{{org_field_logo}}

{{org_field_name}}

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}} has effective arrangements for the prevention and management of exposure to blood-borne viruses (BBVs), including hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV).

This policy supports compliance with the Regulation and Inspection of Social Care (Wales) Act 2016; the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, including Regulations 12, 56 and 57; the Health and Safety at Work etc. Act 1974; the Control of Substances Hazardous to Health Regulations 2002 (COSHH); and, where applicable to the healthcare activities undertaken by the service, the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.

{{org_field_name}} will identify and assess risks arising from potential occupational exposure to blood and other potentially infectious body fluids and will implement suitable measures to prevent or adequately control those risks.

The service will maintain appropriate standards of hygiene and infection prevention and control, ensure the safe handling and disposal of clinical waste and sharps, provide appropriate information and training to staff, and maintain arrangements for the prompt management of occupational exposure incidents.

All individuals receiving care will be treated with dignity, respect and without unlawful discrimination irrespective of known or suspected BBV status. Standard infection prevention and control precautions will be applied according to the activity and risk rather than on the basis of a person’s known or assumed BBV status.

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)

Standard infection control precautions must be applied by staff whenever there is a risk of exposure to blood or body fluids, regardless of whether an individual’s BBV status is known.

Staff must undertake an assessment of the task and risk and apply the precautions appropriate to that activity. These include, where relevant:

• performing effective hand hygiene before and after care and after removing gloves;
• covering cuts, abrasions and broken skin with an appropriate waterproof dressing before undertaking activities where contact with blood or body fluids may occur;
• wearing appropriate personal protective equipment (PPE), including disposable gloves and aprons and, where there is a foreseeable risk of splashing to the face or eyes, appropriate eye and/or face protection;
• handling blood and body fluids in a manner that minimises the risk of exposure;
• managing blood and body-fluid spillages promptly using the service’s approved infection prevention and control procedures;
• cleaning and, where necessary, disinfecting or decontaminating reusable equipment following use in accordance with current guidance and the manufacturer’s instructions;
• safely handling, segregating and disposing of clinical waste;
• safely using and disposing of needles, lancets and other sharps; and
• immediately reporting and responding to needlestick, sharps, splash or other occupational exposure incidents.

All blood and body fluids must be regarded as potentially capable of transmitting infection where appropriate to the route of exposure. Additional precautions must not be imposed solely because an individual is known or suspected to be living with a BBV unless a specific clinical or infection-control risk assessment identifies that they are required.

These arrangements form part of the infection prevention and control procedures required by Regulation 56 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

4.4 Managing Clinical Procedures and Sharps Safely

Where staff undertake procedures involving needles, lancets or other medical sharps, {{org_field_name}} will assess the risks associated with those activities and implement suitable control measures.

Where the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 apply to the activities undertaken by the service, {{org_field_name}} will:

• avoid the unnecessary use of medical sharps so far as reasonably practicable;
• use safer sharps incorporating protection mechanisms where reasonably practicable and appropriate following risk assessment;
• ensure staff receive appropriate information and training before using sharps;
• ensure sharps containers conforming to the required standard are available as close as reasonably practicable to the point of use;
• ensure used sharps are disposed of immediately into the appropriate sharps container;
• ensure sharps containers are assembled, labelled, stored, closed and disposed of safely and are not filled beyond the manufacturer’s indicated fill line;
• prohibit the bending, breaking or unnecessary manipulation of used needles; and
• prohibit recapping or resheathing of used needles unless recapping is required by the particular procedure and an appropriate risk assessment has identified that it can be undertaken using a suitable device which controls the risk.

Staff must not attempt to retrieve items from a sharps container or manually compress its contents.

Any needlestick or other sharps injury must be treated as an occupational exposure incident and managed immediately in accordance with Section 4.5 of this policy.

The incident must be reported without delay to the Registered Manager or other designated person, recorded through the service’s incident-reporting arrangements and investigated so that any necessary corrective action can be identified and implemented.

4.5 Post-Exposure Management

Any needlestick injury, sharps injury, bite which breaks the skin, blood splash to the eyes or mouth, or contact between blood or another potentially infectious body fluid and broken or damaged skin must be treated as a potential occupational BBV exposure.

The exposed person must take the following immediate action:

• for a needlestick, sharps injury or other puncture wound, gently encourage the wound to bleed;
• do not suck or scrub the wound;
• wash the affected area thoroughly with soap and running water;
• where the eyes have been exposed, irrigate them immediately and thoroughly with clean water or sterile saline;
• where the mouth has been exposed, rinse the mouth thoroughly with water and spit the water out; and
• do not recap, retain or handle the used sharp unnecessarily following the incident; it must be disposed of safely into the appropriate sharps container.

The incident must be reported immediately to the Registered Manager, senior person on duty or other designated person and an incident record must be completed in accordance with CHW24 – Management of Accidents, Incidents, and Near Misses Policy.

Urgent clinical advice must be obtained following a significant exposure. The exposed person must be supported to obtain prompt assessment through the appropriate occupational health service, NHS service, emergency department or other locally agreed clinical pathway. Clinical assessment must not be unnecessarily delayed while information about the source individual is being obtained.

The healthcare professional assessing the exposure will determine the need for:

• assessment of the nature and significance of the exposure;
• baseline blood tests and subsequent follow-up testing;
• hepatitis B vaccination and/or hepatitis B immunoglobulin where clinically indicated;
• HIV post-exposure prophylaxis (PEP) where clinically indicated;
• specialist advice concerning hepatitis C exposure; and
• counselling, psychological support or additional occupational health support.

Where HIV PEP is clinically indicated, it must be accessed as urgently as possible because effectiveness is dependent upon prompt assessment and treatment.

Information about the source individual must be managed lawfully and confidentially. Testing of another individual must not be undertaken without appropriate lawful authority and consent processes. Staff must not make assumptions about infection risk based upon a person’s diagnosis, appearance, background or lifestyle.

Following an occupational exposure, {{org_field_name}} will investigate the circumstances of the incident, review the relevant risk assessment and control measures, identify any equipment, procedural or training issues and take action to reduce the likelihood of recurrence.

Where the incident meets the criteria for statutory reporting under RIDDOR or notification to CIW, the reporting requirements in Section 4.10 of this policy must be followed.

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, Risk Assessment and Occupational Safety

{{org_field_name}} will assess the risk of occupational exposure to blood-borne viruses arising from the work undertaken by employees in accordance with the Control of Substances Hazardous to Health Regulations 2002 and other applicable health and safety legislation.

The assessment will consider, where relevant:

• activities involving contact with blood or potentially infectious body fluids;
• the use and disposal of needles, lancets and other sharps;
• the possibility of accidental exposure through broken skin or mucous membranes;
• arrangements for cleaning, decontamination, laundry and clinical waste;
• appropriate PPE and other control measures;
• availability and suitability of safer sharps;
• arrangements for managing exposure incidents; and
• the need for hepatitis B immunisation.

Where a risk assessment identifies that an employee is at occupational risk of exposure to hepatitis B and an effective vaccine is appropriate, {{org_field_name}} will make arrangements for the employee to be offered hepatitis B immunisation in accordance with current national immunisation guidance. Appropriate occupational health advice, including any required pre-exposure assessment and follow-up, will be provided.

Employees will not be required to personally fund vaccination or other protective measures which the employer is required to provide because of occupational risk.

Relevant occupational health and immunisation records will be managed confidentially and retained in accordance with applicable health and safety, employment and data protection requirements.

Employees who believe that they may have been exposed to a BBV, or who have concerns regarding their own BBV status, will be supported to obtain confidential occupational health or medical advice without unlawful discrimination.

Where an employee is living with a BBV, any assessment of their fitness to undertake particular duties will be based upon the duties they perform, current occupational health advice and applicable professional guidance. Reasonable adjustments will be considered where required by the Equality Act 2010.

4.8 Training and Competency

All staff and volunteers must receive infection prevention and control information, instruction and training appropriate to their role and the activities they undertake.

Training must form part of induction and must be refreshed at intervals determined by the service’s training needs analysis, risk assessment, changes in legislation or national guidance, changes in staff duties, identified competency concerns, incidents or audit findings.

Training relevant to this policy will include, according to role:

• routes of transmission of blood-borne viruses;
• standard infection control precautions;
• hand hygiene;
• appropriate selection and use of PPE;
• prevention and management of blood and body-fluid exposure;
• management of blood and body-fluid spillages;
• safe handling and disposal of clinical waste;
• safe use and disposal of sharps;
• action following a needlestick, sharps or splash exposure;
• incident reporting and escalation arrangements; and
• confidentiality, dignity, equality and avoidance of discriminatory practice relating to BBV status.

Staff whose role requires them to undertake procedures involving sharps, blood sampling, wound care or other activities carrying an increased risk of BBV exposure must receive appropriate role-specific training and must be assessed as competent before undertaking those activities without appropriate supervision.

Records of relevant training and competency assessments must be maintained.

The Infection Control Lead, {{org_field_infection_control_lead_name}}, {{org_field_infection_control_lead_role}}, will support oversight of infection prevention and control training and competency, with overall accountability remaining with the service provider, Registered Manager and Responsible Individual in accordance with their respective statutory responsibilities.

4.9 Monitoring, Audit and Governance

{{org_field_name}} will monitor compliance with this policy and the effectiveness of its infection prevention and control arrangements.

Monitoring will include, where relevant:

• infection prevention and control audits;
• hand-hygiene practice;
• availability and appropriate use of PPE;
• management of blood and body-fluid spillages;
• safe use, storage and disposal of sharps;
• clinical-waste management;
• environmental cleaning and decontamination arrangements;
• occupational exposure incidents and near misses;
• staff training and competency;
• identified patterns, trends or recurring concerns; and
• implementation of actions arising from incidents, audits or external advice.

Needlestick injuries, sharps injuries and other occupational BBV exposure incidents must be recorded and investigated in accordance with the service’s accident and incident procedures.

Findings from incidents, audits and investigations will be used to identify learning and required improvements. Relevant actions will be monitored to completion and, where appropriate, shared with staff through supervision, team meetings, training or other governance arrangements.

Infection prevention and control information, including relevant incidents and trends, will contribute to the service’s systems for monitoring, reviewing and improving the quality and safety of care and support.

The Registered Manager and Responsible Individual will ensure that statutory notifications are made where the circumstances meet the criteria prescribed by legislation. An occupational BBV exposure is not automatically notifiable to Care Inspectorate Wales solely because an exposure has occurred. Notification to CIW will be made where the event falls within a notifiable category under the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, including, where applicable, an outbreak of an infectious disease, a serious accident or injury to an individual, an incident reported to the police or another event specified within Schedule 3.

4.10 Statutory Reporting and Notifications

The Registered Manager, service provider and Responsible Individual must ensure that incidents arising under this policy are considered against all applicable statutory reporting and notification requirements.

Care Inspectorate Wales

Notifications must be made to Care Inspectorate Wales where an event falls within a category specified in the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

Relevant categories may include:

• an outbreak of an infectious disease;
• a serious accident or injury to an individual receiving care and support;
• an incident which has been reported to the police; or
• an event which prevents, or could prevent, the provider from continuing to provide the service safely.

Notifications must be made within the timescale and using the method required by the applicable Regulations and CIW.

Where the service provides care and support to children, the Registered Manager and service provider must also consider any additional notifications required by Schedule 3 of the Regulations to the relevant local authority, health board, police or other prescribed body.

RIDDOR

Work-related needlestick, sharps or BBV exposure incidents must be assessed against the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR).

A report to the relevant enforcing authority must be made where the statutory RIDDOR reporting criteria are met. This includes circumstances in which:

• an employee suffers a sharps injury from a sharp known to be contaminated with a blood-borne virus and the incident meets the dangerous-occurrence reporting criteria;
• an employee is diagnosed with a BBV attributable to occupational exposure and the applicable occupational-disease reporting criteria are satisfied; or
• an injury resulting from the incident otherwise meets a reportable injury criterion under RIDDOR.

The Registered Manager must ensure that an appropriate person is responsible for determining whether a RIDDOR report is required and for submitting any required report within the applicable statutory timescale.

Internal incident reporting does not replace any statutory obligation to notify CIW, the Health and Safety Executive or another relevant authority.

5. Policy Review

This policy will be kept under review and updated whenever necessary to ensure that it remains consistent with the service’s Statement of Purpose, applicable legislation, statutory guidance, current national infection prevention and control guidance and the requirements of Care Inspectorate Wales.

A formal review will take place at least annually and earlier where required, including following:

• a change in relevant legislation, statutory guidance or regulatory requirements;
• publication or revision of relevant national infection prevention and control or occupational health guidance;
• a significant BBV exposure, sharps incident or outbreak;
• identification of a recurring incident, trend or control failure;
• an infection prevention and control audit identifying a material deficiency;
• a change to the activities undertaken by the service which alters BBV or sharps exposure risks; or
• advice or findings from Care Inspectorate Wales, Public Health Wales, the Health and Safety Executive, the local Health Protection Team or another relevant statutory body.

The Responsible Individual will ensure that suitable arrangements are in place for this policy and associated procedures to be kept up to date. Relevant changes will be communicated to staff and incorporated into training, supervision, risk assessments and working practices as necessary.

---

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.