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NA56-Sharps and Needlestick Injury Policy

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Registration Number: {{org_field_registration_no}}

Sharps and Needlestick Injury Policy

1. Purpose

The purpose of this policy is to provide clear, comprehensive, and up-to-date guidance on the safe handling and disposal of sharps, and the management of needlestick and sharps-related injuries within {{org_field_name}}. As a temporary staffing agency supplying registered nurses and healthcare assistants to care homes and other healthcare settings, {{org_field_name}} recognises its legal and moral duty to protect staff, service users, and others from the risks associated with sharps and needlestick injuries. This policy sets out the procedures that all staff must follow to minimise the risk of injury and blood-borne virus (BBV) transmission, and to comply with national legislation and best practice guidance.

This policy has been prepared with reference to the Health and Safety at Work etc. Act 1974; the Management of Health and Safety at Work Regulations 1999; the Control of Substances Hazardous to Health Regulations 2002; the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013; the Personal Protective Equipment at Work Regulations 1992, as amended; the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013; the Safety Representatives and Safety Committees Regulations 1977; the Health and Safety (Consultation with Employees) Regulations 1996; the Employment Agencies Act 1973; the Conduct of Employment Agencies and Employment Businesses Regulations 2003; the UK General Data Protection Regulation; the Data Protection Act 2018, as amended by the Data (Use and Access) Act 2025; and relevant guidance issued by the Health and Safety Executive, the UK Health Security Agency and the Department of Health and Social Care.

{{org_field_name}} is an employment business supplying temporary healthcare workers. It does not itself provide or manage regulated care and is not relying on this policy as evidence that it carries on a regulated activity requiring registration with the Care Quality Commission. Workers must nevertheless follow lawful local infection-prevention and sharps procedures operated by the healthcare provider at each placement.

2. Scope

This policy applies to:

This policy applies alongside the placement provider’s health and safety, infection-prevention, clinical-waste, occupational-health and incident-reporting procedures. Where the placement provider’s procedure imposes a higher standard of protection, the higher standard must be followed, provided it is lawful and has been communicated to the worker.

{{org_field_name}} and the placement provider must co-operate and exchange sufficient information to manage the worker’s health and safety. The placement provider ordinarily controls the premises, equipment, local working environment, supervision and immediate emergency arrangements. {{org_field_name}} remains responsible for the matters within its control, including suitable worker selection, provision of information, confirmation of competence, escalation, worker support and monitoring of placement safety.

3. Related Policies and Procedures

This policy should be read together with the following:

4. Policy Statement

{{org_field_name}} will take all reasonably practicable steps within its control to prevent injury and infection arising from medical sharps and occupational exposure to blood or other potentially infectious material.

In particular, {{org_field_name}} will:

Workers must use medical sharps only where they are competent, authorised and acting within their professional scope of practice and the placement’s documented procedures.

5. Responsibilities

5.1 Directors

The directors of {{org_field_name}} will:

5.2 Health and Safety Lead or Clinical Lead

The designated Health and Safety Lead or Clinical Lead will:

5.3 Recruitment and Placement Personnel

Recruitment and placement personnel will:

5.4 Placement Provider or Hirer

Before accepting or continuing a placement, {{org_field_name}} will seek written confirmation that the placement provider:

5.5 Agency Workers

Agency workers must:

6. Definitions

For the purposes of this policy:

Medical sharp means an object or instrument required for a healthcare activity which can cut, prick or otherwise cause injury. It includes needles, syringes with attached needles, cannulae, scalpels, lancets, stitch cutters, blades and other sharp medical instruments.

Safer sharp means a medical sharp designed and constructed with an integrated safety feature or mechanism which prevents or minimises accidental cutting or skin puncture.

Sharps injury means any cut, puncture, scratch or other injury caused by a sharp. For legal purposes under the Sharps Regulations, injury includes infection.

Occupational exposure incident includes:

Blood-borne virus means a virus transmitted through blood or certain body fluids, including hepatitis B, hepatitis C and human immunodeficiency virus.

Broken glass and other non-medical sharps are covered by the general duties under health and safety and COSHH legislation, even where they do not meet the specific definition of a “medical sharp” under the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.

7. Hazards Associated with Sharps and Blood Exposure

Sharps injuries and occupational exposure incidents may result in:

Circumstances increasing risk include:

8. Risk Assessment and Placement Suitability

{{org_field_name}} will assess the sharps-related risks within its control and will obtain sufficient information from the placement provider to determine whether the proposed work is suitable for the worker.

Before deployment, or as soon as reasonably practicable where an urgent placement is accepted, {{org_field_name}} will seek information about:

Risk assessments must consider the hierarchy of control and must:

The risk assessment must be reviewed where:

9. Information Before Placement

Before a worker undertakes duties involving sharps, {{org_field_name}} will provide or arrange access to sufficient information about:

The worker must promptly inform {{org_field_name}} if the actual assignment materially differs from the information supplied, particularly where the work involves clinical procedures or sharps use that were not disclosed before placement.

10. Safe Use and Handling of Sharps

Workers must:

Needles must not be recapped after use. An exception may only be made where recapping is specifically required to control another identified risk, the requirement is documented in a suitable risk assessment, and a purpose-designed appliance, tool or other equipment is used so that the needle is not held directly by hand.

Workers must not:

11. Safe Disposal of Sharps

Used sharps must be disposed of immediately at the point of use into a correctly assembled, clearly marked, secure and suitable sharps container.

Workers must:

Workers must not:

The placement provider is responsible for arranging collection, secure storage and lawful disposal of sharps waste generated on its premises, unless a written agreement expressly allocates that responsibility differently.

12. Personal Protective Equipment

Suitable PPE must be selected on the basis of the risk assessment and the procedure being undertaken.

Depending on the task, PPE may include:

Gloves may reduce contamination but do not prevent a needle or other sharp from puncturing the skin. PPE must therefore be used alongside, and not as a substitute for, safer equipment, safe systems of work, suitable disposal arrangements, training and supervision.

Workers must:

13. Hepatitis B Immunisation and Occupational Health

Where a risk assessment identifies foreseeable occupational exposure to blood or blood-stained body fluids, {{org_field_name}} will have arrangements to determine, through an appropriate occupational-health process, whether the worker has been offered suitable hepatitis B immunisation.

Effective immunisation must be offered to workers who are not already appropriately immunised and who are exposed to a relevant occupational risk. The vaccine must be made available without charge to the worker.

Workers must be given information about:

A worker may decline vaccination, but the decision and the information provided should be documented by the relevant occupational-health service. Refusal of vaccination does not remove the employer’s duty to control exposure by other reasonably practicable measures.

{{org_field_name}} should ordinarily receive only confirmation relevant to fitness for work, restrictions, recommended adjustments or required follow-up. Detailed clinical results must remain with the occupational-health or treating service unless disclosure is lawful and necessary.

14. Immediate Action Following a Sharps or Occupational Exposure Incident

The affected worker must stop work safely and take immediate first-aid action.

14.1 Puncture, cut or bite

The worker must:

14.2 Splash to the eye

The worker must:

14.3 Splash to the mouth or nose

The worker must:

14.4 Contact with broken or damaged skin

The worker must wash the affected area thoroughly with soap and running water and obtain clinical advice where exposure to blood or potentially infectious material may have occurred.

14.5 Immediate notification

Following first aid, the worker must immediately:

Medical assessment must not be delayed while an internal incident form is being completed or while responsibility for the incident is being discussed.

15. Urgent Clinical Assessment and Post-Exposure Management

Every potentially significant occupational exposure must receive an urgent assessment by a suitably qualified clinician, occupational-health professional, emergency department or specialist exposure service.

The assessment should consider:

HIV post-exposure prophylaxis is time-sensitive. Where it may be clinically indicated, assessment and access to treatment must occur without delay. The decision to prescribe, amend or discontinue post-exposure medication must be made by an appropriately qualified clinician.

{{org_field_name}} must maintain a clear arrangement for obtaining urgent advice outside normal office hours. A worker must not be directed merely to wait until the agency office or routine occupational-health service reopens.

The worker must:

{{org_field_name}} will provide reasonable support, including assistance with appointments, communication with the placement provider, wellbeing support and review of any work restrictions recommended by occupational health.

16. Source Individual Assessment and Testing

Where assessment or testing of the source individual may assist clinical management, it must be undertaken only by the placement provider or another authorised healthcare professional in accordance with applicable clinical, consent, confidentiality and capacity requirements.

Agency workers and agency office personnel must not:

A discarded sharp found in the environment must not be assumed to have been used on a particular individual unless this is reliably established.

The absence of source testing must not delay the affected worker’s urgent clinical assessment or clinically indicated treatment.

17. Internal and Statutory Incident Reporting

Every sharps injury, occupational exposure incident, defective safety device and relevant near miss must be reported promptly:

The report should record, so far as known:

Confidential clinical details, source-patient information and test results must not be entered into general incident records unless they are necessary, proportionate and lawfully recorded.

17.1 RIDDOR

The organisation responsible for the work activity must determine whether the incident is reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013. {{org_field_name}} and the placement provider must co-operate to identify the legally responsible reporting person and must not assume that the other organisation has submitted a report.

Depending on the circumstances, reporting may be required where:

An injury resulting in more than three consecutive days’ incapacity but not more than seven days must be recorded even where it is not reportable as an over-seven-day injury.

A clean needlestick injury, or an injury from a sharp whose contamination status is unknown, is not automatically reportable solely because infection was theoretically possible. The facts must be assessed against the applicable RIDDOR category and current HSE guidance.

Any RIDDOR decision, including a decision not to report, must be documented with the reasons and the identity of the competent person who made the decision.

18. Incident Investigation and Corrective Action

{{org_field_name}} will co-operate with the placement provider to investigate sharps injuries, exposure incidents and significant near misses.

The investigation must focus on prevention and should consider:

Corrective action may include:

Investigations must not automatically blame the injured worker or rely solely on retraining where equipment, workload, environment, supervision or organisational arrangements contributed to the incident.

19. Information, Instruction, Training and Competence

Workers who may be exposed to medical sharps must receive suitable information and training before undertaking relevant duties and at appropriate intervals thereafter.

Training must cover, where relevant:

Where practical skill is required, completion of online or classroom training alone is not sufficient. Competence must be assessed through evidence appropriate to the role, which may include supervised practice, simulation, manufacturer-specific instruction or confirmation by the placement provider.

Refresher training must be provided:

Training records must state the date, content, provider and assessment outcome.

20. Supervision, Welfare and Post-Incident Support

Placement providers must provide suitable local supervision having regard to the worker’s duties, experience, familiarity with the environment and the risks involved.

{{org_field_name}} will:

A worker must not be treated adversely merely because they report an injury, seek medical advice, participate in an investigation or raise a genuine safety concern.

21. Data Protection and Confidentiality

Information about an occupational exposure, vaccination status, blood-test result, diagnosis, medication or occupational-health recommendation is health information and special-category personal data.

{{org_field_name}} will process such information in accordance with the UK GDPR and the Data Protection Act 2018, as amended by the Data (Use and Access) Act 2025.

The organisation will:

Consent must not automatically be treated as the legal basis for routine employment-related health processing because the imbalance in the employment relationship may mean that consent is not freely given. Consent may nevertheless be relevant to specific clinical procedures or disclosure by a healthcare professional.

Managers should ordinarily receive only information about fitness for work, restrictions, adjustments and necessary follow-up, rather than detailed diagnoses or test results.

Information about a source individual must be treated as confidential and must not be disclosed to the affected worker or agency beyond what the treating clinician considers lawful and necessary for clinical management.

22. Consultation with Workers

{{org_field_name}} will consult workers, and any recognised safety representatives, on matters affecting their health and safety in accordance with applicable consultation legislation.

Consultation may include:

Workers are encouraged to identify hazards and recommend improvements without fear of detriment.

23. Monitoring, Audit and Continuous Improvement

The directors and designated Health and Safety Lead will monitor:

Information used for management reporting should be anonymised or aggregated where individual identification is unnecessary.

Where monitoring identifies serious, repeated or unresolved shortcomings, {{org_field_name}} will consider:

24. Policy Review

This policy will be formally reviewed at least annually and sooner where:

organisational responsibilities or occupational-health arrangements change.

relevant legislation or authoritative guidance changes;

a serious sharps injury or occupational exposure occurs;

incident or near-miss trends indicate that controls may be ineffective;

new equipment or working practices are introduced;

a placement provider, worker, safety representative, occupational-health provider or enforcing authority identifies a concern;

an audit identifies non-compliance; or

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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