CONTROL OF SUBSTANCES HAZARDOUS TO HEALTH POLICY Links to the following Policies and Procedures: Health and Safety Policy, Risk Assessment Policy, Infection Control Policies and Procedures, Waste Management Policy, Serious Incidents Reporting & Handling Procedures, Latex Policy, Medicines Policy, Pregnant Staff and New Mothers Policy, Safe Management of Contractors Policy

Document Type H&S Policy Unique Identifier HS-001 Document Purpose Health and Safety of employees and non-employees Document Author Health and Safety Managers Target Audience All staff Responsible Group H&S Committee Date Ratified June 2014 Expiry Date June 2017

The validity of this policy is only assured when viewed via the Worcestershire Health and Care NHS Trust website (hacw.nhs.uk.). If this document is printed into hard copy or saved to another location, its validity must be checked against the unique identifier number on the internet version. The internet version is the definitive version. If you would like this document in other languages or formats (i.e. large print), please contact the Communications Team on 01905 760020 or email [email protected].

Control of Substances Hazardous to Health Policy

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Version History Version 1

Circulation Date 09/11

2 3 4

10/11 11/11 11/13

5

05/14

Job Title of Person/Name of Group Brief Summary of Change Circulated to H&S Committee members & Union Merge of PCT and MHPT policy H&S Reps JNCC N/A Quality & Safety Committee Ratified for use Quality & Safety Committee Amended for new incident reporting system H&S Committee members & Union Minor changes as part of H&S Reps scheduled review

Accessibility Interpreting and Translation services are provided for Worcestershire Health and Care NHS Trust, including: • • • •

Face to face interpreting; Instant telephone interpreting; Document translation; and British Sign Language interpreting

Please refer to intranet page: http://nww.hacw.nhs.uk/a-z/services/translation-services/ for full details of the service, how to book and associated costs.

Training and Development Worcestershire Health and Care NHS Trust recognise the importance of ensuring that its workforce has every opportunity to access relevant training. The Trust is committed to the provision of training and development opportunities that are in support of service needs and meet responsibilities for the provision of mandatory and statutory training. All staff employed by the Trust are required to attend the mandatory and statutory training that is relevant to their role and to ensure they meet their own continuous professional development.

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CONTROL OF SUBSTANCES HAZARDOUS TO HEALTH POLICY CONTENTS Page 1.

Introduction

4

2.

Definitions

4

3.

Purpose / Statement

4

4.

Responsibilities

5

5.

Arrangements

5

6.

Risk Assessment

6

7.

Record Keeping

7

8.

Risk Reducing Measures

7

9.

Personal Protective Equipment

8

10.

Training & Information

8

11.

Spillage / Contamination / Disposal

8

12.

Health Surveillance

9

13.

Consultation & Communication with Stakeholders

9

14.

Development & Approval of Procedural Documents

9

15.

Dissemination

9

16.

Planning & Implementation

9

17.

Monitoring & Review

10

18.

Outcomes /Key Performance Indicators

10

19.

References

10

Appendices 1.

Handling Cytotoxic Material

2.

Dangerous Substances and Explosive Atmospheres Regulations

11

– (DSEAR) Guidance

12

3.

COSHH Inventory

13

4.

COSHH Assessment Form

14

An Equality Analysis Assessment has been carried out on this policy

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CONTROL OF SUBSTANCES HAZARDOUS TO HEALTH POLICY 1.

INTRODUCTION Worcestershire Health and Care NHS Trust (the Trust) acknowledges that it has a duty to protect its employees, patients/service users and others who may be exposed, to hazardous substances. The Control of Substances Hazardous to Health Regulations (COSHH) require the Trust to assess and control the risks which employees and others may be exposed to from hazardous substances at work. The Trust will ensure that such assessments are carried out and that all reasonable steps are taken to ensure that exposure is either prevented or at least controlled to within statutory limits. Where exposure cannot be adequately controlled by engineering means or safe systems of work, then appropriate personal protective equipment (PPE) will be provided. All staff will be provided with comprehensible information and instruction on the nature and likelihood of their exposure to substances hazardous to health. The implementation of this policy requires the co-operation of all members of staff and management.

2

DEFINITIONS Hazardous substances: All substances with the potential to cause harm by chemical or biological properties. Examples include: 

Those substances classified as very toxic, toxic, harmful, corrosive, irritant, sensitising, carcinogenic, mutagenic or toxic to reproduction.



Substances assigned a Workplace Exposure Limit (WEL).



Dust.



Biological agents such as bacteria, viruses, fungi, parasites.

Substances that do not fall under COSHH include – asbestos, lead, substances containing explosive or flammable properties, medicines prescribed for treatment purposes. Material Safety Data Sheets (MSDS): information on any classified hazardous substance which the manufacturer or supplier is legally required to provide to the Trust. Personal Protective Equipment (PPE): any item of clothing or equipment designed to provide protection to an individual from exposure to a hazard via ingestion, absorption, impact, inhalation or puncture e.g. gloves, face masks, eye shields.

3

PURPOSE / STATEMENT This policy applies to all employees, contractors, patients and visitors who may come into contact with hazardous substances used by the Trust. The Trust is committed to ensuring peoples’ exposure to hazardous substances is either prevented or adequately controlled. It aims to do this by: a)

Assessing the health risks that may arise from hazardous substances used by the Trust in order to evaluate control measures and identify how these risks could be removed or reduced.

b)

Implementing systems of work for hazardous substances that allows them to be used, handled and stored safely.

c)

Providing guidance and information to staff on the risks from hazardous substances and the controls in place to protect peoples’ health.

d)

Monitoring controls to ensure they are adhered to i.e. maintenance and testing of equipment, up to date inventory records, communication of assessment findings. Control of Substances Hazardous to Health Policy

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4.

RESPONSIBILITIES 4.1

Chief Executive

The Chief Executive has overall responsibility for this policy and to ensure that reasonably practicable control measures can be implemented to reduce any health risks from hazardous substances used at work. 4.2

Risk and Health & Safety Managers

These staff are responsible for monitoring and reviewing this policy to ensure it allows the Trust to comply with current legislation. They can provide guidance and support to staff who are undertaking assessments or need assistance in identifying what measures can be taken to remove or reduce risks from exposure. They will monitor ill health incidents that are believed to be caused by poor use and handling of hazardous substances and report these to the H&S Committee as appropriate. 4.3

Line Managers

Managers have a responsibility for the health and wellbeing of their staff. They are expected to identify any hazardous substances used within their service areas, maintaining an inventory of these substances and their associated MSDS (see Appendix 1). Managers are responsible for ensuring the completion of COSHH risk assessments and the implementation of any risk reduction measures as a result of the assessments (see Appendix 2). These measures and safe systems of work must be communicated with their staff and anyone who may be exposed to the substance. Managers are also responsible for assessing any new substances and reviewing assessments annually to ensure information is still valid. Managers should ensure their staff have received sufficient information and instruction in the safe use, storage and disposal of any hazardous substances, including emergency procedures for dealing with spills and the use of PPE. They should also ensure that staff are referred to Occupational Health for health surveillance in line with any risk assessment findings. 4.4

Employees

All staff are required to comply with the policy and co-operate with the completion of any assessments. They must take reasonable care of themselves and others while using hazardous substances and follow any manufacturer’s instructions or safe system of work designed to control exposure. In line with the PPE Regulations, staff are legally required to use any PPE that has been provided for their protection. They should inform their line manager of any faulty PPE or defective equipment. This includes reporting incidents, spills etc. All staff should practice a high standard of personal hygiene and make proper use of facilities for washing, eating and drinking. They should also report any health concerns to their line manager and attend any health surveillance arranged with Occupational Health. 4.5

Occupational Health Service

The Worcestershire Acute Trust Occupational Health team are available to provide health surveillance checks on staff who are exposed to hazardous substances. They will inform staff and managers of the surveillance results and keep records on file. They can also offer advice and counselling to any Trust staff who suspect they may be suffering from a health problem related to workplace hazardous substances.

5.

ARRANGEMENTS The Trust will, in consultation with staff and their representatives, implement the following: a)

Any departments who use hazardous substances will maintain an inventory of items together with appropriate safety information. Control of Substances Hazardous to Health Policy

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6.

b)

Any work that involves exposure to a hazardous substance will be assessed and appropriate control measures will be taken where elimination or substitution of the substance is not possible.

c)

All engineering controls will be properly maintained and monitored by the Estates and Facilities Department or an appointed contractor, to ensure their effectiveness.

d)

All members of staff who work in the affected areas will be informed by the Estates and Facilities Department of the purpose and safe operation of all engineering controls.

e)

PPE will be provided and used where necessary following an assessment of the need and appropriateness of such equipment. (See Section 9 below)

f)

All PPE will be maintained according to manufacturers’ instructions.

g)

Appropriate instruction will be provided for members of staff, who are required to wear items of PPE.

h)

All changes to control measures and changes of PPE will be properly assessed and no new substances will be introduced into the workplace without prior permission from the responsible manager.

RISK ASSESSMENT A COSHH assessment is legally required for each hazardous substance used by the Trust. The assessment form is provided in Appendix 2. The line manager will undertake these assessments in consultation with the staff who use the substance. When completing these assessments, staff will need access to the MSDS, manufacturer’s instructions and any HSE best practice guidance. Support is also available from the Risk and H&S Managers. The assessment should consider the following arrangements: •

Storage – substances stored in a safe and secure manner

•

Labelling – substances kept in their original containers

•

Transport – arrangements for arriving on site, moving around site

•

Use – safe handling

•

Local ventilation – visual checks on equipment and maintenance every 14 months

•

General ventilation – in line with building requirements

•

Waste disposal – in line with legislation

•

Provision of PPE – correct type, protective standard, size, maintained in a clean condition and stored securely

•

Training – new starters instructed in local procedures, safe systems of work and all staff receive information on new substances

•

Health surveillance – routine monitoring by Occupational Health

•

Welfare facilities – adequate wash rooms and changing facilities

•

Emergency procedures – arrangements for dealing with incidents

The assessment will evaluate the existing control measures and determine whether further action is needed to remove or reduce the risk of harm from exposure to the substance (see Risk Reduction Measures below). Managers are required to communicate the assessment findings to their staff and retain a copy of the assessment on file. Assessments should be reviewed annually or alternatively when there are significant changes to the work process, the environment, or the user’s health.

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7.

RECORD KEEPING The Trust will hold and maintain the following records:

8.

a)

An inventory of hazardous substances

b)

Assessments on the risks of exposure, including the control measures provided for staff

c)

Details of any examination, testing and repairing of control measures will be kept by the Estates department.

d)

Results from any exposure monitoring used to identify background exposure or proof of adequate levels of control will be kept by the Estates department. Results from the monitoring of individuals, who may be exposed, will be kept on their personal files.

e)

Details of any training given to staff relating to the safe use of hazardous substances

RISK REDUCING MEASURES If the risk assessment has identified that further control measures are needed, then the following factors should be considered and implemented where reasonably practicable: •

Eliminating the substance and/or substituting it for a safer alternative

•

Modifying the work process to isolate the substance and/or the number of people exposed

•

Using engineering controls or equipment which are properly maintained and cleaned

•

Developing safe systems of work and emergency procedures that are followed by staff

•

Using personal protective equipment in line with manufacturer’s instructions

•

Staff follow up to date hazard information e.g. MSDS



Ensure that members of staff are trained in the nature of the hazards and the use of control measures.



Ensure that staff report faults and problems immediately upon discovery.

The HSE recommend the following storage arrangements to reduce the risk of harm occurring: •

Control access to the storage area

•

Use signage to identify the storage area and any cabinets

•

Ensure the area is ventilated, well lit and organised

•

Ensure all product containers are labelled

•

Keep ignitable materials and oxidising agents in a separate store room

•

Ensure that containers are easy to pour from, don’t drip and don’t trap liquid in a rim

•

Always replace container lids

•

Store containers so their labels face forwards

•

Keep the minimum quantity of substance necessary

•

Store incompatible substances separately

•

Small product containers can be stored in a suitable, robust storage cabinet

•

Use removable trays within cabinets to contain leaks / spills, and make cleaning easier

•

Keep storage cabinets locked Control of Substances Hazardous to Health Policy

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9.

•

Storage cabinets should be cool, dark and dry

•

Store heavier items and corrosive chemicals on lower shelves

PERSONAL PROTECTIVE EQUIPMENT (PPE) The Trust will provide PPE, when the risk presented by a work activity cannot be adequately controlled by other means. The proper use of such protective equipment can help to reduce risks to a minimum. Where any risk assessment has identified the use of PPE, line managers will need to ensure that these items are selected in accordance with the recommendations from the substance manufacturer. The PPE should therefore be: 

The correct type



Provide the appropriate level of protection



Suitable for the individual and fit them correctly



Available in different sizes or styles to suit the needs of the staff e.g. if there is a latex allergy



Stored in suitable accommodation



Have adequate cleaning, disposal and replacement arrangements

These arrangements should be in line with any instructions from the PPE manufacturers, HSE best practice and advice from Infection Control. Where a problem arises in the use of PPE, the member of staff must complete an incident report and inform their manager / supervisor immediately. Where a member of staff raises a concern, related to health and safety in the use of PPE, the Trust will take all necessary steps to investigate the circumstances and, where appropriate, implement any corrective measures. PPE is only effective in protecting the wearer or user, where the following steps are taken:

10

a)

Only use PPE, in accordance with the manufacturer’s instructions and only for activities, for which it is designed to provide protection.

b)

Only use PPE, if fully trained in its safe use.

c)

Store, clean, repair and maintain PPE correctly, replacing any items which have been damaged and are no longer serviceable.

d)

If provided, staff have a legal duty to wear PPE

TRAINING & INFORMATION Basic instruction in the safe and correct use of hazardous substances is included within this policy. Information on hazardous substances is provided to new staff as part of their departmental induction. This will be via MSDS information, risk assessments and instruction from a supervisor. In depth support and/or guidance on the safe use of hazardous substances is available to staff via the Risk and H&S Managers, Occupational Health or Infection Control. As far as possible the Trust will follow any HSE best practice. Any requirements for additional training should be raised with the staff member’s line manager and identified within their training needs analysis. Specific in-house COSHH training is available to the Facilities staff for the substances they use.

11

SPILLAGE / CONTAMINATION / DISPOSAL Any contamination of the skin should be washed thoroughly with lots of soap and water. Contaminated clothing must be removed as soon as possible and washed separately. Eyes that have been contaminated should be bathed immediately with water for at least five Control of Substances Hazardous to Health Policy

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minutes. Medication examination in Minor Injuries or A&E is recommended in case further treatment is required. Spills should be cordoned off immediately and signs displayed warning of the hazard. Staff should follow the manufacturer’s recommendation for dealing with any spills as this may vary depending on the type of substance. Any instances of contamination or injury resulting from a hazardous substance should be reported via the Trust’s incident reporting system. Hazardous substances must be disposed of in accordance with the manufacturers’ MSDS information. This will normally be via the appropriate waste stream using licensed waste disposal companies. Where chemicals can be disposed of using other methods, the contaminant must not affect the water table by the inappropriate use of surface drains.

12

HEALTH SURVEILLANCE The Trust has access to Worcestershire Acute Trust’s Occupational Health Services. They are able to provide health surveillance to staff under the following conditions: •

If staff are exposed to a substance which is linked to an identifiable disease or adverse health effect

•

If there is a reasonable likelihood that the disease/health effect will occur under the conditions of work, and

•

If there are techniques for detecting the disease or health effect

The Occupation Health team will manage any health surveillance. The findings will be communicated to the staff and their line managers.

13

CONSULTATION & COMMUNICATION WITH STAKEHOLDERS The Trust’s Health and Safety Committee provides a forum at which management can consult with staff about any health and safety issues, in good time, before the introduction of change, new equipment or new technology. It allows union representatives to communicate with managers, in order to raise health and safety concerns that cannot be resolved at local level. Staff side members of the H&S Committee are accredited Trade Union Safety Representatives. The H&S Committee is directly accountable to the Quality and Safety Committee.

14

DEVELOPMENT & APPROVAL OF PROCEDURAL DOCUMENTS This policy is drafted and developed by the Risk and H&S Managers in accordance with legislation and HSE best practice. Key stakeholders and specialist staff are involved in the consultation process e.g. infection control staff and accredited H&S reps. The H&S Committee is responsible for approving the policy. Final ratification rests with the Quality and Safety Committee. An equality impact assessment has been undertaken on the legal content and best practice guidance contained in the policy to ensure it is valid and applicable to all.

15. DISSEMINATION Policy documents are available via the Trust’s website. The principles embedded within the policy will be included in Induction Training for staff and in the mandatory Health and Safety e-learning package.

16. PLANNING & IMPLEMENTATION The Chief Executive will agree annual objectives related to health and safety management with all Executive Directors who will ensure appropriate cascading of relevant objectives throughout the area of their responsibility. Executive Directors will ensure that health and safety planning forms an integral part of their business planning process, in order to ensure that needs are identified, prioritised, and that appropriate resources are allocated. Control of Substances Hazardous to Health Policy

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17. MONITORING & REVIEW Incidents of exposure to hazardous substances and ill health are reported quarterly to the H&S Committee. The investigation of these incidents will be used to identify the adequacy of existing controls and the effectiveness of the policy in imparting information and guidance. Monitoring of the policy will be undertaken via the analysis of RIDDOR incidents and the completion of COSHH assessments. Policies will be subject to review in line with health and safety legislation or if there are changes to technology, processes or practice. The review of policies will also be based on the prioritisation of risk within the Trust and as a consequence of any serious incidents.

18. OUTCOMES / KEY PERFORMANCE INDICATORS Care Quality Commission requires Trusts to achieve a required level of compliance for health and safety control. This is Outcome 10: Safety and Suitability of Premises, and Outcome 11: Safety, Availability and Suitability of Equipment.

19. REFERENCES Health and Safety at Work Act 1974 Management of Health and Safety at Work Regulations Control of Substances Hazardous to Health Regulations Personal Protective Equipment Regulations Chemical Hazard Information & Packaging Regulations (CHIP)

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Appendix 1

HANDLING CYTOTOXIC MATERIAL (Refer also to the Trust’s Medicines Policy Sec 3.11) 1.

Introduction Most cytotoxic drugs and their metabolites are primarily eliminated in the urine and/or faeces. Some are also excreted in saliva and sweat. Because many cytotoxins have been demonstrated to be mutagenic or carcinogenic the handling of food, vomit and other body wastes from patients receiving cytotoxic drugs, without protective clothing, may result in direct skin contact. This could lead to the unchanged drug or metabolite being absorbed or local toxic and/or allergic reactions. There is also a slight chance that cytotoxic drugs used as aerosols may come into contact with the eyes, mucous membranes or be inhaled. All members of staff should wear goggles, disposable plastic aprons and clinical gloves, when dealing with cytotoxic drugs or where there is a possible risk of contamination. As unchanged drugs or their active metabolites can be present in body waste up to seven days after finishing a course of treatment, it is important that up to date patient medication records are available. The risks of contamination will be greater for nurses and carers working with patients who are receiving continuous or long-term oral or parenteral chemotherapy.

2.

Disposal When handling potentially contaminated waste, bedding or clothing, disposable plastic apron and gloves should be worn to reduce the risk of skin contamination. Potentially contaminated waste should be double flushed down the toilet. Any contaminated bedding or clothing should be washed separately, at the appropriate temperature, using a wash cycle, which is not economic with water, in order to dilute any excreted drug. All waste material, containers, used syringes, swabs, tissues, gloves, disposable aprons etc should be transferred to a large sharps container, before returning to base for disposal. It is wise to use 2 containers, 1 for waste items as above and 1 for any sharps. All containers must be labelled as ‘Cytotoxic Waste’. Please refer to the Trust Waste Policy, for further guidance. Commodes should be thoroughly cleaned using disposable cloths, hot water and general purpose detergent. Disposable gloves and a plastic apron should be worn and care taken to avoid splash contamination.

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Appendix 2

Dangerous Substances and Explosive Atmospheres Regulations – (DSEAR) Guidance The term 'dangerous substances' covers any solid, liquid, dust, mist, gas or vapour that has the potential to cause a fire or an explosion. A dangerous substance may have adverse health effects but, by definition, it is 'a substance or preparation which is explosive, oxidising, extremely flammable, highly flammable or flammable' (as defined in Dangerous Substances and Explosive Atmospheres Regulations 2002. According to the DSEAR regulations, employers are required to: 

Find out what dangerous substances are in their workplace and what the fire and explosion risks are.



Put control measures in place to either remove those risks or, where this is not possible, control them.



Put controls in place to reduce the effects of any incidents involving dangerous substances.



Prepare plans and procedures to deal with accidents, incidents and emergencies involving dangerous substances.



Make sure employees are properly informed about and trained to control or deal with the risks from the dangerous substances.



Identify and classify areas of the workplace where explosive atmospheres may occur and avoid ignition sources (from unprotected equipment, for example) in those areas.

The COSHH assessment form (appendix 5) has check boxes for these properties and relevant information can be found on the data sheets provided by the supplier. Further information, related to quantities held, storage facilities, etc. should be completed on the COSHH Inventory (appendix 4). Both of these are the responsibility of the departmental / local manager and the compiled information contained, therein, will identify if a full DSEAR assessment is required. Separate, routine DSEAR assessments may not be necessary as most Trust premises will not contain sufficient quantities of these substances. The main areas of potential risk are the Orchard Place and Shrub Hill workshops and possibly the Estates departments, which may contain sufficient amounts of such substances to require separate, detailed DSEAR assessments. The following checklists (details of which are available on request) are Estates related and may need to be considered when maintenance / contract work, etc. is undertaken. 

Hazard Elimination or Reduction Features for New Equipment



Questions to Ask when Storing Dangerous Substances



Storage of Dangerous Substances - Control Measure Safety Checks



Safety Assessments Before Carrying Out Maintenance / Cleaning Work - General Safety Assessment



Safety Assessments Before Carrying Out Maintenance / Cleaning Work - Procedural Safety Assessment



Hot Work Safety Assessment



Hot Work - Gas Cutting and Welding Equipment Safety Assessment



Information to be Included in a Permit-to-Work

If required, the Fire Safety Consultant is qualified to undertake full DSEAR assessments.

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Appendix 3 CONTROL OF SUBSTANCES HAZARDOUS TO HEALTH INVENTORY Service Delivery Unit

Material / Substance

Service Area Ref. Code

Supplier

Control of Substances Hazardous to Health Policy

Hazard Category

Site/Location Container Type Size

Normal Stock Held

Data Sheet RA Review Y/N Completed Date

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Appendix 4 COSHH & INITIAL DSEAR ASSESSMENT Date: Hazardous substance

Location:

Supplier details Hazard details Combustible Corrosive Explosive Flammable Highly flammable Harmful Irritant Oxidising Radioactive Toxic Very toxic Carcinogenic Mutagenic Teratogenic Biohazard Environmental hazard Intended use

Potential route of exposure Inhalation Ingestion Skin Inoculation Eyes All Risk (R-) phrases

Safety (S-) phrases

Other (additional comments)

Persons at risk Admin. & clerical Staff Allied health professionals Ancillary/maintenance* staff Contractors* Managers Medical staff Nurses/HCAs New or expectant mothers Scientific & technical staff Students* Visitors *if working in department/ward Other (please specify)

Risks to health and safety

First aid requirements in the event of an accident

Conclusions about risk Substance risk Low Medium High Exposure risk Low Medium High Assessor Designation Telephone E-mail

To control risk, refer to attached: Departmental procedure Material Safety Data Sheet

To monitor risk Monitoring required? Health surveillance? If yes please give details

Spillage/disposal/emergency action, refer to attached: Departmental procedure Material Safety Data Sheet

Control of Substances Hazardous to Health Policy

Signature

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