32226
32235
GP/C3
Health & Safety Advisor
Health & Safety Advisor
Director of Human Resources
01 May 2010
01 May 2016
01 May 2019
4

1. FUNCTION

1.1 NHS Fife recognizes its duty to comply with the Control of Substances Hazardous to Health Regulations 2002 (as amended)

1.2 The Control of Substances Hazardous to Health Regulations 2002 (as amended) requires employers to prevent or reduce risks to health and safety from exposure to hazardous substances (including biological agents) at work. The duties in the Regulations are in addition to the general duties set out in the Health & Safety at Work etc. Act 1974 and other legislation made under the Act.

1.3 The substances referred to here can be solid, liquid, gas, fume, dust, vapour or micro-organisms which can endanger health by being inhaled, ingested or injected or absorbed through the skin or mucous membranes.

1.4 This Procedure outlines the steps to be taken by NHS Fife to ensure staff or others are not exposed to substances that may damage health.

1.5 This Procedure supports the Risk Register and Risk Assessment and Health Surveillance Policies and reference must be made to those policy documents to identify general responsibilities for risk assessment and health surveillance

 2. LOCATION

This Procedure is applicable to all staff and by agreement, contractors working within NHS Fife. Persons responsible for developing local COSHH related guidance must ensure they comply with this Procedure.

3. RESPONSIBILITY

3.1. Senior and Line Managers are responsible for:
Preparing an inventory of hazardous substances used in their area;

3.2 Ensuring risk assessments of the work environment are carried out where exposure to hazardous substances is indicated as a potential hazard and that action is taken to eliminate or reduce the risk from that exposure;

3.3 Ensuring that staff are consulted through partnership arrangements, on matters relating to their Health and Safety;

3.4 Putting procedures, safeguards and safe systems of work into practice, which are designed to eliminate or reduce the likelihood of harmful exposure to hazardous substances;

3.5 Providing suitable Personal Protective Equipment (PPE) including Respiratory Protective Equipment (RPE) where the risk assessment has identified the need to supplement other risk control measures with the use of PPE.

3.6 Preparing plans to deal with accidents, incidents and emergencies involving hazardous substances;

3.7 Ensuring that all staff are aware of this Procedure, understand its content and those of local and associated procedures;

3.8 Ensuring that COSHH risk assessments are reviewed at least annually or immediately if the review is in response to changes in procedures, equipment, location, type of personnel, legislation or other external requirements;

3.9 Ensuring that staff groups and individuals identified as being at risk, are given appropriate information, instruction, training and supervision;

3.10 Monitoring the effectiveness of risk control measures for COSHH through an effective system of reporting, investigating and recording of incidents;

3.11 Ensuring staff are sent for health surveillance where there is an identified potential exposure which may give rise to a significant risk to health (see also NHS Fife Health Assessment and Surveillance Policy, GP/H5).

 All Employees are responsible for:

3.2.1 Taking reasonable care of themselves and others who may be affected by their actions;

3.2.2 Co-operating by following guidelines for safe work with hazardous substances and working in a manner which controls risk to as low a level as is reasonably practicable;

3.2.3 Reporting all incidents and unsafe conditions arising out of work with hazardous substances that did or could result in loss, injury or damage;

3.2.4 Taking part in training and education designed to meet the requirements of this Procedure;

3.2.5 Attending health assessment and surveillance appointments where indicated as a requirement by the COSHH risk assessment process.

4. OPERATIONAL SYSTEM

4.1 The Control of Substances Hazardous to Health Regulations 2002 (as amended) creates duties to assess the risk from exposure to hazardous substances in the workplace. There is also the requirement to eliminate the exposure, or to reduce it to as low a level as reasonably practicable.

4.2 The hazards of harmful substances and how they will be used should be considered before purchase. The safest form and type of substance possible should be selected.

4.3 Prevention and Control
Managers must make sure that staff are not exposed to hazardous substances or, if that is not reasonably practicable, that the risks of exposure are adequately controlled (see further information in Guidance on Prevention, Risk Reduction, and Control of risks for compliance with the Control of Substances Hazardous to Health (COSHH), Procedure version 1, Aug 2015.  

Adequate control is achieved if employers meet the following criteria:

4.3.1 If the level of exposure of a substance which could be inhaled and has a Workplace Exposure Limit (WEL) is reduced as far as is reasonably practicable (and in any case below the WEL);

4.3.2 The absence of a WEL does not mean that a substance which could be inhaled is safe. Employers should control the level of exposure to that which most of the population could be exposed to repeatedly without any effect on their health;

4.3.3 Employers should control exposure to any substance which can be dangerous if swallowed, absorbed through the skin or mucous membranes or which comes into contact with the skin or mucous membranes (chemical burns, dermatitis and microbial infection) to a standard where most of the population could be exposed repeatedly to it without any effect on their health;

4.3.4  Employers should prevent exposure to carcinogens and mutagens, if this is reasonably practicable, or must at least control exposure to as low a level as is reasonably practicable.

Preventing exposure is the main aim.

Where prevention is not possible, measures that employers can consider for controlling exposure are outlined inGuidance on Prevention, Risk Reduction, and Control of risks for compliance with the Control of Substances Hazardous to Health (COSHH) Procedure, version 1, Aug 2015.

 5. RISK MANAGEMENT

5.1 This Procedure is a part of NHS Fife’s system for managing risk as described in the NHS Fife Risk Assessment and Risk Register Policy.

 6. RELATED DOCUMENTS

Guidance on Prevention, Risk Reduction, and Control of Risks for Compliance with the Procedure on Control of Substances Hazardous to Health (COSHH), version 1, Aug 2015.

 7. REFERENCES

PIN Managing Health at Work Guideline 8: Biological and Chemical Hazards

The Control of Substances Hazardous to Health Regulations 2002 (as amended): Approved Code of Practice and Guidance (HSE L5)

Classification, Labelling and Packaging of Substances and Mixtures Regulation 1272/2008 (CLP 2008), Official Journal of the European Union L353/1.

The Management of Health and Safety at Work Regulations 1999 (HSE L21)

NHS Fife Risk Register and Risk Assessment Policy, GP/R7

NHS Fife Adverse Events Policy, GP/I9

NHS Fife Health Assessment and Surveillance Procedure, GP/H5