled in other ways (PPE at Work Regs 1992). This is because it is better to control the risk at source rather than to protect from the outcome. Another problem, is that people often either refuse to wear PPE, or don't use it properly if they find it cumbersome, (requiring further measures to ensure its proper use) and so it should therefore, be a last resort when risks cannot be controlled any other way. 7.0 Welfare facilities Welfare facilities (e.g. for washing or first aid) can control the extent of harm that occurs in the event of an accident. Risks must be tackled at source however, with controls in place to prevent accidents occurring in the first place. Welfare facilities should be present in all workplaces, but only as a back-up in the case of emergency situations where all other measures have failed. 13