HSPOL14 COSHH Policy v6 by Provide Community

Control of Substance Hazardous to Health (COSHH) Policy

Version: V6

Ratified by: Finance and Investment Committee (FIC)

Date ratified: 25/05/2022

Job Title of author:

Health, Safety, Fire and Security Manager –Estates and Facilities

Reviewed by Committee or Expert Group Property Health and Steering Group

Equality Impact Assessed by:

1. Introduction

Control of Substances Hazardous to Health (COSHH) regulation, is the legal requirement placed on employers to protect their employees and all other visitors to the organisation who may come into contact with hazardous substances. This includes any partner organisations, patients, visitors and the general public.

Hazardous substances come in a variety of forms such as:

• Chemicals

• Fumes

• Dusts

• Vapours

• Biological Agents (bacteria, viruses, body fluids)

• Gases (mists)

The organisation has tried to minimise the use of hazardous substances where possible, however the use of some products forms part of everyday practice within a healthcare setting.

By assessing the risks, implementing appropriate control measures and ensuring that appropriate advice and training is given to users the risks of exposure to hazardous substances can be avoided.

2. Purpose

The purpose of this policy is to set out the measures required by Provide to ensure compliance with the Control of Substance Hazardous to Health (COSHH) Regulations 2002 (as amended)

3. Definitions

Substances Hazardous to Health

Any material, mixture or compound that is being used or that a person may come into contact with that could be harmful to health.

Routes of Entry

The method by which, substances could enter the body.

• Inhalation

• Ingestion

• Absorption (through skin contact)

• Injection (needle puncture)

WEL

Workplace Exposure Limit. WEL’s are British Occupational Exposure limits and are set in order to help protect the health of worker. WELS are concentrations of Hazardous Substances in the air, averaged over a specified period of time, referred to as a time weighted average (TWA). Two time periods are used:

• Long term (8) hours

• Short Term (15 Minutes)

CHIP

CHIP is the abbreviated name for the Chemicals (Hazard Information and Packaging for Supply) Regulations

CHIP was replaced by the European CLP Regulation in June 2015

CLP (Classification, Labelling and Packaging of Substances)

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:

• Adopted in the EU the Globally Harmonised System (GHS) on the classification and labelling of chemicals;

• Was phased in through a transitional period which ran 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);

• Replaced the Chemicals (Hazard Information and Packaging for Supply) Regulations 2009 – CHIP – from 1 June 2015

Hazard Symbols and Pictograms

Old CHIP symbols

New CLP symbols

You’ll see that the harmful symbol is missing.

This has been replaced by the exclamation mark pictogram:

This pictogram will refer to less serious health hazards such as skin irritancy / sensitisation.

A couple of new pictograms have also been introduced:

This pictogram reflects serious longer term health hazards such as carcinogenicity and respiratory sensitisation.

This pictogram means “Contains gas under pressure”

Hazard statements

New hazard statements replaced the CHIP risk phrases.

Hazard Statements are separated into:

• H200s for Physical Hazards

• H300s for Health Hazards

• H400s for Environmental Hazards

Hazard statements provide information about the nature and the degree of the hazard and each hazard statement has a corresponding identification code. Many of the phrases, although have a similar meaning, are worded differently, e.g.:

• R28 ‘Toxic if swallowed’ is replaced by H300 ‘Fatal if swallowed’.

• R42 ‘May cause sensitisation by inhalation’ is replaced by ‘H334 May cause allergy or asthma symptoms or breathing difficulties if inhaled’

Precautionary statements

New precautionary statements replaced the CHIP safety phrases.

Precautionary Statements are separated into:

• P100s for General

• P200s for Prevention

• P300s for Response

• P400s for Storage

• P500s for Disposal

Precautionary statements provide information on the measures to take to minimize or prevent effects from physical, health or environmental Hazards. As such, they serve the same purpose as the well – known ‘S phrases’.

These include First aid and emergency measures (response).

For example:

• P103 – Read label before use

• P271 – Use only outdoors or in a well-ventilated area

• P304 – If inhaled…….

• P405 – Store Locked up

• P501 – Dispose of contents to…….

Signal word

The CLP introduced a new requirement for labelling – a signal word, either “warning” or “danger” depending on the severity of the hazard

It is worth noting that whilst all new products purchased will comply with the newer CLP regulations there may be some older (CHIP) products still in use; however where noted these are being removed and replaced.

4. Duties Organisation

The organisation has a duty of care under the Health & Safety at Work Act 1974 to ensure that:

• All ‘reasonably practicable’ steps will be taken under the COSHH Regulations to avoid the risks, which may affect the health of employees working with hazardous substances.

• The organisation has prepared plans and procedures to deal with accidents, incidents and emergencies

• All staff are given appropriate information and health and safety training in line with regulations

• Nominated staff will be required to attend COSHH training as per the regulations

Managers:

• Compile an inventory of Hazardous Substances (Appendix 2)

• Ensure that COSHH assessments are carried out by competent persons

• Ensure all COSHH assessments are collated in an accessible COSHH folder (this may be an electronically stored file)

• Compile a register of employees exposed to any Group 3 or Group 4 biological agent, indicating the type of work done and, where known, the biological agent to which they have been exposed. Records of exposures, accidents and incidents, should be recorded as appropriate

• Ensure that Planned Preventive Maintenance is carried out for control measures used

• Ensure that the type and use of Personal Protective Equipment (PPE) is assessed and maintained according to manufacturers’ instructions. Ensure that the number of different types of PPE used is minimised, to prevent compatibility issues, or mistakes with servicing or replacement. Any staff using Respiratory PPE must be trained in its safe use and correct fitment

• Carry out or arrange appropriate exposure monitoring where required

• Liaise with the Health, Safety, Fire and Security Manager for advice where required, and to update the biological agent users register as appropriate

• Liaise with our Occupational Health provider where health surveillance may be required

• Ensure employees have appropriate information, instruction and training and are released for appropriate training programs

• If an identified exposure takes place, ensure that those affected, and their managers and representatives, are informed immediately. Inform the Health, Safety, Fire and Security Manager if there is a potential risk to health

Health, Safety, Fire and Security Manager

• Provide advice to managers on completion of COSHH assessments

• Assist managers in the selection of appropriate exposure monitoring where required

• Liaise and consult with Occupational Health provider where required

• Ensure that relevant training programs are made available, including training for nominated assessors and competent persons

Occupational Health Provider

• Provide advice to managers on completion of COSHH assessments

• Carry out or arrange appropriate health surveillance where required

• Inform employees of results of health surveillance and any actions required.

• Liaise with General Practitioners if necessary

• Where required by the relevant legislation, keep health records for 40 years from date of last entry

• Liaise and consult with the Health, Safety, Fire and Security Manager as appropriate

Employees

• All employees have a duty to take reasonable care for themselves and others as required by the Health and Safety at Work etc. Act 1974; this duty extends to the safe use of substances hazardous to health

• Make full and proper use of all engineering controls or systems of work provided or developed by the employer

• Use PPE as indicated or dictated by the risk assessment

• Bring to the attention of managers any problems relating to the safe use of chemicals, including control measures or PPE

• Attend for health surveillance, where required by management or the Occupational Health provider

5. Consultation and Communication

This Policy applies to all Provide employees working in premises where the organisation functions.

6. Monitoring

This policy will be reviewed every 2 years, unless there is a significant change in legislation or following a serious incident.

7. Process

Using chemicals or other hazardous substances at work put people’s health at risk, so law requires employers to control exposure to hazardous substances to prevent ill health. They have to protect both employees and others who may be exposed by complying with the Control of Substances Hazardous to Health Regulations 2002 (COSHH).

COSHH is a useful tool of good management which sets out eight basic measures that employers, and sometime employees, must take. These are:

1. Assess the risk.

2. Decide what precautions to take.

3. Prevent or adequately control exposure.

4. Ensure that control measures are used and maintained.

5. Monitor the exposure.

6. Carry out appropriate health surveillance.

7. Prepare plans and procedures to deal with accident, incidents and emergencies.

8. Ensure employees are properly informed, trained and supervised.

There is a hierarchy of control measures under Regulation 7, which is as follows:

Prevent Exposure by:

1. Eliminating the substance.

2. Substitution with a substance less hazardous to health.

Control Exposure by:

1. Total enclosure of the process, therefore removing exposure.

2. Limiting the area of contamination.

3. The use of LEV (Local Exhaust Ventilation).

4. Dilution Ventilation.

5. Reducing the period of exposure.

6. Providing suitable PPE.

Personal Protective Equipment DOES NOT REMOVE THE HAZARD

Monitoring exposure and health surveillance:

• Where required, exposure monitoring must be carried out by a competent person

• Health surveillance is arranged in conjunction with the Occupational Health provider and is required when the following circumstances are met:

o there is a statutory duty to do so; or

o exposure could lead to an identifiable disease (or health effect), that is reasonably foreseeable under the particular conditions of

work and there are valid techniques for detecting signs of the disease

• Records of personal monitoring should be retained for 40 years from date of last entry

Performing COSHH Assessments:

(Page 14 gives the assessment form, which must be used for this purpose). In addition please also refer to and use the Provide Risk Management Policy if appropriate.

• Gather information about substances hazardous to health in your area of work i.e. establish an inventory of substances used

• Identify workers likely to be exposed, but note also that account should be taken of non-employees who may be exposed, as far as reasonably practicable

• Collate relevant information from material safety data sheets and / or other sources of information

• Evaluate the risk for each substance (see definitions section 4): is the risk significant, insignificant or not significant due to effective control measures?

• Determine how any risks present can be prevented or controlled

• For existing controls, determine whether these are adequate and maintained in an efficient state, working order and good repair

• If LEV systems are in place, they must be tested every 14 months and a record kept

• Liaise with Health, Safety, Fire and Security Manager as required

• Liaise with Occupational Health provider re: the need for health surveillance

• Ensure sufficient information, instruction and training is provided to staff and that training needs are identified and met

• Record the COSHH assessment and determine when it should be reviewed

• At the date of review if no further action is required the assessment should be resigned and dated

8. Process – Quick Reference Guide

This guide must be followed in full when developing or reviewing and amending Provide procedural documents.

For quick reference the flow chart below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

Develop a COSHH inventory.

Collate Material Safety Data Sheets (MSDS’s) in a file. Keep them up to date

Identify the potential hazards/risks from the MSDS’s

Look at how the substances are actually used:

- Method - Frequency - Quantities exposed to Record these on the assessment

Identify who could be harmed:

- Staff - Patients - Contactors/Visitors

Record the control measures which need to be in place. Consider: Elimination, Reduction, Isolation and Control of the hazards

Identify: - Personal Protective equipment that must be used

- Emergency Measures needed (fire, first aid, Spillage)

Document all of these significant findings on the COSHH assessment form. Communicate to all relevant staff

Review your COSHH assessment within a reasonable period of time: - Annually - Change of practice or procedure - New products

9. Training Requirements

Employees must be given guidance and training as required on ALL substances that they may be required to use or be exposed to as part of the Local Induction process within their department.

The L&D Training team can arrange training for COSHH assessors on an ‘as needs’ basis.

10.References

HSE: Chemical Classification

Read the label: How to find out if chemicals are dangerous Leaflet INDG352 www.hse.gov.uk/pubns/indg352.pdf

INDG 136 Working with Substances Hazardous to Health

Appendix 1 - COSHH Risk Assessment

Product:

SDS – Date of Issue:

Supplier: Tel:

Description of use in the Department

Where is it used

What is it used for Frequency of use

Quantity of use Who is exposed Exposure time

Classification

Hazard Type Gas Vapour

Route of Exposure

Inhalation Skin Eyes Ingestion Puncture Other

Workplace Exposure Limits

Long Term (8hr TWA)

Short Term (15 mins)

Is Health Surveillance required Yes No Is Monitoring Required Yes No

Risks to Health (H300’s)

Eg: H312 Harmful in Contact with Skin

(List of hazard and Precautionary Statements)

Control Measures

Personal Protective Equipment

First Aid Procedures

Inhalation Skin

Eyes Ingestion

Storage

Disposal

Spill Procedure

Additional Safety

Local Exhaust ventilation

Required Y N If yes: date & examination of test

Is Exposure Adequately controlled YES NO

Name of Assessor Date of Assessment

Signature Review Date

Appendix 2 - COSHH Inventory List

Site: Team Date: Completed by

Ref No

Substance Name Chemical Composition

Hazard Data Sheet

Obtained

Yes No

Location Where Used Last Annual Assessment

To be completed annually and a copy sent to Health, Safety, Fire and Security Manager by June each year

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 1: ‘Screening’

Name of project/policy/strategy (hereafter referred to as “initiative”):

COSHH Policy

Provide a brief summary (bullet points) of the aims of the initiative and main activities:

Project/Policy Manager: Health, Safety, Fire and Security Manager Date: May 2022

This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community – i.e. on the grounds of race (incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equality neutral” (i.e. have no effect either positive or negative). In the case of gender, consider whether men and women are affected differently.

Q1. Who will benefit from this initiative? Is there likely to be a positive impact on specific groups/communities (whether or not they are the intended beneficiaries), and if so, how? Or is it clear at this stage that it will be equality “neutral”? i.e. will have no particular effect on any group.

Neutral

Q2. Is there likely to be an adverse impact on one or more minority/under-represented or community groups as a result of this initiative? If so, who may be affected and why? Or is it clear at this stage that it will be equality “neutral”?

Neutral

Q3. Is the impact of the initiative – whether positive or negative - significant enough to warrant a more detailed assessment (Stage 2 – see guidance)? If not, will there be monitoring and review to assess the impact over a period time? Briefly (bullet points) give reasons for your answer and any steps you are taking to address particular issues, including any consultation with staff or external groups/agencies.

Neutral

Guidelines: Things to consider

Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.

The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.

Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.

Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan.

Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?

It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.

It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 2:

(To be used where the ‘screening phase has identified a substantial problem/concern)

This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.

Q1. What data/information is there on the target beneficiary groups/communities? Are any of these groups under- or over-represented? Do they have access to the same resources? What are your sources of data and are there any gaps?

N/A

Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations? If yes, how? Which are the main groups it will have an impact on?

N/A

Q3. Will the initiative have an adverse impact on any particular group or community/community relations? If yes, in what way? Will the impact be different for different groups – e.g. men and women?

N/A

Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative? Summarise (bullet points) any important issues arising from the consultation.

N/A

Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact? Are there specific factors which need to be taken into account?

N/A

Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required.

N/A

Guidelines: Things to consider

An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised. It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations, and could form a specific part of the initiative. The consultation process should form a meaningful part of the initiative as it develops, and help inform any future action.

If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.

Further information:

Useful Websites www.equalityhumanrights.com Website for new Equality agency www.employers-forum.co.uk – Employers forum on disability www.disabilitynow.org.uk – online disability related newspaper www.womenandequalityunit.gov.uk – Gender issues in more depth www.opportunitynow.org.uk - Employer member organisation (gender) www.efa.org.uk – Employers forum on age www.agepositive.gov.uk – Age issues in more depth

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage One: ‘Screening’