Aim

This policy sets out the arrangements for complying with the Control of Substances Hazardous to Health (COSHH) Regulations. The aim is to prevent injuries and reduce ill health at work.

Scope

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. 

In this policy, 'employee' includes all these groups unless stated otherwise.

This policy complies with current legislation and meets the aims of the Public Sector Equality Duty of the Equality Act 2010.

Definitions

This policy applies to all hazardous substances used or created during work activities.

The COSHH regulations do not apply to the following, which have their own specific regulations:

• lead
• asbestos
• radioactive substances

A hazardous substance is any substance with the potential to cause harm. This includes substances that are inhaled, swallowed, injected, or come into contact with the skin. They can be:

• solids
• liquids
• vapours
• mists
• fumes
• dusts
• gases and asphyxiating gases
• products containing chemicals
• nanotechnology
• germs that cause diseases such as leptospirosis or Legionnaires' disease 
• germs that cause diseases such as leptospirosis or Legionnaires' disease 
• germs used in laboratories
• biological agents 

A substance is considered hazardous if it has a warning label, a Workplace Exposure Limit (WEL), or a safety data sheet.

A biological agent is a micro-organism, cell culture, or parasite that may cause infection, allergy, or other hazards to human health.

A COSHH assessment is a risk assessment that checks if the precautions for handling a hazardous substance are sufficient, or if more control measures are needed.

Health surveillance is the monitoring of an employee's health to protect them from risks at work. An occupational health professional may carry this out, and the results are confidential.

Personal Protective Equipment (PPE) are wearable items designed to keep people safe, such as masks, respirators, gloves, eye protection, and lab coats.

RIDDOR is the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations, used to inform the authorities of a work-related incident.

Safety Data Sheets (SDS) are documents from suppliers that describe a substance's hazards, storage, handling, and emergency measures. They must be used when conducting a COSHH assessment.

Workplace Exposure Limit (WEL) is the maximum concentration of an airborne substance an employee can be exposed to, as approved by the Health and Safety Executive (HSE).

Roles and responsibilities

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.

Employer

The employer must make sure:

• Risks from hazardous substances are assessed and controlled in accordance with the COSHH hierarchy of control.
• Equipment is properly maintained, and procedures are followed.
• Monitor employee exposure and carry out an appropriate form of health surveillance, where indicated by the COSHH assessment.
• Employees are instructed and trained on the risks and precautions.
• Appropriate resources are provided to reduce risk, so far as is reasonably practicable

Manager

The manager must:

• Identify and create an inventory of hazardous substances in their area of responsibility.
• Make sure COSHH assessments are completed for all tasks involving potential exposure to hazardous substances. These must be reviewed regularly at the intervals identified in the COSHH assessment.
• Record all COSHH assessments and reviews.
• Make guidance available to employees who need to carry out assessments.
• Provide COSHH assessments to those at risk from hazardous substances linked to NHS work activities.
• Develop and enforce safe systems of work for all activities within their area of responsibility.
• Inform employees of risks and the control measures they must use.
• Refer employees who report adverse health effects to occupational health.
• Make sure all incidents, including near misses, are reported and investigated.
• Have emergency plans and procedures in place.

Employee

The employee must:

• Take reasonable care of their own health and safety and that of others who may be affected by their acts or omissions at work.
• Follow all training, guidance, and instructions.
• Support the COSHH assessment process.
• Not use any new substance until a COSHH assessment has been completed.
• Report any failures in equipment or safety systems to their manager.
• Report all accidents, incidents, near misses, and uncontrolled hazards.
• Follow safe systems of work when using hazardous substances.
• Participate in health monitoring and surveillance as required.

Health and safety department or service

The health and safety department or service within the health board should:

• Provide clear guidance to managers and employees on their legal duties under COSHH.
• Advise managers on best practices and provide guidance on occupational hygiene issues such as exposure, control measures, and PPE.
• Develop and deliver relevant training for employees.

Procedure

Management of substances hazardous to health process

The management of substances hazardous to health is crucial. A process should be put in place to ensure that risks are mitigated. 

Prevention and control

Preventing exposure to harmful substances is the main aim. Measures that employers can consider for controlling exposure are detailed in the following guides:

• Manager guide
• Employee guide

Employers should always seek to prevent exposure to harmful substances, or at least control them to a level as low as is reasonably practicable. 

In line with the hierarchy of controls, employers should prevent or control exposure in ways other than providing PPE. Where necessary, employers should always introduce process, engineering, procedural, and personal controls before PPE.  

If latex gloves are needed, a risk assessment must be undertaken prior to use.  

Reporting and recording

Employees must report any exposure to hazardous substances using the appropriate incident reporting system. These incidents must be assessed to see if they need to be reported under RIDDOR.

The HSE must be notified if an employee is absent for more than 7 consecutive days due to exposure. A diagnosed occupational disease, such as dermatitis, must be reported as soon as the diagnosis is received.

COSHH assessment

Managers must make sure a COSHH assessment is carried out for any work involving hazardous substances. This must be done before any new substance is introduced to the workplace. A Safety Data Sheet from the supplier should inform the assessment.

The assessment must be carried out by a competent person who has been trained and is familiar with the task. It must be recorded on the organisation's appropriate system and signed by the manager and assessor. A copy of the assessment should be retained for audit purposes.

Managers must review the assessment at an interval identified through the current assessment in accordance with HSE guidance. However, an immediate review must be done in the following circumstances:

• a significant change in the work activity
• a reason to believe the assessment is no longer valid

Local reporting procedures should be in place concerning any additions or deletions to an inventory of hazardous substances. 

In gathering information for an assessment, managers may need expert advice from competent persons, such as:

• health and safety
• occupational health
• infection, prevention, and control services

Adequate controls must include procedures for:

• storage
• disposal of harmful substances
• measures to manage accidental release
• fire and first aid arrangements

COSHH hierarchy of control

You must prevent or control exposure by following this hierarchy:

1. Eliminate—Physically remove the hazard.
2. Substitute—Replace it with a less harmful substance.
3. Engineering controls—Isolate people from the hazard (e.g., using fume cupboards).
4. Administrative controls—Change the way people work (e.g., design safe procedures, provide training).
5. PPE—Use appropriate safety equipment.

Please note that PPE is the least effective control measure as it only protects the person wearing it. If PPE is required, it must meet current legislative requirements. 

These control measures should be supplemented by information, instruction and training. 

Workplace exposure monitoring and health surveillance

Health surveillance is any activity which involves obtaining information about employees' health and which helps protect employees from health risks at work.

For the COSHH regulations, workplace exposure monitoring checks the level of harmful substances staff are exposed to. It uses specific, approved techniques to estimate exposure.

Employers should make sure health surveillance is carried out by a suitably trained individual at defined intervals. It may not necessarily need to be completed by an occupational health professional. However, HSE guidance must be followed and all activities recorded. 

Health surveillance outcomes are personal and must be stored securely. Records must be retained for at least 40 years after the date of the last entry. 

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 an 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 

Occupational health will maintain health records and carry out the appropriate examinations, immunisations and investigations. Services must act on any medical advice to restrict an employee’s use of specific substances or equipment.