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Registration Number: {{org_field_registration_no}}

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Managing Sharps Policy

1. Purpose

The purpose of this Managing Sharps Policy is to ensure that sharps are avoided wherever reasonably practicable and, where their use is necessary, that they are selected, handled, used, stored and disposed of safely within {{org_field_name}}.

The service will manage risks arising from sharps in accordance with applicable health and safety legislation, including 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 Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 and, where the service or activity falls within their scope, the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.

The policy also supports compliance with the Regulation and Inspection of Social Care (Wales) Act 2016 and the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, including the requirements relating to hygiene and infection control, the appropriate disposal of clinical waste, health and safety and safe medicines management.

Sharps include needles, lancets, syringes with attached needles, scalpels and other medical or non-medical items capable of puncturing or cutting the skin. Sharps contaminated with blood or body fluids may expose individuals to bloodborne viruses, including hepatitis B, hepatitis C and HIV.

{{org_field_name}} will ensure that risks associated with sharps are identified, assessed and reduced so far as reasonably practicable and that staff receive the information, training, equipment and support required to work safely. Sharps management will form part of the service’s infection prevention and control, medicines management, health and safety and quality assurance arrangements.

2. Scope

This policy applies to all staff employed at {{org_field_name}}, including healthcare professionals, domestic staff, agency workers, volunteers, and any third-party professionals working on-site. It is particularly relevant to staff who undertake clinical tasks involving the use of sharps for medical purposes, such as administering insulin or performing blood glucose monitoring. It also applies to the safe handling of any non-medical sharp items that may present a hazard.

3. Related Policies

This policy should be read in conjunction with the following policies:

• CHW11 – Safe Care and Treatment Policy
• CHW17 – Infection Prevention and Control Policy
• CHW21 – Medication Management and Administration Policy
• CHW22 – Handling and Disposal of Hazardous Substances Policy
• CHW24 – Management of Accidents, Incidents, and Near Misses Policy
• CHW18 – Risk Management and Assessment Policy
• CHW16 – Health and Safety at Work Policy

4. Policy Implementation and Operational Guidance

Risk Assessment and Sharps Register

The Registered Manager {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}} will ensure that suitable and sufficient risk assessments are completed for work involving sharps and for activities where staff or other persons may reasonably be expected to encounter discarded or contaminated sharps.

The risk assessment must consider:

• whether the use of a sharp can be avoided altogether;
• whether a needle-free or other non-sharp system can be used;
• where the use of a medical sharp cannot be avoided, whether a safer sharp incorporating an appropriate safety mechanism can reasonably practicably be used instead of a conventional unprotected sharp;
• the tasks and procedures in which sharps are used;
• the staff, individuals and other persons who may be exposed to risk;
• staff who may encounter sharps indirectly, including domestic, laundry, waste-handling and maintenance staff;
• the possibility of exposure to blood or other potentially infectious body fluids;
• the location and circumstances in which a sharps injury could occur;
• the equipment, safe systems of work, personal protective equipment, immunisation and occupational health arrangements required to control the identified risks;
• the location and suitability of sharps containers and arrangements for immediate disposal at the point of use;
• arrangements for managing sharps used by individuals who self-administer medicines; and
• emergency, reporting and post-exposure arrangements.

Control measures identified through the risk assessment must be implemented and communicated to relevant staff.

Risk assessments must be reviewed whenever there is reason to believe that they are no longer valid, following a sharps or exposure incident where the findings indicate that controls may need to change, and whenever there is a significant change in equipment, procedures, individuals’ needs, working arrangements or relevant legislation or guidance.

A Sharps Register will be maintained where this forms part of the service’s local risk-control arrangements. The register will identify the types of sharps used, their normal storage or use locations and the staff or roles authorised to use them. The register does not replace the requirement for suitable risk assessment.

Training and Competency

All staff who are required to use, handle or dispose of sharps will receive appropriate information, instruction and training before undertaking these duties and will receive refresher training in accordance with the service’s training programme, risk assessment and any change in equipment, procedure, legislation or guidance.

Training will include, as relevant to the person’s role:

• the risks associated with sharps and exposure to blood and body fluids;
• the correct use of sharps and safer sharps devices;
• measures for avoiding unnecessary use of sharps;
• safe handling and disposal procedures;
• correct selection, assembly, positioning, closure and disposal of sharps containers;
• circumstances in which recapping is prohibited and the exceptional arrangements that apply where recapping is required by a risk assessment;
• use of appropriate personal protective equipment;
• bloodborne-virus risks and relevant immunisation arrangements;
• action to take following a needlestick, sharps or blood/body-fluid exposure;
• internal incident-reporting arrangements;
• circumstances in which an incident may require reporting to external authorities; and
• the importance of reporting all sharps injuries and near misses so that risks can be investigated and reduced.

Training will be competency based and, where the role involves use of sharps, will include assessment of practical competence. Staff must not undertake a sharps procedure independently until they have been assessed as competent by an appropriately competent assessor.

Training and competency records will be maintained in accordance with the service’s staff training and record-keeping arrangements.

Occupational Health, Immunisation and Health Surveillance

The service will maintain appropriate occupational health arrangements for staff who may be exposed to blood, body fluids or contaminated sharps.

Where a COSHH risk assessment identifies a risk of occupational exposure to a biological agent for which an effective vaccine is available, arrangements will be made to establish whether relevant staff are already adequately immunised and the appropriate vaccine will be offered to staff who are not immune. Any vaccination required as a protective measure because of occupational risk will be made available without charge to the employee.

In relation to occupational exposure to blood and body fluids, particular consideration will be given to hepatitis B immunisation in accordance with current national immunisation guidance and the findings of the risk assessment.

Staff will be provided with appropriate information about:

• the benefits and limitations of vaccination;
• the consequences of accepting or declining vaccination;
• any required vaccination course, boosters or follow-up testing; and
• the action they must take following an occupational exposure.

An employee’s decision not to accept vaccination will be respected. Where an employee is not immune, the service will review the individual’s occupational risk and determine whether additional controls are required to enable them to work safely.

Occupational health and immunisation information will be handled confidentially. Appropriate health surveillance and health records will be maintained where required by the risk assessment and applicable health and safety legislation.

Use of Safer Sharps and Devices

The use of sharps will be avoided wherever reasonably practicable.

Where the use of a medical sharp cannot reasonably be avoided, the service will substitute a conventional unprotected medical sharp with a safer sharp incorporating a protection mechanism where it is reasonably practicable to do so.

Selection of safer sharps will take account of:

• whether the device is clinically appropriate for the intended procedure;
• whether it provides an effective reduction in the risk of accidental injury;
• reliability of the safety mechanism;
• ease and safety of activation;
• whether activation can be achieved without placing the user’s hands near the sharp;
• whether activation is clearly indicated by an audible, tactile or visual signal where applicable;
• whether use of the device introduces any additional risks; and
• the training and competency required for its safe use.

Staff who use a safer sharp must be trained and assessed as competent in the correct use and activation of its safety mechanism.

Where a suitable safer sharp is not reasonably practicable for a particular procedure, the reason must be addressed through the relevant risk assessment and safe working procedures must be implemented to reduce the risk of injury.

Handling of Sharps

All staff must follow safe working practices whenever sharps are used or handled.

Staff must:

• minimise unnecessary handling of sharps;
• keep the sharp pointed away from themselves and other persons during handling;
• use only equipment for which they have received appropriate training and, where required, have been assessed as competent;
• activate the safety mechanism of a safer sharp immediately after use in accordance with the manufacturer’s instructions;
• dispose of the sharp immediately after use into the appropriate sharps container at the point of use;
• ensure an appropriate sharps container is readily accessible and positioned safely before commencing the procedure;
• avoid passing exposed sharps directly from one person to another wherever this can reasonably be avoided;
• never bend, break or otherwise manually manipulate a used needle before disposal;
• never attempt to retrieve an item from a sharps container; and
• use personal protective equipment identified as necessary by the relevant risk assessment and infection prevention and control precautions.

Used needles must not be recapped.

The only exception is where a documented risk assessment has identified that recapping is itself necessary to prevent a greater risk. In such exceptional circumstances, a suitable device or procedure specifically designed to control the risk of recapping injury must be used. Two-handed manual recapping must not be undertaken.

Sharps must never be left unattended on beds, tables, medication trolleys, trays or other surfaces awaiting later disposal.

Where an individual self-administers an injectable medicine, the individual’s personal plan and relevant risk assessment must identify how sharps will be stored, used and disposed of safely while respecting the individual’s independence.

Sharps Containers and Disposal

Only approved, rigid, puncture-resistant and leak-resistant sharps containers suitable for the intended waste stream will be used.

Sharps waste must be segregated according to the contents of the sharp and any medicinal contamination. The appropriate waste stream must be selected in accordance with current Welsh healthcare-waste guidance and the service’s authorised waste-disposal arrangements.

As applicable:

• an orange-lidded sharps container will be used for sharps that are not contaminated with medicinal products;
• a yellow-lidded sharps container will be used for sharps contaminated with medicines other than cytotoxic or cytostatic medicines; and
• a purple-lidded sharps container will be used for sharps contaminated with cytotoxic or cytostatic medicines.

Staff must not deliberately discharge residual medicine from a syringe or other device solely in order to place the sharp into a different waste stream.

Sharps containers must:

• be correctly assembled in accordance with the manufacturer’s instructions before use;
• be clearly labelled in accordance with the manufacturer’s and waste contractor’s requirements, including appropriate identification of the source/location;
• be placed as close as reasonably practicable to the point where sharps are used;
• be positioned securely on an appropriate surface or mounting device and at a safe working height;
• be kept away from unauthorised access, including access by children or individuals whose assessed needs make access unsafe;
• not be positioned on the floor;
• not be used for items that are not appropriate to the designated waste stream;
• have the temporary closure applied when the container is not in active use where the container design requires this;
• never be filled beyond the manufacturer’s marked fill line;
• be permanently closed and correctly labelled before removal from the point of use; and
• be transferred to the designated secure clinical-waste storage area pending collection.

Once permanently closed, a sharps container must not be reopened.

Sharps waste must be collected and transported by an appropriately authorised waste contractor in accordance with applicable waste legislation and the service’s waste-management arrangements.

Waste transfer, consignment and collection documentation required for the service must be retained in accordance with applicable legal and organisational record-retention requirements.

Incident Reporting and Needlestick Injuries

Every needlestick injury, sharps injury, exposure to blood or potentially infectious body fluid, and sharps-related near miss must be reported promptly in accordance with the service’s incident-reporting arrangements.

Following a needlestick or sharps injury, the affected person must immediately:

1. encourage the wound to bleed gently without sucking or aggressively squeezing the wound;
2. wash the affected area thoroughly with soap and running water;
3. cover the wound with an appropriate waterproof dressing;
4. where blood or body fluid has splashed into the eyes, mouth or other mucous membrane, irrigate the affected area immediately with plenty of water;
5. report the incident immediately to the senior person on duty; and
6. obtain immediate medical advice through the service’s occupational health or other designated urgent post-exposure pathway.

The Registered Manager or person in charge must ensure that the incident is recorded and that an appropriate clinical risk assessment of the exposure is obtained without delay.

Where the injury has exposed, or may have exposed, an employee to a biological agent, the service will:

• ensure the employee receives immediate medical advice;
• ensure that any treatment advised by a registered medical practitioner, including post-exposure prophylaxis where indicated, is made available promptly;
• ensure appropriate follow-up arrangements are made; and
• consider whether counselling or other psychological support should be offered.

Confidentiality relating to both the injured person and any potential source individual must be maintained. Testing of, or obtaining information from, a source individual must only take place in accordance with consent, capacity, confidentiality and applicable clinical requirements.

All employee sharps injuries will be investigated to establish:

• the circumstances of the incident;
• the immediate and underlying causes;
• whether the relevant risk assessment was suitable and sufficient;
• whether appropriate equipment and a safer sharp were available and used;
• whether the sharps container was available and correctly positioned;
• whether training and competency were adequate; and
• what action is necessary to prevent recurrence.

Corrective action identified through the investigation must be implemented and monitored.

The Registered Manager must also determine whether the incident is reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013. This includes consideration of, but is not limited to:

• a sharps injury involving a sharp known to be contaminated with blood or body fluid infected with a relevant bloodborne virus;
• a diagnosed occupational infection resulting from exposure to a biological agent;
• an injury resulting in the applicable period of incapacity from work; or
• another specified reportable injury or dangerous occurrence.

Where an incident involves an individual receiving care and support, the service must additionally consider whether notification to Care Inspectorate Wales or another authority is required under the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

A sharps injury is not automatically notifiable to CIW solely because a sharp was involved. Where the injury to an individual meets the regulatory criteria for a serious accident or injury, the service provider must notify CIW without delay in the form and manner required by the service regulator. Current CIW notifications will be submitted through CIW Online.

Where a sharps incident raises a safeguarding concern, suspected abuse, neglect or improper treatment, the service’s safeguarding procedures and the Wales Safeguarding Procedures must also be followed.

Sharps incidents, exposure incidents and near misses will be reviewed for trends, learning and opportunities to improve safety.

Infection Control and Cleaning Protocols

Sharps management forms part of the service’s Infection Prevention and Control arrangements and must be undertaken in accordance with the service’s infection prevention and control policy, applicable COSHH assessments and current national infection prevention and control guidance.

This includes:

• regular checks of sharps containers and their locations;
• ensuring sharps containers are appropriately assembled, labelled, positioned and closed;
• ensuring the designated clinical-waste storage area is secure, clean and appropriately maintained;
• prompt and safe management of blood and body-fluid spillages;
• use of appropriate personal protective equipment and spill-management equipment;
• appropriate cleaning and decontamination of contaminated environmental surfaces or equipment; and
• safe disposal of contaminated waste through the correct waste stream.

Staff must follow standard infection prevention and control precautions and must treat blood and relevant body fluids as potentially infectious.

Audit and Monitoring

Monthly sharps-management audits will be undertaken as part of the service’s health and safety, infection prevention and control and quality assurance arrangements.

The audit will include, as applicable:

• the types and locations of sharps in use;
• whether use of sharps remains necessary;
• availability and appropriate use of safer sharps;
• correct positioning, assembly, labelling, temporary closure and final closure of sharps containers;
• correct segregation of sharps into the appropriate waste stream;
• whether any containers have been filled beyond the manufacturer’s fill line;
• security of sharps and clinical-waste storage;
• availability of appropriate personal protective equipment;
• staff training and competency;
• occupational health and immunisation arrangements where applicable;
• sharps injuries, blood/body-fluid exposures and near misses;
• incident investigations and completion of corrective actions;
• RIDDOR considerations and reports where applicable; and
• CIW notifications where applicable.

Any shortfall identified through audit must be risk assessed and acted upon in accordance with its seriousness. Where an immediate risk to individuals or staff is identified, action must be taken without delay.

Sharps incidents, near misses, audit findings and resulting actions will be included in the service’s wider quality assurance arrangements. Relevant aggregated information will be made available to the Responsible Individual to inform the review of the quality of care and support required by Regulation 80 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

The quality of care and support review must be undertaken as often as required and at least every six months. Relevant trends, lessons learned and required improvements arising from sharps management will be incorporated into that review and monitored through the service’s improvement arrangements.

5. Policy Review

This policy will be reviewed annually, or sooner if required by changes in legislation, guidance from Public Health Wales, or regulatory requirements. The Registered Manager is responsible for ensuring this policy remains up to date, is fully implemented, and reflects the high standards expected by CIW.

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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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