The following guide forms part of the standard for workforce policies. These policies apply to all eligible staff within NHS Scotland, regardless of the board you are employed by.

What is the purpose of the COSHH Policy?

The aim of the COSHH Policy is to protect your team from harm caused by hazardous substances at work. It sets out the rules and procedures you must follow in the workplace to prevent injuries and illness. These guidelines help to make sure all employees follow the official Control of Substances Hazardous to Health Regulations.

Who is covered by this policy?

This policy applies to everyone working within NHS Scotland. That includes all employees, plus bank, agency, and sessional workers, volunteers, contractors, and anyone on placement, such as students or trainees.

Manager responsibilities

As a manager, you are responsible for leading COSHH safety in your area. You must:

• Know your substances—Create and maintain an inventory of all hazardous substances used or stored in your area.
• Assess the risks—Make sure COSHH assessments are completed for all relevant tasks, reviewed regularly, and properly recorded.
• Support your team—Provide guidance for employees doing assessments and share the results with anyone at risk.
• Enforce safe working—Develop, implement, and monitor safe systems of work and control measures.
• Communicate clearly—Inform employees about identified risks and the protective measures they must use.
• Look after employee health—Refer employees to Occupational Health if they report adverse health effects from their work.
• Manage incidents—Make sure all incidents and near misses are reported according to local procedures and have emergency plans in place.

Health and safety department or service

The health and safety department in your health board provides guidance to you and your employees on COSHH rules. They advise on controlling exposure and using Personal Protective Equipment (PPE) and deliver training for your team.

Management of substances hazardous to health process

Managing hazardous substances is crucial for identifying risks and putting controls in place to prevent harm. This should include understanding area site plans for inventory management and emergency response. The site plan should detail where substances are stored and accessed in the event of an emergency.

Your goal is to achieve adequate control of exposure. This means:

• Reducing exposure to substances with a Workplace Exposure Limit (WEL) to a level that is as low as reasonably practicable.
• Controlling exposure to all other substances to a level that is unlikely to cause harm.

Prevention and control

Your primary responsibility is to prevent exposure where possible. If not, you must control it to the lowest practical level. To do this, you must lead the implementation of the hierarchy of control. Think of it as layers of defence, starting with the most effective.

1. Eliminate—Remove the hazardous substance completely.
2. Substitute—Replace it with a safer alternative.
3. Engineering controls—Ventilate the area or isolate people from the hazard.
4. Administrative controls—Change how people work, including providing supervision, not allowing eating or drinking in contaminated areas, and restricting access where possible to minimise exposure.

Personal Protective Equipment (PPE), including masks or Respiratory Protective Equipment (RPE), should only be used as a last resort. Only use PPE after all other safety options have been exhausted.

If you do need to use PPE, it must always be:

• suitable for the specific hazard
• properly fitted to you personally
• maintained and stored correctly

Poorly chosen or ill-fitting equipment can give a false sense of security and may not protect you at all.

These control measures should be supplemented by information, instruction and training to make sure employees understand the risks and how to work safely.  

COSHH assessment

A COSHH assessment is a safety check for every hazardous substance used in the workplace. It’s done by a trained person to identify the risks and establish the safest ways of working.

As a manager, you are responsible for making sure a COSHH assessment is carried out for any work activity involving hazardous substances. This must be done before any new substance is introduced. You must use the Safety Data Sheet (SDS) from the manufacturer to inform the assessment.

• Who can do an assessment?—The assessment must be done by a competent person who has completed recent training and is familiar with the task.
• Recording and reviewing—Assessments must be recorded on the correct system and signed. You must review them regularly or immediately if the work changes.
• Implementing controls—You must implement all controls identified in the assessment, such as safe work systems, supervision, emergency procedures, and PPE.

Workplace exposure monitoring and health surveillance

Workplace exposure monitoring is the formal process of measuring your team's exposure to harmful substances.

As a manager, you are responsible for making sure that an assessment is carried out to assess the risks arising from work activities involving hazardous substances, including those released or produced during the process.  

Before introducing any new substance into the workplace, you must complete a COSHH assessment. If a manufacturer supplies the substance, you must refer to the Safety Data Sheet provided when conducting the assessment. 

A competent person must only carry out the COSHH assessment. They must have recently completed COSHH assessment training and be familiar with the task. This includes coordinating any advice and guidance, if necessary, for employees who may be required to undertake assessments.  

The COSHH assessment must be recorded on the organisation’s appropriate system. You or the appropriate manager and assessor should fully complete and sign this. A copy of the assessment should be retained for audit purposes. 

You must review your assessments regularly, following current HSE guidance. You also need to review them immediately if the work activity changes significantly or you suspect an assessment is out of date.

You must also have a local process in place for updating your inventory of hazardous substances. This makes sure that your list of materials is always current and that all assessments are linked to the correct substances.

When gathering information, you may need to seek advice from competent persons, such as:

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

Required controls identified in the COSHH assessment must be implemented in the workplace. These controls include:  

• safe systems of work  
• provision of necessary tools and equipment  
• provision of information, instruction and training 
• supervision  
• emergency procedures  
• PPE 
• exposure monitoring 
• safe storage and disposal procedures 
• measures for accidental release and fire safety 
• appropriate first aid arrangement  

Workplace exposure monitoring and health surveillance  

As a manager, you are responsible for workplace exposure monitoring. Valid and suitable techniques must be used to estimate employee exposure to harmful substances. This must be done by a suitably trained individual at defined intervals and in accordance with HSE guidance. You must also make sure that all monitoring activities are properly recorded. 

You are also responsible for making sure that health surveillance is in place where required. Health surveillance involves gathering information about employees’ health to help protect them from work-related health risks. This should be carried out by a suitably trained individual, in accordance with organisational procedures. If an employee reports any adverse health effects due to working with hazardous substances, you must refer them to occupational health. 

You must make sure that health surveillance is arranged and repeated at appropriate intervals where exposure risks are identified. 

Health surveillance is implemented when: 

• there is a known link between exposure and a specific disease or health effect 
• the work conditions increase the likelihood of that disease or effect occurring 
• valid methods exist for detecting early signs of the disease or effect 

Where health surveillance is required, occupational health services must be involved. They are responsible for maintaining health records and carrying out necessary examinations, immunisations, and investigations. 

All health surveillance outcomes are confidential and must be securely stored. Records must be retained for at least 40 years from the date of the last entry. 

Reporting and recording

As a manager, you should make sure that employees report all incidents of exposure to hazardous substances to you. This must include near misses, such as spillages that could have caused harm. You are responsible for recording and investigating the incident in accordance with local protocols and procedures.  

If an employee is absent for more than 7 days due to exposure to a hazardous substance, you must notify the HSE within 10 days of the incident.  

Under RIDDOR, you have a legal duty to report certain incidents to the HSE. This includes work-related deaths, specific occupational absences of more than 7 days due to an incident.