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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Control of Substances Hazardous to Health (COSHH) Policy

1. Purpose

This policy sets out the arrangements used by {{org_field_name}} to prevent or adequately control exposure to substances hazardous to health and to protect people who use the service, employees, contractors, visitors and others who may be affected by the activities of the service.

{{org_field_name}} will comply with the Health and Safety at Work etc. Act 1974, the Control of Substances Hazardous to Health Regulations 2002, as amended (“COSHH”), and other applicable health and safety legislation. The service will also meet the requirements relevant to health, safety and risk management under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including Regulation 12, Safe care and treatment, Regulation 15, Premises and equipment, Regulation 17, Good governance, and Regulation 18, Staffing.

Exposure to a substance hazardous to health will be prevented where reasonably practicable. Where prevention is not reasonably practicable, exposure will be adequately controlled by applying the COSHH hierarchy of control. Personal protective equipment will not be used as a substitute for reasonably practicable measures that control exposure at source.

The service will ensure that hazardous substances and work activities involving hazardous substances are identified, suitably and sufficiently assessed, appropriately controlled, safely stored and disposed of, and that employees receive suitable and sufficient information, instruction and training.

2. Scope

This policy applies to all staff, including care workers, cleaners, maintenance personnel, and any contractors handling hazardous substances within {{org_field_name}}. It covers all aspects of identifying, assessing, handling, storing, using, and disposing of hazardous substances in a way that minimises risk and ensures compliance with legal requirements.

3. Related Policies

• Health and Safety at Work Policy (CH16)
• Infection Prevention and Control Policy (CH17)
• Risk Management and Assessment Policy (CH18)
• Fire Safety and Evacuation Procedures Policy (CH20)
• Medication Management and Administration Policy (CH21)

4. Policy Statement

{{org_field_name}} is committed to preventing, so far as is reasonably practicable, exposure to substances hazardous to health. Where exposure cannot reasonably be prevented, the service will ensure that exposure is adequately controlled.

No work involving a substance hazardous to health will be undertaken unless the risks created by that work have been suitably and sufficiently assessed and the measures required to comply with COSHH have been identified and implemented.

Control measures will follow the required hierarchy of control. The service will first consider whether the hazardous substance or process can be eliminated, avoided or replaced with a safer substance or process. Where this is not reasonably practicable, appropriate engineering controls, safe systems of work and other organisational measures will be used. Suitable personal protective equipment will be provided where adequate control cannot be achieved by other reasonably practicable means, or where it is required in addition to other controls.

Employees who may be exposed to substances hazardous to health will receive suitable and sufficient information, instruction and training appropriate to their role and the risks involved. They will be informed of the hazards, the findings of relevant COSHH assessments, required control measures, correct use of personal protective equipment, safe storage and disposal arrangements, and the action to take in the event of an accident, incident, exposure or emergency.

5. Identifying Substances Hazardous to Health

For the purposes of this policy, substances hazardous to health include substances and mixtures classified as hazardous, substances with a Workplace Exposure Limit, biological agents, dusts present at specified concentrations, and other substances which, because of their chemical, toxicological or biological properties and the way in which they are used or present at work, create a risk to health.

Substances and activities requiring consideration may include:

• cleaning and disinfecting products, including bleaches, detergents, descalers and concentrated cleaning chemicals;
• substances that are harmful, toxic, corrosive, irritant, sensitising, carcinogenic or otherwise hazardous to health;
• gases, vapours, fumes, mists, aerosols and dusts generated by work activities;
• biological agents where employees may be exposed through blood, bodily fluids, contaminated materials, infectious waste or other work activities;
• pest-control products or other hazardous chemicals used at the service;
• hazardous products used by maintenance staff or contractors; and
• any other substance or work process identified as presenting a risk to health.

A current inventory of substances hazardous to health that are used or stored by the service will be maintained, together with access to the relevant safety data sheets where applicable.

Safety data sheets will be used as a source of hazard information but will not replace the service’s own COSHH assessment.

Where asbestos or asbestos-containing materials are present or may be disturbed, they will be managed in accordance with the Control of Asbestos Regulations 2012 and the service’s asbestos-management arrangements rather than being treated as an ordinary COSHH substance.

6. COSHH Risk Assessments

A suitable and sufficient COSHH assessment must be completed before work involving a substance hazardous to health is undertaken where employees or others may be exposed to a risk to health.

The assessment must be completed by a person who has sufficient knowledge, training and competence to identify the hazards, evaluate the risks and determine the controls required.

The COSHH assessment will consider, where relevant:

• the hazardous properties of the substance or biological agent;
• information supplied by the manufacturer or supplier, including the current safety data sheet where one is provided;
• the type, level and duration of exposure;
• the circumstances of the work, including the quantity of the substance involved;
• the routes by which exposure may occur, including inhalation, ingestion, skin or eye contact, absorption through the skin and accidental injection;
• the potential health effects of exposure;
• any relevant Workplace Exposure Limit;
• the effects of preventive and control measures already in place or proposed;
• the results of any relevant exposure monitoring;
• the results of relevant health surveillance;
• activities such as maintenance, cleaning, spill response or other non-routine tasks where there may be a foreseeable risk of significant exposure;
• risks to employees, contractors, people who use the service, visitors and any other person who may be affected;
• additional risks to any employee who may require specific consideration because of their circumstances; and
• the arrangements required for safe use, handling, storage, transport, disposal, first aid, accidental exposure and emergencies.

The assessment must identify the measures necessary to prevent exposure or, where prevention is not reasonably practicable, adequately control exposure.

Where {{org_field_name}} employs five or more employees, the significant findings of the assessment and the steps taken to meet the requirements of COSHH will be recorded.

COSHH assessments will be kept up to date. They will be reviewed regularly and immediately where:

• there is reason to suspect that the existing assessment is no longer valid;
• there has been a significant change in the work, substance, equipment, process or conditions to which the assessment relates;
• a new substance or process is introduced;
• an accident, incident, spill, exposure or case of work-related ill health indicates that the existing controls may be inadequate; or
• new information about the hazards or required control measures becomes available.

Where a review identifies that changes are required, the COSHH assessment and control measures will be revised without undue delay.

7. Prevention and Control of Exposure, Safe Handling and Storage

{{org_field_name}} will prevent exposure to substances hazardous to health where reasonably practicable, including by eliminating an unnecessary hazardous substance or process or substituting it with a safer substance, form or process where reasonably practicable.

Where prevention is not reasonably practicable, exposure will be adequately controlled using appropriate measures in accordance with the COSHH hierarchy of control. These may include:

• suitable work processes, systems and engineering controls;
• reducing the amount of hazardous substance used or present;
• controlling exposure at source;
• suitable ventilation or extraction where required;
• restricting access to areas where exposure may occur;
• reducing the number of people exposed and the duration or level of exposure;
• safe methods of work, including appropriate cleaning and hygiene arrangements;
• appropriate storage, handling and disposal arrangements; and
• suitable personal protective equipment where adequate control cannot be achieved by other reasonably practicable means, or as an additional control where required.

Substances hazardous to health must be stored in accordance with the COSHH assessment and the manufacturer’s instructions. Storage arrangements must take account of the nature and quantity of the substance, incompatible substances, ventilation requirements, fire and environmental risks, and the risk of unauthorised access.

Hazardous substances must be secured against access by people who may be placed at risk, including people who use the service, taking account of their individual needs and foreseeable behaviours.

Products must normally be retained in their original correctly labelled containers. Where a product has to be transferred to another container as part of an authorised safe system of work, the alternative container must be suitable, compatible with the substance and appropriately identified. Hazardous substances must never be transferred into food, drink or other misleading containers.

Safety information and relevant COSHH assessments must be readily accessible to employees who use or may be exposed to the substance.

Substances that are incompatible must be segregated where required.

Where substances present a fire or explosion risk, they will additionally be assessed and controlled in accordance with applicable fire-safety requirements and the Dangerous Substances and Explosive Atmospheres Regulations 2002 where those Regulations apply.

8. Personal Protective Equipment and Respiratory Protective Equipment

Personal protective equipment will be provided where the COSHH assessment identifies that it is necessary to achieve adequate control of exposure or to provide additional protection alongside other control measures.

PPE will not be used as a substitute for reasonably practicable measures that prevent exposure or control exposure at source.

PPE must:

• be appropriate for the substance, task and route of exposure;
• be suitable for the wearer and the conditions in which it will be used;
• be compatible with any other PPE worn at the same time;
• be readily available in sufficient quantities;
• be used in accordance with the COSHH assessment and manufacturer’s instructions;
• be stored appropriately;
• be maintained, cleaned, replaced or disposed of as required; and
• be provided without charge to employees where it is required for work.

Employees must receive appropriate information, instruction and training in the correct fitting, use, removal, storage, limitations and disposal or decontamination of PPE.

Where respiratory protective equipment is necessary, suitable equipment with an adequate assigned protection factor must be selected. Where tight-fitting respiratory protective equipment relies on a seal to the wearer’s face, face-fit testing must be arranged for the wearer using the model and size of mask that they will use.

Reusable respiratory protective equipment and other reusable PPE must be appropriately examined, maintained and stored. Defects must be reported immediately and defective equipment must not be used.

Single-use or contaminated PPE must be removed and disposed of through the appropriate waste stream in accordance with the applicable waste assessment and infection prevention and control arrangements.

9. Maintenance, Examination and Testing of Control Measures

All measures provided to prevent or control exposure to substances hazardous to health must be properly used and maintained in an efficient state, in efficient working order, in good repair and in a clean condition where appropriate.

{{org_field_name}} will establish arrangements for the inspection, examination, maintenance and, where necessary, testing of control measures at intervals appropriate to the equipment and risk and in accordance with COSHH and manufacturer requirements.

Where local exhaust ventilation is used to control exposure to a substance hazardous to health, it must be thoroughly examined and tested by a competent person at least once every 14 months unless COSHH specifies a different interval for the particular process.

Records of examinations and tests of engineering control measures required under COSHH will be retained for at least five years from the date on which they were made.

Any defect or deterioration that could affect the effectiveness of a control measure must be reported immediately. Where adequate control cannot be maintained, the relevant activity must stop unless alternative effective controls have been implemented.

Employees must make full and proper use of control measures provided and must report defects or failures promptly.

10. Monitoring Exposure and Health Surveillance

Exposure monitoring

Where the COSHH assessment identifies that monitoring of employee exposure is required by COSHH, {{org_field_name}} will arrange suitable exposure monitoring by a competent person.

Monitoring will be carried out where necessary to demonstrate that adequate control of exposure is being maintained or where specifically required by COSHH.

Where a Workplace Exposure Limit applies, control measures must ensure that exposure does not exceed that limit. Exposure to substances for which COSHH requires exposure to be reduced as low as is reasonably practicable will be controlled accordingly.

Records of personal exposure monitoring required under COSHH will be retained for the statutory period. Where the record relates to an identifiable employee, it will be retained for at least 40 years from the date of the last entry. Other required exposure-monitoring records will be retained for at least five years.

Health surveillance

Suitable health surveillance will be provided where the COSHH assessment and Regulation 11 require it, including where:

• employees are exposed to substances or processes for which medical surveillance is specified under COSHH; or
• there is an identifiable disease or adverse health effect related to the exposure, there is a reasonable likelihood that it may occur under the particular conditions of work, and valid techniques are available for detecting indications of the disease or effect.

Where health surveillance is required, it will be carried out by an appropriately competent person and an appropriate health record will be maintained.

Individual health records required by COSHH will be retained for at least 40 years from the date of the last entry.

Where health surveillance indicates that an employee has an identifiable disease or adverse health effect considered to result from exposure to a hazardous substance at work, the service will take the actions required by COSHH, including reviewing the relevant risk assessment and control measures and obtaining appropriate occupational health advice.

11. Accidents, Incidents, Spills and Emergency Arrangements

Where the COSHH assessment identifies a foreseeable risk of an accident, incident or emergency involving a substance hazardous to health that could result in exposure beyond that associated with normal day-to-day work, {{org_field_name}} will establish appropriate procedures to protect employees and other people who may be affected.

Emergency arrangements will be proportionate to the nature of the substance and foreseeable incident and will include, where applicable:

• the foreseeable accident, incident or emergency and the substances involved;
• immediate actions required to contain or control the incident;
• arrangements for raising the alarm and obtaining assistance;
• evacuation or restriction of access where necessary;
• suitable PPE and respiratory protective equipment where required;
• first-aid and decontamination arrangements;
• spill-control equipment appropriate to the substances used;
• safe clean-up and waste-disposal arrangements;
• procedures for obtaining relevant medical advice or treatment;
• emergency contact information;
• arrangements for notifying the Registered Manager or other responsible person;
• information that must be provided to the emergency services where applicable; and
• suitable practice or safety drills where these are required by the risk assessment.

Spill kits will be provided where the COSHH assessment identifies that they are required. Their contents must be suitable for the substances concerned; a generic spill kit must not be assumed to be suitable for every chemical or biological spill.

In the event of an accident, incident or emergency:

• immediate steps must be taken to mitigate the effects of the incident;
• only people essential to carrying out repairs or other necessary work may remain in the affected area where there is a continuing risk;
• those people must be provided with appropriate PPE and any necessary specialised safety equipment;
• unnecessary exposure must be prevented;
• affected persons must receive appropriate first aid or medical attention;
• the incident must be reported and recorded; and
• the relevant COSHH assessment and control measures must be reviewed before normal work resumes where the incident indicates that existing arrangements may no longer be adequate.

12. Disposal of Hazardous Substances and Healthcare Waste

Hazardous substances, contaminated materials and healthcare waste must be segregated, stored, handled and disposed of safely and in accordance with applicable waste legislation, the waste producer’s duty of care, current healthcare-waste requirements, the service’s waste procedures and the requirements of the authorised waste contractor.

Waste must be correctly classified before the appropriate waste stream and packaging are selected.

Healthcare waste must not automatically be placed in yellow clinical-waste bags. The correct colour-coded waste stream must be selected according to the nature and classification of the waste, including whether it is infectious, medicinally contaminated, chemically contaminated, cytotoxic or cytostatic, offensive hygiene waste, or another waste type.

Sharps must be disposed of immediately into an appropriate UN-type-tested sharps container of the correct colour coding for the contents. Sharps containers must not be overfilled and must be closed and disposed of in accordance with the manufacturer’s instructions and the service’s waste procedure.

Medicines, including controlled drugs where applicable, must be disposed of in accordance with applicable medicines legislation and the Medication Management and Administration Policy (CH21). Waste containing cytotoxic or cytostatic medicines must be segregated into the designated cytotoxic/cytostatic waste stream.

Unused, surplus or waste chemicals must not be poured into drains, toilets or sinks unless this method of disposal is expressly authorised by the manufacturer’s instructions, the COSHH assessment and applicable environmental requirements.

Chemical waste must be retained in suitable, correctly identified containers and disposed of through an authorised route appropriate to the waste classification.

Waste must only be transferred to a person authorised to receive it. Required waste-transfer or hazardous-waste documentation must be completed and retained in accordance with applicable legal requirements.

Waste storage areas must be secure and designed and managed to prevent unauthorised access, leakage, spillage, contamination and exposure.

13. Information, Instruction, Training and Responsibilities

Registered Manager

The Registered Manager, or an appropriately competent person acting under delegated authority, is responsible for ensuring that:

• substances hazardous to health used or stored within the service are identified;
• suitable and sufficient COSHH assessments are completed before relevant work begins;
• the significant findings of assessments are implemented;
• exposure is prevented or adequately controlled;
• control measures are properly used, maintained, examined and tested where required;
• exposure monitoring and health surveillance are provided where required;
• appropriate accident, incident and emergency arrangements are established;
• current safety data sheets and other relevant safety information are accessible;
• employees receive suitable and sufficient information, instruction and training;
• COSHH assessments are reviewed when required;
• relevant records are maintained; and
• deficiencies identified through incidents, audits, inspections or staff concerns are addressed promptly.

Employees

Employees who work with, or may be exposed to, substances hazardous to health must:

• follow the COSHH assessment and safe system of work;
• use hazardous substances only for their intended purpose and in accordance with instructions;
• make full and proper use of control measures provided;
• wear PPE and respiratory protective equipment where required;
• not mix chemicals unless expressly authorised by the manufacturer’s instructions and COSHH assessment;
• not transfer chemicals into inappropriate or unlabelled containers;
• follow required hygiene, storage and disposal procedures;
• report damaged containers, missing labels, defective controls, spills, accidental exposures, symptoms of possible work-related ill health and other concerns promptly; and
• attend and participate in required information, instruction, training, health surveillance or monitoring arrangements.

Information, instruction and training

Employees who may be exposed to substances hazardous to health must receive suitable and sufficient information, instruction and training appropriate to their work.

This will include, where relevant:

• the names of substances to which they may be exposed and the risks those substances present;
• relevant Workplace Exposure Limits;
• access to relevant safety data sheets and COSHH assessments;
• significant findings of the COSHH assessment;
• precautions and actions required to protect themselves and others;
• correct operation and use of control measures;
• correct selection, use, removal and disposal of PPE;
• use and limitations of respiratory protective equipment where applicable;
• safe handling, storage and disposal;
• signs and symptoms that may indicate harmful exposure;
• the purpose of any exposure monitoring or health surveillance;
• arrangements for dealing with spillages, accidental exposure, incidents and emergencies; and
• the actions employees must take if controls fail.

Information, instruction and training must be updated where appropriate to take account of significant changes in the work, substances, risks, control measures or emergency arrangements.

The service will determine refresher frequency according to the risks involved, staff competence, changes in practice and the findings of monitoring, incidents and audits rather than relying solely upon a fixed statutory annual interval.

Housekeeping, Maintenance Staff and Contractors

Housekeeping and maintenance staff must work in accordance with the relevant COSHH assessments and safe systems of work.

Contractors undertaking work that may introduce or generate substances hazardous to health must provide sufficient information to allow the service to assess risks to people who use the service, employees and others. The service must provide contractors with relevant information about hazards on the premises that could affect their work.

Where responsibilities are delegated to a contractor, {{org_field_name}} retains responsibility for meeting applicable CQC requirements in relation to the safety of the regulated service.

14. Incident Reporting, Statutory Reporting and Compliance Monitoring

Any accident, incident, spill, loss of containment, failure of a control measure, accidental exposure or suspected case of ill health associated with a substance hazardous to health must be reported promptly to the Registered Manager or other designated responsible person and recorded in accordance with the service’s incident-reporting procedure.

The Registered Manager must ensure that the incident is investigated at a level proportionate to the risk and that consideration is given to:

• the immediate and underlying causes;
• whether the relevant COSHH assessment remains suitable and sufficient;
• whether existing preventive and control measures remain adequate;
• whether additional information, instruction, training or supervision is required;
• whether occupational health advice, health surveillance or medical assessment is required; and
• whether any statutory notification or report is required.

Where an accident, dangerous occurrence or diagnosed occupational disease meets the criteria of the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR), the responsible person must ensure that it is reported to the relevant enforcing authority within the applicable statutory timescale.

This includes consideration of reportable occupational diseases associated with exposure to hazardous substances, such as occupational dermatitis or occupational asthma, where the statutory reporting criteria are met.

Where an incident affecting a person who uses the service also meets a CQC statutory notification requirement or the requirements of the statutory duty of candour, the Registered Manager must follow the service’s relevant notification and duty of candour procedures.

The service will operate monitoring and auditing arrangements sufficient to demonstrate that:

• the hazardous-substance inventory is current;
• COSHH assessments are present and up to date;
• required control measures have been implemented;
• substances are appropriately stored and secured;
• control equipment is maintained and tested where required;
• relevant training and competency records are current;
• monitoring and health-surveillance requirements have been met where applicable;
• emergency equipment and arrangements remain suitable; and
• corrective actions arising from incidents, audits or identified risks are completed.

Records relating to the management of COSHH must be accurate, complete, current, appropriately retained and available for inspection where legally required.

15. Monitoring and Review of COSHH Arrangements

{{org_field_name}} will monitor the effectiveness of its arrangements for controlling exposure to substances hazardous to health.

The Registered Manager will ensure that identified shortcomings are addressed promptly and that lessons from accidents, incidents, exposure events, health-surveillance findings, audits, staff concerns and regulatory findings are incorporated into relevant risk assessments, procedures, training and control measures.

COSHH assessments must be reviewed in accordance with Section 6 of this policy and must not wait for the scheduled review of this policy where there is reason to suspect that an assessment is no longer valid or where a significant change has occurred.

16. Policy Review

This policy will be reviewed at planned intervals and sooner where necessary because of:

• a change in relevant legislation or regulatory requirements;
• material changes to HSE or CQC requirements or guidance;
• a significant change in the activities or arrangements of the service;
• findings from an accident, incident, enforcement action, audit or inspection that indicate the policy requires amendment; or
• evidence that the existing policy is no longer effective.

A scheduled policy-review date does not replace the requirement to review individual COSHH assessments whenever the circumstances specified in Section 6 arise.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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