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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Managing Blood-Borne Viruses (BBVs) Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} has robust, safe, and evidence-based procedures in place to manage blood-borne viruses (BBVs), including Hepatitis B (HBV), Hepatitis C (HCV), and Human Immunodeficiency Virus (HIV), in line with the Regulation and Inspection of Social Care (Wales) Act 2016, the Health and Safety at Work etc. Act 1974, the Control of Substances Hazardous to Health (COSHH) Regulations 2002, and guidance issued by Public Health Wales and Care Inspectorate Wales (CIW). This policy promotes a culture of safety, dignity, and inclusion, ensuring the protection of individuals receiving care, staff, and visitors while preventing discrimination and safeguarding public health.

2. Scope

This policy applies to all employees, agency staff, contractors, and volunteers at {{org_field_name}}. It covers all individuals receiving care, including those known to be living with a BBV or where BBV status is unknown. The policy also extends to anyone providing personal or clinical care, first aid, or handling sharps and bodily fluids within the care setting.

3. Related Policies

This policy should be read in conjunction with:
CHW11 – Safe Care and Treatment Policy
CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy
CHW16 – Health and Safety at Work Policy
CHW17 – Infection Prevention and Control Policy
CHW22 – Handling and Disposal of Hazardous Substances Policy
CHW24 – Management of Accidents, Incidents, and Near Misses Policy
CHW30 – Equality, Diversity and Inclusion Policy

4. Policy Details

4.1 Understanding Blood-Borne Viruses
BBVs are viruses that are carried in the blood and can be transmitted through direct contact with infected blood or certain body fluids. Common BBVs include HIV, HBV, and HCV. They are not transmitted through casual contact such as hugging, shaking hands, or sharing food. The main routes of transmission include sharing needles, needlestick injuries, unprotected sexual contact, and blood-to-blood contact via broken skin or mucous membranes.

4.2 Non-Discrimination and Confidentiality
{{org_field_name}} is committed to the inclusion and equal treatment of individuals living with BBVs. A person’s BBV status will not be used to deny access to care or services, nor will it result in unnecessary restrictions or disclosure. Information about an individual’s BBV status is confidential and treated in accordance with CHW34 – Confidentiality and Data Protection Policy. Only staff with a clear need to know (i.e., involved in direct care or medical support) will be informed, and this will be on a strictly ‘need-to-know’ basis, with consent wherever possible. All residents have the right to privacy and dignity in how their health information is managed.

4.3 Standard Infection Control Precautions (SICPs)
All staff must adhere to SICPs at all times, regardless of whether a person’s BBV status is known. This includes:
Wearing appropriate personal protective equipment (PPE), such as gloves and aprons, when handling blood or bodily fluids
Performing hand hygiene before and after all personal or clinical contact
Cleaning and disinfecting equipment and surfaces after use
Using safe procedures for the disposal of waste and sharps
Reporting and acting upon any exposure incidents (e.g., needlestick injuries)

These universal precautions eliminate the need to treat individuals differently based on their health status and ensure all staff and service users are protected.

4.4 Managing Clinical Procedures and Sharps Safely
Staff performing procedures involving blood (e.g., diabetes care, wound care) must be trained in safe techniques. Sharps (needles, lancets, etc.) must be disposed of in designated sharps bins that are clearly labelled and not overfilled. Sharps bins must be stored safely and replaced in accordance with waste management protocols. Needles must never be recapped. If a needlestick injury occurs, it must be treated immediately, with the wound encouraged to bleed, washed thoroughly, and reported to the Registered Manager. A risk assessment and occupational health referral must follow promptly.

4.5 Post-Exposure Management
In the event of a suspected BBV exposure (e.g., needlestick injury, bite, or blood splash to eyes or broken skin), the following steps must be taken:
Provide immediate first aid to the affected area
Report the incident to the Registered Manager and complete an incident form under CHW24
Seek medical advice from a GP, A&E, or occupational health service within one hour where possible
Support the staff member emotionally and ensure follow-up testing and counselling as needed
Investigate the incident and review any procedural failings or training gaps

Where PEP (Post-Exposure Prophylaxis) is appropriate, staff must be supported to access this without delay.

4.6 Caring for Individuals Living with a BBV
Care for individuals known to have a BBV is based on the same person-centred principles as all other care. No additional restrictions or precautions are applied unless clinically justified. The care plan will include any relevant medical considerations, with the individual’s informed consent. This may include medication adherence support or access to community clinics. Staff must ensure the person’s privacy and dignity at all times. Conversations about BBVs must be handled sensitively and without stigma. Staff are encouraged to support the individual’s understanding and self-management of their condition through appropriate information and access to external support.

4.7 Staff Health and Occupational Safety
All clinical staff at {{org_field_name}} who are at risk of occupational exposure to BBVs are offered hepatitis B vaccination in line with public health guidance. Vaccination status is recorded confidentially. Staff who have concerns about their own BBV status are supported to seek advice confidentially and without discrimination. Risk assessments are carried out for staff living with a BBV where necessary, and reasonable adjustments are made in line with occupational health advice and CHW30 – Equality, Diversity and Inclusion Policy.

4.8 Training and Competency
All staff receive mandatory infection prevention and control training on induction, with updates at least annually. This training includes BBV awareness, safe handling of sharps, and post-exposure protocols. Staff involved in clinical procedures receive additional training in aseptic technique, risk assessment, and managing incidents. The Infection Control Lead, {{org_field_infection_control_lead_name}}, {{org_field_infection_control_lead_role}}, oversees training compliance and audits procedures regularly.

4.9 Monitoring, Audits and Governance
Routine infection control audits are carried out to ensure compliance with SICP, waste disposal, sharps management, and environmental cleaning. Any incidents involving exposure to BBVs are logged, reviewed at management meetings, and reported to CIW under Regulation 60 if required. Lessons learned are shared with staff through debriefs and supervision. Policies are updated in line with best practice guidance from Public Health Wales and the local Health Protection Team: {{org_field_outbreaks_support_local_health_protection_team_website}}

5. Policy Review

This policy is reviewed annually, or earlier if there are changes to CIW requirements, public health guidance, or following any incident that highlights the need for change. It forms part of our wider commitment to infection prevention and control, staff safety, and human rights-based care.

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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.