NHSScotland 'Once for Scotland' Workforce Policies - Managing Health at Work - Public Consultation
The ‘Once for Scotland’ Workforce Policies Programme is designed to review and transform existing workforce policies (previously known as Partnership Information Network (PIN) Policies) in line with our vision:
‘Once for Scotland Workforce policies will promote NHSScotland as a modern, exemplar emp
10. Control of Substances Hazardous to Health (COSHH) Policy
10.1. Aim
10.1.1. To set out the arrangements to comply with the Control of Substances Hazardous to Health Regulations, with the aim of preventing injuries and reducing acute or chronic ill health at work.
10.2. Scope
10.2.1. This policy applies to all employees. It also applies to bank, secondees, agency, sessional workers, volunteers, contractors, and those on placement, such as trainees, students, or individuals undertaking work experience.
10.2.2. Reference to employees applies to all these groups unless otherwise stated.
10.2.3. This policy is compliant with current legislation and meets the aims of the Public Sector Equality Duty of the Equality Act 2010
10.3. Definitions
10.3.1. This policy applies to all hazardous substances used in connection with or arising from work activities. These include some medicines and all processes that can generate hazardous substances.
10.3.2. The COSHH regulations do not apply to the following substances as they have their own specific regulations:
10.3.3. The COSHH Regulations apply to a wide range of substances, preparations and mixtures of two or more substances with the potential to cause harm if they are inhaled, ingested or come into contact with, or are absorbed through, the skin.
10.3.4. These substances can occur in many forms, such as solids, liquids, vapours, gases, dusts, fibres, fumes, mist and smoke.
10.3.5. Hazardous substances mean the intrinsic property of that substance which has the potential to cause harm to a person; such properties include one or more of the following:
- Substances (chemicals) that carry a warning label, have a Workplace Exposure Limit (WEL) or have a safety data sheet
- Biological agents arising from work activities
- Medicines which pose a risk to health
- Substantial concentration of airborne dust
- Respiratory sensitisers
- Carcinogens
- Gases and vapours which, when present at high concentrations in the air can be harmful.
10.3.6. These hazardous substances include biological agents.
10.3.7. Biological agents are micro-organism, cell culture, or human endoparasite, whether or not genetically modified, which may cause infection, allergy, toxicity or otherwise create a hazard to human health.
10.3.8. A COSHH assessment is an examination of how substances can harm people to check if precautions are sufficient or if more control measures are needed.
10.3.9. Safety data sheets are documents that suppliers must provide by law under the UK registration, evaluation, authorisation and restriction of chemicals (REACH) regulation. These 16 point information sheets describe warning and safety information about chemicals including hazards, storage, handling, and emergency measures. These sheets should be used when undertaking a COSHH assessment.
10.3.10. Health Surveillance is any activity which involves obtaining information about employees' health and which helps protect employees from health risks at work. Health surveillance may need to be completed by an occupational health professional. The clinical outcomes from health surveillance should be treated as personal.
10.3.11. Personal protective equipment (PPE) are wearable items designed to keep people safe. It includes items such as masks, respirators, breathing apparatus, gloves, eye protection and aprons, coveralls or lab coats.
10.3.12. Workplace exposure limit (WEL) refers to the maximum concentration of an airborne substance to which employees may be exposed. Exposure limits are set by the Health and Safety Executive.
10.4. Roles and Responsibilities
10.4.1. There is a range of standard expectations which underpin all policies. Read more about standard roles and responsibilities. In addition, the following specific responsibilities apply to this policy.
10.5. Employer
10.5.1. The employer should:
- Make sure that risks to health arising from work with hazardous substances are assessed and control measures are implemented in accordance with the COSHH hierarchy of control.
- Make sure equipment is properly maintained and procedures are observed
- Monitor the exposure of individuals and carry out the appropriate form of surveillance of their health, where indicated by the COSHH assessment
- Make sure employees are instructed and trained on the risks and the precautions to be taken
- Make sure appropriate resources are allocated to reduce risk, so far as is reasonably practicable
10.6. Manager
10.6.1. The manager should:
- Identify and prepare an inventory of hazardous substances used in their area of responsibility
- Make sure COSHH assessments are undertaken for all tasks involving potential exposure to hazardous substances
- Make sure COSHH assessments are reviewed at the intervals identified in the COSHH assessment
- Make sure COSHH assessments and reviews are recorded
- Make sure there are sufficiently trained COSHH Assessors with enough time to perform their duties
- Make sure that COSHH Assessors share copies of assessments with other organisations or individuals at risk from hazardous substances linked to NHS work activities.
- Make sure that safe systems of work are developed and followed for all activities within their area of responsibility
- Provide employees with information on identified risks and the protective and preventative measures to be used
- Put measures in place to monitor compliance with safe systems of work and identified control measures
- Refer any staff who report adverse health effects from working hazardous substances to the Occupational Health Service.
- Make sure staff report incidents, including near misses, and are reported in accordance with the local procedure
- Make sure there are plans and procedures in place to deal with incidents and emergencies.
10.7. Employee
10.7.1. The employee should:
- Take reasonable care of their own health and safety and that of any other individual who may be affected by their acts or omissions at work
- Actively support the COSHH assessment process
- Only use a new substance once a COSHH assessment has been carried out
- Inform their manager or COSHH Assessor of any failure in equipment or systems of work that may affect them or others
- Report accidents, adverse events, incidents, unplanned exposures and uncontrolled hazards
- Undertake training as necessary and follow guidance and instruction as required
- Follow systems of work for safe working with hazardous substances
- Engage in health monitoring and health surveillance as required
10.8. Health & Safety Department or Service
10.8.1. The Health & Safety Department or Service within the Health Board should make sure that all managers and staff are aware of their legal obligations under the COSHH Regulations.
10.8.2. It should advise managers on the implementation of these regulations and best practices, provide guidance on occupational hygiene issues such as exposure, control measures and PPE, and develop and deliver training and information for employees.
10.9. Management of Substances Hazardous to Health Process
10.9.1. The management of substances hazardous to health is crucial. A process should be put in place to ensure that risks are mitigated.
10.10. Prevention and control
10.10.1. Preventing exposure to harmful substances is the main aim. Measures that employers can consider for controlling exposure are detailed in the Manager and Employee Guide.
10.10.2. Employers should always seek to prevent exposure to harmful substances, or at the least, control it a level that is as low a level as possible and that is reasonably practicable.
10.10.3. Employers should prevent or control exposure in ways other than only providing PPE. Employers should always introduce process, engineering, procedural and personal controls before PPE, where necessary.
10.11. COSHH Assessment
10.11.1. Managers have a responsibility to make sure that an assessment is carried out to assess the risks arising from work activities involving hazardous substances. Substances released or produced as part of the process must also be assessed.
10.11.2. Before any new substance is introduced to a workplace within the organisation, the manager must make sure that a COSHH assessment is completed.
10.11.3. Where a harmful substance is supplied by a manufacturer, a safety data sheet must be supplied by the manufacturer and should be referred to when undertaking a COSHH assessment.
10.11.4. The COSHH assessment must only be carried out by someone who is deemed competent by having recently completed COSHH assessment training and being familiar with the task.
10.11.5. The COSHH assessment must be recorded on the organisation’s appropriate form. This should be fully completed and signed by the appropriate manager and assessor. A copy of the assessment should be retained for audit purposes.
10.11.6. Managers must review the COSHH assessment at an interval identified through the current assessment in accordance with HSE guidance, or sooner, if there has been a significant change in the work activity or if there is reason to suspect the assessment is no longer valid. Local reporting procedures may be in place concerning any additions or deletions to an inventory of hazardous substances.
10.11.7. In gathering information for an assessment, managers may need expert advice from Competent Persons, such as Health and Safety, Occupational Health and Infection Prevention and Control Services.
10.11.8. Adequate controls must include procedures for disposal of harmful substances, measures to manage accidental release and fire and first aid arrangements.
10.11.9. Employers should prevent exposure or implement control exposures by following the COSHH Hierarchy of Control:
- Eliminate: physically remove the hazard
- Substitute: replace with a less harmful substance / form of substance
- Engineering Controls: isolate people from the hazard
- Administrative Controls: design procedures to minimise exposure
10.11.10. Note that PPE is the least effective control measure. If PPE equipment is required, it must meet current legislative requirements.
10.11.11. These control measures should be supplemented by information, instruction and training.
10.12. Workplace exposure monitoring and Health Surveillance
10.12.1. For the purpose of the regulations, workplace exposure monitoring involves using valid and suitable techniques to estimate the exposure of staff to harmful substances.
10.12.2. Managers are responsible for making sure that this is being carried out by a suitably trained individual at defined intervals, in accordance with HSE guidance and that these activities are recorded.
10.12.3. Health surveillance is any activity which involves obtaining information about employees' health and which helps protect employees from health risks at work.
10.12.4. Health surveillance may not necessarily need to be completed by an occupational health professional.
10.12.5. The clinical outcomes from health surveillance are personal and must be stored securely. Health Surveillance records must be retained for at least 40 years after the date of the last entry.
10.12.6. Health surveillance is appropriate when staff are exposed to substances in circumstances where:
- an identifiable disease or negative health effect may be related to the exposure
- there is increased likelihood that the disease or negative effect may occur under the particular conditions of the work
- valid techniques exist for detecting disease or effect.
10.12.7. This will involve the services of occupational health who will be responsible for maintaining health records and carrying out the appropriate examinations, immunizations’ and investigation. Services must act on any medical decision to restrict a staff member’s work with a specific substance.
10.13. Useful Links:
- COSHH Regulations
- Workplace Exposure limits EH40/2005
- Health and Safety Executive’s (HSE) Approved List of Biological agents
- European Regulation (EC) No 1272/2008 on classification, labelling and packaging of substances and mixture ( the CLP Regulation)
- Scottish Government Records Management: NHS Code of Practice (Scotland) Version 2.0
- HSE Clearing the air A simple guide to buying and using local exhaust ventilation (LEV)
- Training for employees working with substances hazardous to health
10.14. Supporting documentation
It is proposed that the supporting documents listed below will be developed to support the policy. Supporting documents are not part of the consultation. These will be drafted following the consultation when responses have been analysed and the policy is developed in a final draft.
- Employee guide
Descriptor: guide to help employees use and understand the Control of Substances Hazardous to Health (COSHH) Policy.
- Manager guide
Descriptor: guide to help managers use and understand the Control of Substances Hazardous to Health (COSHH) Policy.
- Glove Selection Guide
Descriptor: provides guidance on glove choice for those working within NHSScotland.
10.15. Consultation questions
We are inviting responses to this consultation using the Scottish Government’s consultation hub. The following questions are set.
In your response, all questions have the option to answer yes or no. You are invited to provide further comment in a free text box. If you wish to make specific reference to a section of the policy, please quote the relevant numbered line in this consultation document.
5. Do you feel there are any gaps in the policy?
6. Do you feel there are any gaps in the proposed list of supporting documents?
7. Do you have any other comments to make on the policy?
8. Do you have any views on the potential impacts of this policy on equalities groups?
It is against the law to discriminate against someone because of: age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation. These are protected characteristics under the Equality Act, 2010.
Contact
Email: ofs.pm@gov.scot
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