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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Managing Sharps Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} safely manages the handling, use, storage, and disposal of sharps in compliance with CQC regulations, Health and Safety (Sharp Instruments in Healthcare) Regulations 2013, and Control of Substances Hazardous to Health (COSHH) Regulations 2002. This policy aims to:

• Prevent needlestick injuries and exposure to bloodborne pathogens.
• Ensure safe handling and disposal of sharps to protect staff, people we support, and visitors.
• Maintain compliance with CQC Fundamental Standards and best infection prevention and control practices.
• Provide guidance on immediate actions following sharps injuries or exposure incidents.

2. Scope

This policy applies to all employees, agency workers, healthcare professionals, and visitors within {{org_field_name}}. It covers all situations involving the handling and disposal of sharps, including needles, syringes, scalpels, lancets, and glass ampoules.

3. Policy Statement

{{org_field_name}} is committed to ensuring that:

• All sharps are handled and disposed of safely and correctly.
• Staff receive regular training and competency assessments on sharps management.
• The risk of needlestick injuries is minimised through safe working practices and equipment use.
• A robust incident reporting and post-exposure management system is in place.
• Regular audits and risk assessments are conducted to ensure compliance with infection control policies.

4. Safe Use and Handling of Sharps

{{org_field_name}} will ensure that the risks associated with the use and handling of sharps are eliminated or reduced so far as is reasonably practicable.

• The use of medical sharps must be avoided so far as is reasonably practicable. Where an appropriate needle-free or other non-sharps alternative can safely be used, this must be considered as part of the risk assessment.
• Where a medical sharp is necessary, a safer sharp incorporating a protection mechanism must be used so far as is reasonably practicable, taking account of the procedure being undertaken, the equipment available, the needs and safety of the person receiving care and the findings of the relevant risk assessment.
• Staff must be trained and competent in the correct use of any safer sharp or safety mechanism provided and must activate the safety feature immediately after use in accordance with the manufacturer’s instructions.
• Needles must not normally be recapped after use. Recapping is permitted only where a suitable risk assessment has identified that recapping is necessary to control a specific risk and the risk of injury is effectively controlled through the use of a suitable appliance, tool or other equipment. Needles must never be manually recapped by hand where this exception does not apply.
• Used disposable sharps must be placed directly into the appropriate sharps container immediately after use. They must not be passed from hand to hand unnecessarily, left on surfaces, carried unprotected or placed in ordinary waste containers.
• Clearly marked, secure sharps containers must be available close to the area where medical sharps are used. The container must be correctly assembled, appropriately positioned, stable during use and suitable for the type of sharps and any medicinal contamination being disposed of.
• Sharps containers must not be filled above the manufacturer’s marked fill line. Once the fill line has been reached, or earlier where required by the manufacturer’s instructions or risk assessment, the container must be securely closed and removed for appropriate storage and disposal.
• Written instructions on the safe use and disposal of medical sharps must be available to relevant staff.
• Staff must not attempt to retrieve an item from a sharps container, press down its contents, shake the container to create additional space or otherwise place their hands or fingers inside the container.
• Staff must follow the organisation’s risk assessments, infection prevention and control procedures, medicines procedures and waste-management arrangements whenever sharps are used or handled.

5. Storage and Disposal of Sharps

• All sharps must be stored securely in a designated area with restricted access.
• Sharps bins must comply with BS EN ISO 23907:2012 and be clearly marked for disposal.
• Used sharps containers must be disposed of through an authorised hazardous waste collection service.
• A sharps disposal log must be maintained and reviewed to ensure compliance with regulations.

6. Preventing Needlestick Injuries

• Staff must wear appropriate personal protective equipment (PPE) when handling sharps.
• Use of safe injection techniques and appropriate disposal must be enforced.
• Avoid unnecessary use of sharps where alternative methods exist.
• Staff should be trained on reducing risk factors, including safe positioning when using sharps.
• Posters and reminders should be displayed in key areas to reinforce best practices.

7. Managing Sharps Injuries and Exposure Incidents

Any sharps injury or occupational exposure to blood or potentially infectious body fluid must be treated promptly. Staff must report the incident to the person in charge or Registered Manager as soon as practicable and must follow the organisation’s exposure-incident procedure.

Immediate first aid

Where the skin has been punctured or cut:

1. Encourage the wound to bleed gently, preferably while holding it under running water. The wound must not be aggressively squeezed or sucked.
2. Wash the wound thoroughly with running water and soap. Do not scrub the wound.
3. Dry the area and cover it with a waterproof dressing.

Where blood or body fluid has splashed into the eyes:

• irrigate the eyes immediately and thoroughly with clean water or sterile saline; and
• do not rub the eyes.

Where blood or body fluid has entered the mouth:

• rinse the mouth thoroughly with water;
• spit the water out; and
• do not swallow the rinsing water.

Where blood or body fluid has contacted broken or damaged skin, the area must be washed thoroughly with soap and running water.

Medical assessment and treatment

Following a sharps injury or other exposure that has exposed, or may have exposed, an employee to a biological agent:

• the employee must receive immediate medical advice through the organisation’s occupational health arrangements, NHS urgent care arrangements, accident and emergency department or other appropriate medical service;
• the potential exposure must be medically risk assessed without unnecessary delay;
• any treatment advised by a registered medical practitioner, including post-exposure prophylaxis where clinically indicated, must be made available to the employee;
• appropriate follow-up testing, health surveillance and occupational health review must be arranged where indicated; and
• {{org_field_name}} must consider whether counselling or other psychological support should be offered to the employee.

Staff must not delay obtaining medical advice while waiting for information about the source person’s infection status.

Any testing or disclosure involving the person whose blood or body fluid was the potential source must be managed lawfully, with appropriate consent, confidentiality and clinical advice.

Recording, investigation and follow-up

Every employee injury caused by a medical sharp must:

• be reported internally as soon as practicable;
• be recorded in the organisation’s incident reporting system;
• have the circumstances and cause investigated;
• result in any necessary corrective or preventive action being taken to reduce the likelihood of recurrence; and
• be reviewed for any applicable RIDDOR reporting requirement.

The investigation must consider, where relevant:

• the type of sharp involved;
• the activity being undertaken;
• whether an appropriate safer sharp was available and correctly used;
• whether the sharps container was correctly positioned and used;
• staffing, training, competency and supervision;
• whether procedures and risk assessments were followed;
• environmental or equipment factors; and
• whether changes to equipment, working practices, training or risk controls are required.

Information about the employee’s medical assessment, treatment or test results must be handled confidentially and separately from general incident records where appropriate.

8. Training, Information, Immunisation and Competency

{{org_field_name}} will ensure that employees who may be exposed to a risk of injury from medical sharps receive appropriate information, instruction and training relevant to the work they undertake.

Training must be provided before a member of staff undertakes sharps-related duties without appropriate supervision and must be updated or repeated where necessary, including where there are changes to equipment, working practices, risk assessments or procedures, or where an incident, audit or competency assessment identifies a need for further training.

The organisation’s existing requirement for annual sharps training will continue to apply.

Training and information must include, where relevant:

• the risks of injury from medical sharps;
• the risk of exposure to blood-borne viruses and other biological agents, including hepatitis B, hepatitis C and HIV;
• relevant legal requirements for the prevention of sharps injuries and the duties of employers and employees;
• good practice in preventing sharps injuries;
• avoidance of unnecessary sharps use;
• safe use, handling and disposal of medical sharps;
• correct selection and use of safer sharps and their safety mechanisms;
• the limited circumstances in which needle recapping may lawfully occur and the equipment that must be used where this has been specifically identified by risk assessment;
• correct selection, assembly, positioning, use, closure and disposal of sharps containers;
• what to do immediately following a sharps injury, needlestick injury or exposure to blood or body fluid;
• how and to whom an incident must be reported;
• the medical advice, post-exposure assessment, treatment, health surveillance and follow-up arrangements provided following an occupational exposure;
• the support available to an employee following a sharps injury;
• the benefits and drawbacks of vaccination and non-vaccination in relation to relevant blood-borne diseases; and
• the organisation’s infection prevention and control procedures relevant to sharps and blood or body-fluid exposure.

Where a risk assessment identifies an occupational risk of exposure to a biological agent for which an effective vaccine is available, {{org_field_name}} will have arrangements to establish whether relevant employees are appropriately immunised and will offer appropriate vaccination to employees who are not adequately protected, in accordance with occupational health advice. This includes consideration of hepatitis B vaccination for employees whose work places them at occupational risk. Any vaccination required as a protective measure because of occupational risk will be provided without cost to the employee.

The benefits, limitations and potential disadvantages of relevant immunisation must be explained to employees. An employee’s decision concerning vaccination must be respected and managed in accordance with the risk assessment and occupational health advice.

Competency must be assessed for staff who use medical sharps or safer-sharps devices. Competency must be reassessed where there is reason to doubt competence, following relevant changes to equipment or procedures, or where an incident or audit identifies a need for reassessment.

Training, competency assessments and any required refresher training must be recorded.

9. Risk Assessments and Audits

• A risk assessment must be completed for all sharps-related activities.
• Regular audits must be conducted to review sharps disposal practices and incident trends.
• Findings must be reviewed by the Infection Control Lead and appropriate action taken to improve safety.

10. Reporting and Monitoring

All sharps injuries, needlestick incidents and relevant occupational exposures involving employees must be reported through {{org_field_name}}’s internal incident-reporting arrangements, regardless of whether the incident is reportable to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR).

The Registered Manager, or other person with delegated responsibility, must consider each incident individually to determine whether a statutory RIDDOR report is required.

A sharps or blood/body-fluid exposure may be reportable under RIDDOR where the applicable statutory criteria are met, including where:

• a needlestick or sharps injury involves blood or body fluid known to be infected with a blood-borne virus and meets the criteria for a dangerous occurrence;
• an accident or incident results, or could have resulted, in the release or escape of a biological agent likely to cause severe human infection or illness;
• an employee acquires an infection that is attributable to occupational exposure to a biological agent; or
• the injury results in a period of incapacity that meets the applicable RIDDOR reporting threshold.

A sharps injury must not be reported to the Health and Safety Executive merely because it involved a sharp. The Registered Manager must apply the relevant RIDDOR criteria to the facts of the incident and obtain competent health and safety advice where the reporting status is uncertain.

All sharps injuries involving employees must nevertheless be:

• recorded internally;
• investigated to identify the immediate and underlying causes;
• reviewed to determine whether risk assessments, equipment, staffing, working practices or procedures need to change;
• followed by appropriate corrective and preventive action;
• monitored for trends or recurring causes; and
• used to inform training, competency assessment and service improvement.

Where an incident involves potential exposure to a biological agent, the requirements in Section 7 of this policy for immediate medical advice, treatment, post-exposure management and follow-up must also be followed.

Records of incidents, investigations, corrective actions and any statutory reports must be retained in accordance with {{org_field_name}}’s record-retention requirements and applicable legislation. Medical and occupational health information must be treated confidentially.

Learning arising from incidents must be communicated to relevant staff where this is necessary to prevent recurrence, while maintaining the confidentiality of the individuals involved.

11. Policy Review

This policy will be reviewed annually or earlier if required due to changes in legislation, CQC guidance, or internal audit findings.

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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}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.