VELINDRE NHS TRUST. Ref: Black 140

Velindre NHS Trust Policy for the Control of Substances Hazardous to Health Policy Lead: D Hughes Trust Policy VELINDRE NHS TRUST Ref: Black 140 ...
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Velindre NHS Trust

Policy for the Control of Substances Hazardous to Health Policy Lead: D Hughes

Trust Policy

VELINDRE NHS TRUST

Ref: Black 140

Trust Policy

POLICY FOR THE CONTROL OF SUBSTANCES HAZARDOUS TO HEALTH (COSHH)

Policy Lead: D Hughes, Health and Safety Manager

Ref: Black 140 Approved By: Trust Board Approval Date: December 2012 Next Review Date: December 2015

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Velindre NHS Trust Trust Policy

Policy for the Control of Substances Hazardous to Health Policy Lead: D Hughes

Contents

Executive Summary

3

Introduction

4

Policy Aims and Objectives

4

Scope

4

Legislative and National Initiatives

4

Principles of Good Control Practice

5

Definitions

6

Roles and Responsibilities

7

Arrangements

8

Monitoring and Audit

12

Further Information

12

Ref: Black 140 Approved By: Trust Board Approval Date: December 2012 Next Review Date: December 2015

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Velindre NHS Trust

Policy for the Control of Substances Hazardous to Health Policy Lead: D Hughes

Trust Policy

EXECUTIVE SUMMARY Policy for the Control of Substances Hazardous to Health Overview:

Who is the policy intended for:

Key Messages included within the policy:

The Control of Substances Hazardous to Health Policy has been prepared in accordance with the Control of Substances Hazardous to Health Regulations 2002 (as amended in 2003 and 2004), to ensure the continued Health and Safety of employees and others who may enter the workplace.

All staff, whether in directly managed Divisions or Organisations hosted by Velindre NHS Trust

Highlighted responsibilities for various persons including the Chief Executive, Health and Safety Manager, Service Directors, Departmental Managers and all employees. There is a requirement for risk assessments to be undertaken for all tasks involving the use of hazardous substances There is a requirement to provide employees with information on the risks and precautions to be taken whilst working with hazardous substances, along with instruction and training on the implementation of control measures. The organisation must have available information on all hazardous substances used - usually in the form of Safety Data Sheets (SDS). Employees must be aware of the content of the SDS and appropriate emergency arrangements Compliance with the Personal Protective Equipment Regulations 2002 by the provision of appropriate PPE when there is a need identified via risk assessment. The Implementation of Control Measures along with exposure monitoring and Health Surveillance Additional Information: For more information or advice in relation to this policy, please contact the Health and Safety Manager on 02920 615888 or via email: [email protected]

PLEASE NOTE THIS IS ONLY A SUMMARY OF THE POLICY AND SHOULD BE READ IN CONJUNCTION WITH THE FULL POLICY DOCUMENT.

Ref: Black 140 Approved By: Trust Board Approval Date: December 2012 Next Review Date: December 2015

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Policy for the Control of Substances Hazardous to Health Policy Lead: D Hughes

Introduction

This document provides guidance on the management of substances that are hazardous to the health of employees of Velindre NHS Trust. Using hazardous substances can put people’s health at risk and the level of harm can range from minor irritation to death. Hazardous substances are found in nearly all work places and can include: ● Substances used directly in work activities, e.g. cleaning agents ● Substances generated during work activities, e.g. fumes from solvents ● Naturally occurring substances, e.g. fungal spores ● Biological agents such as bacteria and other micro-organisms 2

Policy aims and objectives

Velindre NHS Trust intends, so far as is reasonably practicable, to protect its employees and those affected by its undertaking from the harmful effects of substances that may be used in fulfilling its business. The overall responsibility for implementing the requirements of the policy, ensuring resources are available and ensuring that the Policy is followed rests with the Chief Executive 3

Scope

This policy is applicable to all employees of Velindre NHS Trust and hosted organisations, including non-executive directors, secondees and locums. It applies to all areas where hazardous substances are used, stored or generated. 4

Legislative and national initiatives

Velindre NHS Trust has a duty under section 2 and section 3 of the Health & Safety at Work etc Act 1974, to ensure the health, safety and welfare of its employees and others who may be affected by its working activities. This document has been developed to ensure that Velindre NHS Trust complies with the requirements of the Control of Substances Hazardous to Health Regulations 2002 (COSHH) as amended by the Control of Substances Hazardous to Health (Amendment) Regulations 2004 (COSHH 2004). The COSHH Regulations are intended to prevent workplace adverse health effects resulting from exposure to hazardous substances, for all persons at work and others who may be affected by such work. The Regulations contain principles of control that provide a framework for workplaces to reduce the risk from working with hazardous substances. For this to be effective in the long term, control measures must be practical, workable and sustainable.

Ref: Black 140 Approved By: Trust Board Approval Date: December 2012 Next Review Date: December 2015

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Policy for the Control of Substances Hazardous to Health Policy Lead: D Hughes

4.1 Principles of Good Control Practice a) Design and operate processes to minimise emission, release and spread of contaminants b) Take into account all relevant routes of exposure - inhalation, skin absorption, injection and ingestion - when developing control measures c) Control exposure by measures proportionate to the health risk d) Choose most effective and reliable control options which minimise escape and spread of contaminant from sources e) Where adequate control is not reasonably practicable by other means, provide suitable Personal Protective Equipment (PPE) in combination with other measures f) Check and review regularly, all elements of control measures for continuing effectiveness g) Inform & train all employees on hazards and risks from substances and use of control measures h) Ensure introduction of control measures does not increase overall risk The principles are all equally important in achieving adequate control. Also, the Principles are not listed in rank order: Principle (a) is not more important than Principle (h), although there is a logical progression in how they are presented and should be considered. For the vast majority of commercial chemicals, the presence (or not) of a warning label will indicate whether COSHH is relevant. For example, household washing up liquid doesn’t have a warning label but bleach does, so COSHH applies to bleach but not washing up liquid when used at work. However, a COSHH assessment may still be undertaken if considered necessary by the person undertaking the assessment. However, not all substances are covered by the COSHH Regulations. The following are excluded: ●

Asbestos and Lead, which have their own regulations



Substances which are hazardous only because they are radioactive, at high pressure, at extreme temperature or have explosive or flammable properties (other regulations apply to these risks) Biological agents that are outside the employer’s control, e.g. catching an infection from a colleague.



Ref: Black 140 Approved By: Trust Board Approval Date: December 2012 Next Review Date: December 2015

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Policy for the Control of Substances Hazardous to Health Policy Lead: D Hughes

Definitions

Under COSHH there are a range of substances regarded as hazardous to health: Substances or mixtures of substances classified as dangerous to health under the Chemicals (Hazard Information and Packaging for Supply) Regulations (CHIP) and for which an indication of danger specified for the substance is “very toxic, toxic, harmful, corrosive or irritant”. These can be identified by their warning label and the supplier must provide a safety data sheet for them. However, The European Regulation (EC) No 1272/2008 on classification, labelling and packaging of substances and mixtures – the CLP Regulation – came into force in all EU member states, including the UK, on 20 January 2010. The CLP Regulation: 1. 2.

3. 4. 5.

adopts in the EU the Globally Harmonised System (GHS) on the classification and labelling of chemicals; is being phased in through a transitional period which runs until 1 June 2015. The CLP Regulation applies to substances from 1 December 2010, and to mixtures (preparations) from 1 June 2015; applies directly in all EU member states. This means that no national legislation is needed; is overseen by the European Chemicals Agency (ECHA); will replace the Chemicals (Hazard Information and Packaging for Supply) Regulations 2009 – CHIP – from 1 June 2015.

Substances with workplace exposure limits listed in the HSE publication EH40/2005 Workplace exposure limits. Biological agents (bacteria and other micro-organisms), if they are directly connected with the work, e.g. healthcare, or if the exposure is incidental to the work (e.g. exposure to bacteria from an air-conditioning system that is not properly maintained). Any kind of dust if its average concentration in the air exceeds the levels specified in the COSHH regulations. Any other substance which creates a risk to health, but which for technical reasons may not be specifically covered by CHIP including: asphyxiants (i.e. gases such as argon and helium, which, while not dangerous in themselves, can endanger life by reducing the amount of oxygen available to breathe), pesticides, medicines, cosmetics or substances produced in chemical processes. 6

Roles and responsibilities

6.1 Chief Executive and Directors The Chief Executive and Directors are responsible for: Ref: Black 140 Approved By: Trust Board Approval Date: December 2012 Next Review Date: December 2015

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The implementation of this policy and ensuring that all employees are familiar with its contents, insofar as it is relevant to their role and responsibilities The allocation of sufficient resources to effectively manage risks associated with Hazardous Substances 6.2 Divisional Directors Divisional Directors are responsible for: ● ● ●

● ● ● ●

ensuring that the arrangements for undertaking COSHH risk assessments are defined within their area of responsibility ensuring that employees are trained to use, handle and store safely and correctly all substances used in work activities ensuring that they are familiar with, and ensure that all employees under their control are aware of  any contingency plan involving spillage  the safe disposal of unwanted substances  first aid arrangements appropriate to the substances used ensuring that line managers implement the safe systems of work identified by the risk assessments implementing arrangements to bring this policy and resulting safe working methods (and any revisions) to the notice of all employees within their Service Areas and others who may be affected. ensuring Line Managers receive sufficient training to undertake their role. ensuring that the resources required in implementing this policy and safe working methods are provided, and ensure that financial requirements are included in budget bids.

6.3 Managers Managers are responsible for: ensuring that substances are only used and dealt with in the prescribed manner ensuring that re-assessments are carried out on at least an annual basis. ensuring that up to date safety data sheets are available at each location where employees use hazardous substances. ensuring that all workers receive appropriate supervision, instructions and training relevant to the substances they use. Training should be recorded by the departmental manager on the form attached as Appendix 1 and the training records retained in accordance with departmental procedures. monitoring employees to ensure they are complying with this Policy and safe working methods.

Ref: Black 140 Approved By: Trust Board Approval Date: December 2012 Next Review Date: December 2015

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6.4 Health and Safety Manager The Health and Safety Manager is responsible for providing advice and guidance to managers on the effective implementation of this Policy and safe working methods. 6.5 Employees The main duties of employees are to: (a) co-operate with the Trust so far as this is necessary to enable them to meet their obligations under the COSHH Regulations, e.g. by following established procedures which minimise the risk of exposure; (b) make full and proper use of control measures including personal protective equipment and report defects; (c) ensure that equipment is returned after use to any storage place that is provided for it, and to report immediately to their manager, supervisor or safety representative as appropriate, any defects discovered in equipment; (d) where appropriate, attend Occupational Health medical examinations at the appointed time and give information about their health that may reasonably be required; and (e) report any accident or incident which has or may have resulted in the release into the workplace of a biological agent which could cause severe human disease. 7

Arrangements

7.1 Risk Assessment The COSHH Regulations require an assessment of risk to be undertaken for tasks involving the use of hazardous substances (see section 5 for definition of a hazardous substance). When undertaking the assessment, consideration should be given to the following: ● ● ● ● ● ● ● ●

The hazardous properties of the substance Information on health effects provided by the supplier The level, type and duration of exposure The circumstances of the work, including the quantity used The potential routes of exposure, e.g. inhalation, ingestion, injection and absorption Activities such as maintenance where there is the potential for a high level of exposure Any relevant workplace exposure limit or similar occupational exposure limit The effect of preventive and control measures which have been or will be taken

Ref: Black 140 Approved By: Trust Board Approval Date: December 2012 Next Review Date: December 2015

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Policy for the Control of Substances Hazardous to Health Policy Lead: D Hughes

The results of relevant health surveillance The results of monitoring of exposure The risk presented by exposure to a combination of substances Any additional information needed in order to complete the risk assessment.

The Health and Safety Executive (HSE), in collaboration with the Trades Union Congress (TUC) and the Confederation of British Industry (CBI), have developed a COSHH Essentials website and where there is no local access to COSHH risk assessments, this website can be referenced. COSHH essentials is a generic risk assessment scheme for a wide range of hazardous substances covered by CHIP and COSHH. It leads users to appropriate control advice for a range of common tasks. COSHH essentials can be used as a basis for the recording of the risk assessment. Whilst COSHH essentials has been designed to ensure that a precautionary approach is taken towards control it is a generic guide and cannot guarantee that in all circumstances it will lead to full compliance with the Regulations assessment control requirements. 7.2 Information, instruction and training Following the completion of a COSHH risk assessment the need for information, instruction and training must be considered and appropriate arrangements made by the manager. These might range from a simple instruction to regular formal sessions. Wherever employees are exposed to hazardous substances they must receive information, instruction and, where appropriate, training in the following: ● ● ● ●

The risks to health created by their exposure The precautions that should be taken Control measures, their purpose and how to use them How to use personal protective equipment and clothing provided Results of any exposure monitoring and health surveillance.

7.3 Health surveillance In certain circumstances it will be necessary to undertake health surveillance for employees. Health surveillance is a systematic process which is required when: a) there is an identifiable disease or adverse health effect associated with the work, b) there is a reasonable possibility that the effect may occur under the conditions of the work (e.g. if control is dependent on Personal Protective Equipment) and c) there is a valid means for detecting the effect before it becomes permanent. The objective of health surveillance is to:

Ref: Black 140 Approved By: Trust Board Approval Date: December 2012 Next Review Date: December 2015

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Policy for the Control of Substances Hazardous to Health Policy Lead: D Hughes

Protect the health of individual employees by detecting as early as possible adverse changes which may be caused by exposure to hazardous substances Help evaluate the measure(s) taken to control exposure Collect, keep up to date, and use data and information for determining and evaluating hazards to health.

Health surveillance will be undertaken via the Occupational Health Service 7.4 Emergency Arrangements Where the risks of a substance escaping are high, or the substance is especially hazardous, the local manager will ensure that emergency arrangements are in place as part of the risk assessment process. Guidance can be found on the supplier’s Safety Data Sheet. 7.5 Personal Protective Equipment Where the risk assessment has concluded that it is necessary to use personal protective equipment (PPE), this shall comply with the provisions of the Personal Protective Equipment Regulations 2002. The main requirement of the Regulations is that PPE is to be supplied and used at work wherever there are risks to health and safety that cannot be adequately controlled in other ways. The Regulations also require that PPE is properly assessed before use to ensure it is suitable; is maintained and stored properly; is provided with instructions on how to use it safely; and is used correctly by employees. PPE, including protective clothing, must be properly stored in a well-defined place; checked at suitable intervals; and when discovered to be defective, repaired or replaced before further use. Personal protective equipment which may be contaminated by a substance hazardous to health must be removed on leaving the working area and kept apart from uncontaminated clothing and equipment. This equipment must be subsequently decontaminated and cleaned or, if necessary, destroyed. 7.6 Engineering controls All control measures in use should be visually checked, where possible, at appropriate intervals and without undue risk to maintenance staff. In the case of Ref: Black 140 Approved By: Trust Board Approval Date: December 2012 Next Review Date: December 2015

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local exhaust ventilation (LEV) and work enclosures, such checks should be carried out at least once a week. Procedures for servicing equipment should specify: (a) (b) (c) (d) (e)

which engineering control measures need servicing; the work to be carried out on each of them; when the work should be done; who is to do the work and who is responsible for it; and how to put right any defects found.

In most circumstances control measures will include defined working procedures. These should be observed regularly to check that they are still being followed. They should also be reviewed periodically to confirm that they are still appropriate and workable and to see whether they can be improved. Local exhaust ventilation plant (e.g. fume cupboards) must be inspected at least once every 14 months. Where respiratory protective equipment (RPE) (other than disposable RPE) is provided, thorough examination and, where appropriate, testing of that equipment must be carried out at suitable intervals. Records of examinations and tests carried out, and of any repairs carried out as a result of those examinations and tests, must be kept for at least 5 years. 7.7 Exposure monitoring Where the COSHH assessment shows it is necessary, valid and suitable occupational hygiene techniques should be used to estimate the amount of employees’ exposure to substances hazardous to health. For airborne contaminants, this measurement will normally involve collecting a sample of air from the employee’s breathing zone using personal sampling equipment. It may also, where appropriate, involve sampling the air at the workplace periodically or continuously, using static sampling equipment. Where air sampling techniques alone may not give a reliable indication of exposure, e.g. where there is skin absorption, ingestion or where RPE is being used to adequately control exposure, biological monitoring is often a useful complementary technique to air monitoring. 8

Monitoring and auditing

As part of the Health and Safety Audit process, managers will be required to provide a summary report on the use of Hazardous substances, including: Confirmation that all hazardous substances in current use cannot be replaced by less hazardous alternatives The number of identified concerns in relation to occupational exposure to hazardous substances Ref: Black 140 Approved By: Trust Board Approval Date: December 2012 Next Review Date: December 2015

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Policy for the Control of Substances Hazardous to Health Policy Lead: D Hughes

Confirmation that risk assessments have been either completed or reviewed and that all staff have been made aware of any associated risks. The availability of current Safety Data Sheets for all hazardous substances in use within their remit. Confirmation that engineering controls such as LEV are inspected and maintained to schedule and that records are kept for the required 5 years 9

Further information

HSE COSHH Website http://www.hse.gov.uk/coshh/index.htm The Control of Substances Hazardous to Health Regulations 2002 (as amended). Approved code of practice and guidance (http://books.hse.gov.uk/hse/public/saleproduct.jsf?catalogueCode=9780717629817) . Working with substances hazardous to health - What you need to know about COSHH (http://www.hse.gov.uk/pubns/indg136.pdf) HSE COSHH Essentials Website http://www.hse.gov.uk/coshh/essentials/index.htm Personal Protective Equipment at Work Regulations 1992 (http://www.hse.gov.uk/pubns/indg174.pdf) EH40/2005 Workplace Exposure Limits: Containing the list of workplace exposure limits for use with the Control of Substances Hazardous to Health Regulations 2002 (as amended) (http://www.hse.gov.uk/pubns/books/eh40.htm)

Ref: Black 140 Approved By: Trust Board Approval Date: December 2012 Next Review Date: December 2015

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Policy for the Control of Substances Hazardous to Health Policy Lead: D Hughes

Trust Policy

Appendix 1 Course : COSHH Training Date : Time : Venue : Tutor: Detail of training: (include nature of / details of hazardous substance and use for which training has been given) For Ed&Dev Use Only: OLM Updated

Unable to update OLM because:

Delegate Name

Department

Attendance Confirmed by:

Ref: Black 140 Approved By: Trust Board Approval Date: December 2012 Next Review Date: December 2015

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