DC137-Managing Sharps Policy

Registration Number: {{org_field_registration_no}}

Managing Sharps Policy

1. Purpose

The purpose of this policy is to ensure the safe handling, use, and disposal of sharps within our domiciliary care organisation. This policy is designed to minimise the risk of needlestick injuries, prevent infections, and ensure compliance with health and safety regulations. Proper sharps management is critical for protecting care workers, service users, visitors, and the wider community from potential hazards.

{{org_field_name}} will manage sharps in accordance with 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 Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013, the Health and Social Care Act 2008, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance, CQC Fundamental Standards, relevant waste legislation and UK data protection legislation. This policy supports safe care and treatment, infection prevention and control, good governance, safe staffing, effective incident reporting and the prevention of avoidable harm.

2. Scope

This policy applies to:

All employees, including care workers, administrative staff, and management.
Agency workers, volunteers, and contractors handling sharps.
Service users who require sharps for medical purposes.
Family members, representatives or unpaid carers where they are involved in the use, storage or disposal of sharps within the service user’s home.
Healthcare professionals visiting the service user’s home, including district nurses, community nurses, specialist nurses, GPs, paramedics and other clinicians, where shared care arrangements may affect sharps safety.
Situations where staff encounter sharps that have been used by the service user, their family, another professional, or an unknown person, including sharps found in the home environment.
Regulatory bodies, ensuring adherence to compliance and best practices.

It covers:

Safe handling and disposal of sharps.
Risk assessments and injury prevention.
Staff training and responsibilities.
Incident response and needlestick injury management.
Compliance monitoring and continuous improvement.

In domiciliary care, the service user’s own home is not owned or controlled by {{org_field_name}} in the same way as registered premises. However, staff must still assess and manage risks arising during care visits, including risks linked to prescribed sharps, self-administered medicines, diabetes care, injectable medicines, lancets, clinical waste and any unsafe storage or disposal arrangements. Where risks are identified, they must be recorded in the care plan, escalated to the Registered Manager and, where appropriate, discussed with the service user, their representative, prescriber, district nursing team, pharmacy or local authority.

3. Legal and Regulatory Framework

This policy aligns with the following legislation, regulations and guidance:

Health and Safety at Work etc. Act 1974 – requires employers to protect, so far as reasonably practicable, the health, safety and welfare of employees and others affected by the organisation’s activities.
Management of Health and Safety at Work Regulations 1999 – require suitable and sufficient risk assessments, preventive and protective measures, staff information, instruction and training.
Control of Substances Hazardous to Health Regulations 2002 (COSHH) – require assessment and control of exposure to hazardous substances, including biological agents and blood or body fluids that may present infection risks.
Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 – require the avoidance of unnecessary sharps use where reasonably practicable, use of safer sharps where reasonably practicable, prevention of recapping except in strictly controlled circumstances, clearly marked and secure sharps containers close to the point of use, staff information and training, and arrangements for recording, investigating and responding to sharps injuries.
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR) – require specified work-related injuries, dangerous occurrences and diseases to be reported to the Health and Safety Executive where reporting criteria are met, including certain sharps injuries involving known blood-borne virus contamination, seroconversion or reportable injury severity.
Health and Social Care Act 2008 – establishes the CQC regulatory framework for health and adult social care in England.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – particularly:
- Regulation 9 – Person-centred care, where sharps arrangements must reflect the service user’s individual needs, risks, preferences and care plan.
- Regulation 11 – Need for consent, where staff support or administer treatments involving sharps.
- Regulation 12 – Safe care and treatment, including risk assessment, risk mitigation, safe medicines management, safe equipment, infection prevention and control, and shared care planning.
- Regulation 15 – Premises and equipment, where equipment used in care must be safe, suitable, clean, secure and properly maintained.
- Regulation 17 – Good governance, requiring effective systems to assess, monitor and improve quality and safety and maintain accurate records.
- Regulation 18 – Staffing, requiring staff to have appropriate training, competence, skills and support.
- Regulation 20 – Duty of candour, where a notifiable safety incident involving a service user meets the statutory threshold.
Care Quality Commission (Registration) Regulations 2009, Regulation 18 – Notification of other incidents – requires CQC notification of specified incidents where applicable, including serious injuries to service users and other incidents that meet notification criteria.
Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance – provides statutory IPC guidance that registered providers must have regard to when demonstrating compliance with IPC requirements.
Environmental Protection Act 1990, Controlled Waste (England and Wales) Regulations 2012, Hazardous Waste Regulations and waste duty of care requirements – require healthcare waste, including sharps and contaminated clinical waste, to be correctly segregated, stored, transferred and disposed of through authorised arrangements.
UK GDPR and Data Protection Act 2018 – require personal and health information recorded in sharps risk assessments, incident reports, occupational health referrals, infection exposure records and safeguarding records to be processed lawfully, fairly, securely and confidentially.
NICE, UKHSA, NHS England, HSE and local authority guidance, where relevant to infection prevention and control, medicines safety, clinical waste and occupational exposure management.

4. Definition of Sharps

Sharps include any item, device or object that could cause a cut, puncture wound or laceration, whether or not it has been used for a medical purpose. This includes, but is not limited to:

Hypodermic needles.
Insulin needles and pen needles.
Lancets and finger-prick devices.
Syringes with fixed or detachable needles.
Scalpels and surgical blades.
Razor blades used as part of care or treatment.
Infusion sets or cannulation-related sharps.
Auto-injectors, where a needle is present after use.
Broken glass, glass ampoules or vials.
Any sharp medical instrument or item used in the delivery of personal care, healthcare or treatment.
Any unknown sharp found in a service user’s home, including discarded needles or drug-related litter.

4.1 Types of Sharps Encountered in Domiciliary Care

Sharps encountered in domiciliary care may include:

Prescribed sharps used by the service user, such as insulin needles, lancets or injectable medicines.
Sharps used by visiting healthcare professionals, such as district nurses or specialist nurses.
Sharps handled by care staff, only where this forms part of the agreed care plan and staff are trained and competent.
Sharps found unexpectedly in the home, including discarded needles or unsafe waste.
Contaminated non-medical sharps, such as broken glass contaminated with blood or body fluids.

Staff must not assume responsibility for clinical tasks involving sharps unless this is within the agreed care plan, has been risk assessed, is permitted by the organisation, and the member of staff has been trained, assessed as competent and authorised to undertake the task.

5. Safe Handling and Disposal of Sharps

To prevent injuries and infections, {{org_field_name}} follows strict sharps management procedures:

Handling Guidelines

Staff must only handle sharps where this is part of the agreed care plan, risk assessed, and within their role, training and competence.
The use of sharps must be avoided where reasonably practicable. Where sharps are required, safer sharps devices must be used where reasonably practicable.
Staff must never bend, break, manually remove, manipulate or recap needles after use, unless recapping is required by a specific risk assessment and a suitable appliance, tool or device is used to control the risk.
Sharps must be handled calmly and disposed of immediately after use.
Used sharps must never be passed directly from one person to another by hand.
Sharps must never be placed in domestic waste, recycling bins, handbags, pockets, aprons, medication bags or general clinical waste bags.
Staff must not attempt to retrieve items from a sharps container.
Staff must use appropriate PPE in line with the risk assessment and infection prevention and control procedures.
Any unsafe sharps practice, missing sharps bin, overfilled sharps bin or incorrectly stored sharps must be reported to the office or on-call
Sharps Disposal Procedures:

Sharps must be disposed of immediately after use into an approved sharps container that is correctly assembled, clearly marked, puncture-resistant, leak-resistant, stable and suitable for the type of sharps being used.
Sharps containers must be located as close as reasonably practicable to the point of use.
Sharps containers must be kept upright, temporarily closed when not in use, and stored safely away from children, visitors, pets and anyone who may be at risk.
Sharps containers must not be filled above the manufacturer’s fill line. Where no fill line is visible, the container must be sealed when it reaches no more than three-quarters full.
Staff must never force sharps into a container, shake a container, reopen a sealed container, or attempt to remove items from a container.
Full sharps containers must be locked or sealed in accordance with the manufacturer’s instructions.
Full sharps containers must be collected or returned only through an approved route, such as the supplying pharmacy, GP practice, community nursing service, local authority collection service or licensed waste contractor, according to local arrangements.
Sharps waste must be segregated from domestic waste and other healthcare waste.
Where a sharps container is unavailable, overfilled, damaged, leaking, incorrectly labelled or unsafe, staff must not proceed with the task until safe arrangements have been made and the issue has been escalated.

5.1 Service Users’ Own Sharps and Self-Administration

Where a service user self-administers medicines or treatment involving sharps, this must be reflected in the care plan and risk assessment. The assessment must consider:

Whether the service user can safely use, store and dispose of sharps.
Whether the service user requires prompting, supervision or practical support.
Whether staff are expected to handle any sharps or only observe, prompt or report concerns.
Whether a suitable sharps container is available and safely stored.
Whether the service user, family or representative understands safe disposal arrangements.
Risks to staff, the service user, children, visitors, pets and others in the home.
What action staff must take if sharps are left exposed, incorrectly disposed of, or stored unsafely.

Staff must not take over a clinical procedure involving sharps unless this has been agreed, risk assessed, documented, authorised and supported by training and competency assessment. Where the service user’s own arrangements create a risk, staff must report this to the Registered Manager so that advice can be sought from the prescriber, district nursing team, GP, pharmacist or local authority waste service as appropriate.

5.2 Unexpected or Unsafe Sharps Found in the Home

If staff find an exposed, discarded or unknown sharp in a service user’s home, they must:

Stop and assess the immediate risk.
Keep themselves and others away from the sharp.
Not pick up the item by hand.
Not place the item in domestic waste.
Contact the office, on-call manager or Registered Manager for immediate advice.
Follow the organisation’s risk assessment and local procedure for safe removal or escalation.
Record the concern and action taken.

Where there is an immediate risk to the service user or others, staff must take proportionate action to reduce the risk without putting themselves at risk. Where drug-related litter, repeated unsafe disposal, safeguarding concerns, self-neglect, environmental risk or criminal activity is suspected, the Registered Manager must consider referral to the relevant professional or agency, including the local authority, community nursing team, GP, safeguarding team or police, as appropriate.

6. Risk Assessments and Injury Prevention

A sharps risk assessment must be completed wherever staff may be exposed to sharps during care delivery. This includes care involving injectable medicines, diabetes care, lancets, needles, auto-injectors, clinical waste, or any home environment where sharps may be present.

Risk assessments must consider:

The type of sharps used or likely to be encountered.
Who uses the sharps, including the service user, staff, family members or visiting professionals.
Whether the task is within the care worker’s role and competence.
Whether safer sharps or needle-free alternatives are available and reasonably practicable.
Whether a suitable sharps container is available, correctly labelled, safely stored and close to the point of use.
Whether the sharps container is at risk of overfilling, damage, spillage, tampering or unsafe access.
Risks to staff, service users, children, visitors, pets and other people in the home.
Infection risks, including possible exposure to blood-borne viruses.
The service user’s capacity, dexterity, cognition, mental health, substance misuse risks or behaviours that may affect sharps safety.
PPE requirements.
Waste collection or return arrangements.
Emergency action in the event of sharps injury, spillage or unsafe disposal.

Risk assessments must be reviewed:

At the start of care.
When a new sharps-related task is introduced.
Following any sharps incident, near miss or concern.
When the service user’s needs, medicines, capacity, environment or support arrangements change.
During planned care review, audit or supervision.

The Registered Manager must ensure identified risks are reduced so far as reasonably practicable and that control measures are recorded in the care plan.

6.1 Immunisation and Occupational Health

{{org_field_name}} will assess occupational exposure risks for staff who may come into contact with blood, body fluids or contaminated sharps. Where indicated by risk assessment, staff will be advised about occupational health arrangements, including hepatitis B vaccination, post-vaccination testing where appropriate, and how to access medical advice following exposure.

Staff are encouraged to inform the Registered Manager confidentially if they have any health condition, pregnancy, immunosuppression or other factor that may affect their risk from exposure to blood or body fluids. Any health information will be managed confidentially in accordance with UK data protection legislation.

The organisation will ensure staff know how to access urgent medical advice following a sharps injury, including out-of-hours arrangements.

7. Staff Training and Responsibilities

All staff who may encounter sharps must receive role-appropriate training before undertaking sharps-related tasks and at intervals determined by risk assessment, supervision, audit findings, incidents or changes in guidance. Training must include:

The risks associated with sharps, including blood-borne viruses and infection transmission.
The safe use and disposal of medical sharps.
The correct use of safer sharps where these are used.
The prohibition on bending, breaking, manipulating or recapping needles, except where a specific risk assessment permits recapping using a suitable device.
Correct use, positioning, storage and closure of sharps containers.
The safe management of service users’ own sharps in domiciliary care.
What to do if unsafe sharps or discarded needles are found in the home.
PPE and standard infection prevention and control precautions.
Immediate first aid following a sharps injury.
How to report incidents, near misses and unsafe practice.
RIDDOR reporting principles.
When occupational health, medical advice, post-exposure prophylaxis or counselling may be required.
Record keeping, confidentiality and escalation.

Staff must not carry out sharps-related tasks unless they have been trained, assessed as competent and authorised to do so.

The Registered Manager and supervisors are responsible for:

Ensuring sharps risks are assessed and recorded in care plans.
Ensuring staff are trained, competent and supervised.
Ensuring staff have access to relevant PPE and safe systems of work.
Ensuring incidents, near misses and unsafe conditions are reported, recorded, investigated and acted upon.
Ensuring RIDDOR reports are made where required.
Ensuring CQC notifications are made where a sharps incident meets the relevant notification threshold.
Ensuring learning from incidents is shared with staff and used to improve practice.
Ensuring this policy is reviewed following relevant incidents, audits, changes in legislation or changes in guidance.

8. Incident Response and Needlestick Injury Management

A sharps injury includes any puncture wound, cut, scratch or contamination incident involving a sharp, whether or not the sharp is known to be contaminated. Staff must treat all sharps injuries as potentially significant until assessed.

Immediate first aid following a sharps injury:

Encourage the wound to bleed gently. Do not suck the wound.
Wash the affected area thoroughly with soap and running water.
Dry and cover the wound with a waterproof dressing.
If blood or body fluid splashes into the eyes, nose or mouth, rinse thoroughly with plenty of water.
Report the incident immediately to the office, on-call manager or Registered Manager.
Seek urgent medical advice, especially where the sharp may be contaminated with blood or body fluids.

Management action following a sharps injury:

The Registered Manager or delegated senior person must:

Ensure the staff member receives appropriate medical advice as soon as possible.
Ensure post-exposure prophylaxis is made available where advised by a registered medical practitioner.
Consider whether counselling or wellbeing support is required.
Record the incident in the accident/incident reporting system.
Investigate the circumstances and cause of the incident.
Review the risk assessment and care plan.
Take action to prevent recurrence.
Consider whether the incident is reportable under RIDDOR.
Consider whether a CQC notification, safeguarding referral, duty of candour response or other external notification is required.
Maintain confidentiality of the staff member and service user.

RIDDOR reporting:

A work-related sharps injury must be reported under RIDDOR where it meets reporting criteria. This includes where an employee is injured by a sharp known to be contaminated with a blood-borne virus, where a blood-borne virus acquired through the injury seroconverts, or where the injury itself meets reportable injury criteria. If the sharp is not known to be contaminated and the source cannot be traced, it is not normally RIDDOR-reportable unless the injury causes an over-seven-day absence or the employee later develops a reportable disease attributable to the injury.

Incident learning:

All sharps incidents and near misses must be reviewed for learning. Actions may include staff retraining, care plan review, change of equipment, safer sharps use, improved waste collection arrangements, referral to healthcare professionals, or safeguarding escalation.

8.1 CQC Notification, Safeguarding and Duty of Candour

The Registered Manager must review every sharps incident to decide whether external notification is required. This may include:

CQC notification where the incident meets the threshold for notification under the Care Quality Commission (Registration) Regulations 2009, including serious injury to a service user or another notifiable event.
Duty of candour where a notifiable safety incident involving a service user has occurred and the statutory criteria are met.
Safeguarding referral where unsafe sharps use, unsafe disposal, self-neglect, neglect by others, deliberate harm, domestic abuse, substance misuse risk, environmental risk or exploitation may place the service user or others at risk of abuse or harm.
RIDDOR reporting where a work-related staff sharps injury meets HSE reporting criteria.
Local authority or waste service referral where unsafe clinical waste arrangements create risk.

The rationale for making or not making an external notification must be recorded.

8.2 Blood-Borne Virus Exposure and Source Information

Following a sharps injury, staff must not attempt to obtain blood samples, medical history or infection status from a service user unless this is managed by an appropriate healthcare professional and lawful consent has been obtained. Any information about possible exposure to hepatitis B, hepatitis C, HIV or another infection must be handled confidentially and shared only with those who need it to manage the incident, treatment, reporting or safeguarding response.

Staff must not make assumptions about infection risk based on a person’s age, disability, diagnosis, ethnicity, sexuality, lifestyle, substance misuse history or any protected characteristic. Risk assessment must be based on the circumstances of the incident and professional medical advice.

9. Compliance Monitoring and Continuous Improvement

{{org_field_name}} will monitor compliance with this policy through:

Care plan and risk assessment audits where sharps are used or present.
Checks that sharps arrangements are documented for service users who self-administer injectable medicines or use lancets.
Incident and near-miss analysis.
Review of RIDDOR, CQC notification, safeguarding and duty of candour decisions.
Staff training and competency records.
Supervision and spot checks.
Feedback from staff, service users, families and professionals.
Review of waste collection or return arrangements where the organisation has responsibility for arranging disposal.

Audit findings must be recorded and used to improve practice. Where concerns are identified, the Registered Manager must ensure that corrective actions are allocated, completed and reviewed for effectiveness.

Lessons learned from sharps incidents must be shared with relevant staff while maintaining confidentiality. Where required, the policy, training materials, care plans or risk assessments must be updated.

9.1 Records to be Kept

The following records must be maintained where applicable:

Sharps risk assessments.
Care plan entries relating to sharps use, storage and disposal.
Staff training and competency assessments.
Incident and near-miss reports.
Accident book entries.
Investigation records and action plans.
RIDDOR reports and decisions not to report.
CQC notifications and decisions not to notify.
Safeguarding referrals and outcomes.
Duty of candour records.
Occupational health referrals, where applicable.
Waste transfer or collection documentation where {{org_field_name}} arranges or controls the disposal.

Records must be accurate, factual, timely, securely stored and retained in line with the organisation’s records management policy and legal requirements.

9.2 Waste Management and Duty of Care

Sharps waste must be segregated, stored and disposed of safely. Sharps must never be disposed of in domestic waste, recycling, offensive waste bags or general clinical waste bags.

Where the service user is responsible for their own sharps disposal, staff must check that safe arrangements are documented in the care plan and report any concerns. Where {{org_field_name}} arranges or controls sharps disposal, the organisation must ensure that:

The correct type of sharps container is used.
The container is labelled and securely closed before collection or return.
Waste is transferred only through an authorised route.
Waste transfer documentation is retained where legally required.
Staff do not transport sharps in private vehicles unless this has been risk assessed, authorised and is lawful under the relevant waste and transport requirements.

If there is uncertainty about local disposal arrangements, the Registered Manager must seek advice from the local authority, supplying pharmacy, GP practice, community nursing team or licensed waste contractor.

10. Policy Review and Updates

This policy will be reviewed at least annually or sooner if:

Legislation, statutory guidance, CQC guidance, HSE guidance, IPC guidance or waste guidance changes.
A sharps incident, near miss, RIDDOR report, CQC notification, safeguarding concern or complaint identifies the need for review.
Audit, supervision, spot checks or competency assessments identify gaps in practice.
New sharps-related tasks, medicines, equipment or safer sharps devices are introduced.
There are changes to local waste collection, pharmacy return or community nursing arrangements.
Feedback from staff, service users, families or professionals indicates that the policy requires improvement.

The Registered Manager is responsible for ensuring that any changes are communicated to relevant staff and that staff training, care plans and risk assessments are updated where required.

11. Staff Acknowledgement

Staff who may encounter or handle sharps must confirm that they have read and understood this policy and agree to follow the organisation’s sharps safety procedures. Managers must ensure that staff understanding is checked through induction, supervision, competency assessment, refresher training and incident review.

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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