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CH179-Managing Blood-Borne Viruses Policy

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Registration Number: {{org_field_registration_no}}

Managing Blood-Borne Viruses (BBVs) Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} effectively identifies, assesses, prevents and manages the risks associated with blood-borne viruses (BBVs), including hepatitis B, hepatitis C and HIV, within a care home setting. The policy supports safe, person-centred and non-discriminatory care for people we support, staff, visitors, contractors and the wider community. It sets out the arrangements for standard infection control precautions, safe use and disposal of sharps, occupational exposure management, confidentiality, risk assessment, staff training, vaccination, incident reporting, governance and learning.

This policy supports compliance with the Health and Social Care Act 2008, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including Regulation 9 (Person-centred care), Regulation 10 (Dignity and respect), Regulation 11 (Need for consent), Regulation 12 (Safe care and treatment), Regulation 13 (Safeguarding service users from abuse and improper treatment), Regulation 15 (Premises and equipment), Regulation 17 (Good governance), Regulation 18 (Staffing) and Regulation 20 (Duty of candour), where applicable. It also reflects the Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance, CQC infection prevention and control expectations for care homes, UK Health Security Agency guidance on BBVs in healthcare workers, Health and Safety Executive guidance on blood-borne viruses and the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.

2. Scope

This policy applies to all employees, agency workers, volunteers, students, contractors, visiting professionals and any other person working on behalf of {{org_field_name}} who may come into contact with blood, blood-stained body fluids, sharps, contaminated equipment, contaminated waste, soiled laundry or broken skin during their duties. It applies to all areas of the care home and to any care or support delivered away from the premises on behalf of {{org_field_name}}.

The policy covers the prevention and management of BBV transmission risks, including known or suspected BBV infection, standard infection control precautions, use of PPE, safe sharps practice, cleaning and decontamination, waste and laundry handling, occupational exposure, post-exposure action, staff health, vaccination, confidentiality, equality, consent, care planning, reporting, escalation, governance and learning.

3. Related Policies

This policy should be read in conjunction with:

3.1 Legislation and Guidance

This policy must be read and implemented in line with the following legislation, regulations and guidance, as amended or replaced from time to time:

4. Policy Details

4.1 Understanding Blood-Borne Viruses

BBVs are viruses that may be carried in blood and some body fluids and can cause infection if they enter another person’s bloodstream. The main BBVs relevant to this policy are hepatitis B, hepatitis C and HIV. BBV transmission in a care home setting is most likely to be associated with exposure to infected blood through sharps injuries, needlestick injuries, cuts, bites that break the skin, splashes of blood or blood-stained body fluids to the eyes, mouth or broken skin, unsafe handling of contaminated equipment, or incorrect disposal of contaminated waste.

BBVs are not spread through ordinary day-to-day social contact, including touching, hugging, sharing crockery or cutlery, using the same toilet facilities, or providing routine care where there is no exposure to blood or blood-stained body fluids. Staff must therefore provide care in a way that is safe, respectful, proportionate and non-discriminatory.

Staff must apply standard infection control precautions to all people we support, regardless of known or suspected BBV status. A person’s known or suspected BBV status must never be used as a reason to refuse care, isolate the person unnecessarily, restrict ordinary activities, or treat the person less favourably.

4.2 Standard Infection Control Precautions

Standard infection control precautions must be used with every person we support, regardless of known or suspected BBV status. Staff must not rely on diagnosis or disclosure of BBV status before using safe working practices.

Staff must:

Compliance with standard precautions will be monitored through infection prevention and control audits, hand hygiene observations, PPE checks, care plan reviews, cleaning audits, sharps bin checks, incident analysis, supervision and staff competency checks.

4.3 Sharps Safety

Sharps must only be used where clinically necessary and by staff who have been trained and assessed as competent. Where sharps are used in the service, the Registered Manager must ensure that a sharps risk assessment is completed and reviewed, and that safer sharps devices are used where it is reasonably practicable to do so.

Staff must dispose of sharps immediately at the point of use into an approved sharps container. Sharps must not be passed from hand to hand, left on trays, placed in domestic waste, placed in clinical waste bags, carried loose, placed in pockets, or left in bedrooms, bathrooms, communal areas or treatment areas. Sharps bins must be kept out of reach of people we support and visitors, while remaining accessible to staff who need to use them safely.

Where visiting healthcare professionals use sharps in the home, they remain responsible for their own professional practice. However, staff must challenge and report unsafe practice, including failure to dispose of sharps safely, overfilled sharps containers or sharps left unattended. Any unsafe practice by a visiting professional must be escalated to the Registered Manager and, where necessary, to the professional’s employing organisation.

4.4 Confidentiality and Respect for People We Support

People living with, or suspected of living with, a BBV must be treated with dignity, respect and without discrimination. BBV status is confidential health information and must be processed in line with UK GDPR, the Data Protection Act 2018, the common law duty of confidentiality and {{org_field_name}}’s confidentiality and data protection policies.

Information about a person’s BBV status must only be shared with staff or relevant professionals where there is a lawful basis and a clear care, treatment, safety or infection prevention reason for doing so. Staff must not discuss a person’s BBV status in communal areas, handovers where it is not relevant, staff rooms, with other people we support, visitors, relatives, contractors or professionals who do not need the information.

Where a person has capacity, their consent should normally be sought before sharing information about their BBV status unless there is an overriding legal, safeguarding, public health or serious risk reason to share information. Where a person lacks capacity, decisions about sharing information must be made in their best interests and recorded.

A person’s BBV status must not be displayed on bedroom doors, noticeboards, mobility aids, care equipment or any other visible location. Care plans must focus on the specific risk and control measures required, not on labels or assumptions. Breaches of confidentiality will be treated as a serious matter and may be managed under disciplinary procedures.

4.5 Risk Assessment and Care Planning

BBV risk assessments must be completed where a person is known to have a BBV, where a BBV risk is suspected, or where the person’s care or behaviour creates a foreseeable risk of exposure to blood or blood-stained body fluids. Risk assessments must be individualised, proportionate and reviewed regularly or sooner if needs, behaviour, treatment, medication, wounds, continence, skin integrity or clinical risk changes.

The assessment must consider:

The care plan must describe the practical steps staff must take to provide safe care while maintaining dignity, privacy, independence and ordinary daily life. The care plan must not include unnecessary or excessive restrictions. Where restrictions are considered, they must be lawful, proportionate, risk assessed, in the person’s best interests where they lack capacity, and reviewed.

4.6 Management of Occupational Exposure

An occupational exposure may include a needlestick or sharps injury, a bite that breaks the skin, blood or blood-stained body fluid splashing into the eyes or mouth, or blood or blood-stained body fluid coming into contact with broken skin, cuts, abrasions or eczema.

If exposure occurs, the staff member must take immediate first aid action:

The staff member must immediately report the incident to the Registered Manager, deputy manager or nurse in charge and must obtain urgent medical advice from occupational health, NHS 111, the local emergency department, a sexual health/GUM service or another appropriate urgent clinical service. This must happen as soon as possible because post-exposure prophylaxis or other time-critical treatment may be required.

The manager receiving the report must:

The person we support must not be pressured to disclose their BBV status or undergo testing. Any request for testing or disclosure must be handled by an appropriately qualified healthcare professional, with valid consent or another lawful basis. Staff must continue to provide safe and respectful care while the incident is being managed.

4.7 Post-Exposure Follow-Up and Support

Following any occupational exposure, {{org_field_name}} will support the staff member to access appropriate clinical follow-up, occupational health advice, counselling or wellbeing support. Follow-up may include risk assessment, baseline blood tests, hepatitis B vaccination or booster advice, hepatitis B immunoglobulin where clinically indicated, HIV post-exposure prophylaxis where clinically indicated, hepatitis C follow-up, and further testing or review as advised by the treating clinician.

The Registered Manager must ensure that any recommended work adjustments are considered through occupational health advice and an individual risk assessment. Staff must not be treated unfairly or excluded from work solely because they have experienced an exposure incident or are living with a BBV.

4.8 Staff Health and Immunisation

Staff whose role may expose them to blood, blood-stained body fluids, sharps or contaminated equipment must be offered access to hepatitis B vaccination in line with occupational health advice. Staff must be informed of the benefits and limitations of vaccination and the importance of completing the recommended course and any advised post-vaccination testing or boosters.

Vaccination records, occupational health correspondence and staff health information must be held securely and confidentially, separately from general personnel records where appropriate, and accessed only by those with a legitimate need to know.

Staff living with a BBV are not required to disclose their status unless it may affect their ability to carry out their role safely or they undertake tasks that create a risk to others. Where disclosure is made, the Registered Manager must seek occupational health advice and complete an individual risk assessment. Staff must not be excluded, redeployed or treated less favourably solely because of BBV status. Any work adjustment must be evidence-based, proportionate, confidential and reviewed.

Staff undertaking clinical or exposure-prone procedures must follow any relevant professional, occupational health and UKHSA requirements for health clearance and ongoing monitoring.

4.9 Training and Awareness

All staff must receive BBV awareness and infection prevention and control training appropriate to their role during induction and at the frequency set by {{org_field_name}}’s training matrix. Training must be refreshed sooner where there are changes in legislation or guidance, changes in the service, audit findings, incidents, poor practice, supervision outcomes or identified competency concerns.

Training must include:

Staff who carry out higher-risk tasks, such as wound care, diabetes care, handling sharps, continence care involving blood exposure, or cleaning blood spillages, must receive additional instruction and competency assessment before undertaking these tasks. The Infection Control Lead {{org_field_infection_control_lead_name}}, {{org_field_infection_control_lead_role}}, will oversee training content and ensure it reflects current national guidance.

4.10 Incident Reporting and Learning

All BBV-related incidents, near misses, sharps injuries, unsafe sharps disposal, blood spillages not managed correctly, PPE failures, confidentiality breaches and failures to follow this policy must be reported, recorded, investigated and reviewed in line with {{org_field_name}}’s incident reporting procedure.

The Registered Manager must decide whether the incident requires:

Learning from incidents must be shared with staff through handovers, meetings, supervision, briefings or updated training. The service must be able to evidence what happened, what action was taken, what was learned, and how recurrence has been reduced. Trends must be reviewed through governance meetings and infection prevention and control audits.

4.11 CQC Notifications, RIDDOR, Safeguarding and Duty of Candour

The Registered Manager is responsible for reviewing BBV-related incidents to determine whether any external notification or referral is required. This decision must be recorded.

A CQC statutory notification must be submitted where a BBV-related incident meets the relevant notification criteria, including serious injury to a person using the service, abuse or alleged abuse, police involvement, or an event that stops or may stop the service from running safely and properly. Notifications must be submitted using the current CQC process and within the required timeframe.

A safeguarding referral must be made where a BBV-related incident involves abuse, neglect, organisational abuse, unsafe care, deliberate exposure, failure to provide necessary care, or any concern that a person using the service has experienced or is at risk of abuse or neglect.

RIDDOR reporting must be considered for staff exposure incidents, sharps injuries, occupational infections, dangerous occurrences or other reportable workplace incidents in line with HSE guidance. The Registered Manager must seek advice where there is uncertainty.

Duty of candour must be applied where a BBV-related incident is a notifiable safety incident under Regulation 20. Where duty of candour applies, {{org_field_name}} must act openly and transparently, inform the relevant person as soon as reasonably practicable, provide a truthful account of the known facts, apologise, explain what further enquiries or investigations will take place, keep written records and provide reasonable support.

4.12 Cleaning, Decontamination, Waste and Laundry

Blood spillages and contamination with blood-stained body fluids must be dealt with promptly by trained staff using appropriate PPE and the correct cleaning and disinfection procedure. Staff must restrict access to the affected area until cleaning is complete and the area is safe.

Reusable equipment contaminated with blood or blood-stained body fluids must be cleaned and decontaminated according to the manufacturer’s instructions and the organisation’s cleaning and decontamination policy. Single-use items must never be reused.

Waste contaminated with blood or blood-stained body fluids must be disposed of in the correct waste stream in line with local waste management arrangements. Sharps must only be disposed of in approved sharps containers.

Laundry contaminated with blood or blood-stained body fluids must be handled with gloves and apron, placed in the correct laundry bag or soluble/alginate bag where required, and handled in a way that avoids shaking, leakage or contamination of staff, residents, surfaces or clean linen.

4.13 Visitors, Relatives and Contractors

Visitors, relatives and contractors are not routinely informed of a person’s BBV status. Where visitors, relatives or contractors need infection prevention advice, this must be provided in a way that protects confidentiality and focuses on safe practice rather than diagnosis.

Contractors who may encounter contaminated waste, laundry, sharps containers, blood spillages or contaminated equipment must be given appropriate information about site safety procedures without unnecessary disclosure of personal health information. Any contractor incident involving possible BBV exposure must be reported immediately to the Registered Manager and managed in line with this policy.

4.14 Equality, Human Rights and Non-Discrimination

{{org_field_name}} will not discriminate against any person because they are living with, are perceived to be living with, or are at risk of a BBV. People must have equal access to care, activities, communal areas, relationships and ordinary daily life unless an individual risk assessment identifies a specific, evidence-based and proportionate control measure.

Staff must challenge stigma, myths or discriminatory comments about BBVs. Any discriminatory practice, breach of confidentiality or avoidable restriction linked to BBV status must be reported to the Registered Manager and addressed promptly.

4.15 Governance, Audit and Assurance

The Registered Manager and Infection Control Lead are responsible for monitoring implementation of this policy. Assurance activity will include infection prevention and control audits, hand hygiene audits, PPE checks, sharps bin checks, waste and laundry checks, cleaning audits, staff training compliance, competency checks, care plan audits, incident trend analysis and review of occupational exposure incidents.

Audit findings, incidents, near misses and themes must be reviewed through the service’s governance arrangements. Actions must be recorded, allocated to a responsible person, given a completion date and followed up to confirm completion and effectiveness. Where risks are identified, action must be taken without delay.

5. Policy Review

This policy will be reviewed at least annually, or earlier where required because of:

The review will be led by the Registered Manager and Infection Control Lead. Any changes will be communicated to staff, and training, competency checks, care plans, risk assessments and related procedures will be updated where required.

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.

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