Control of Substances Hazardous to Health
(Coshh)
Version
4
Name of responsible (ratifying) committee
Health & Safety Steering Group
Date ratified
09.01.13
Document Manager (job title)
Health & Safety Advisor
Date issued
6th March 2013
Review date
9th January 2015 or change in regulations
Electronic location
Health and Safety Policies
Related Procedural Documents
Key Words (to aid with searching)
Coshh Chemical Substance Hazardous Health
exposure Hazards; Working environment;
Occupational hazards; Risk management; Dangerous
materials; Safety measures; Hazard control; Forms;
Health service staff
Compliance with Control of Substances Hazardous to Health (COSHH) Regulations 2002 Policy (as amended
2004). Issue 4 06.03.13 (Review date: 09.01.15 or change of regulations)
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CONTENTS
QUICK REFERENCE GUIDE....................................................................................................... 3
1.
2.
3.
4.
5.
6.
7.
8.
9.
INTRODUCTION ................................................................................................................................................. 4
PURPOSE ........................................................................................................................................................... 4
SCOPE ................................................................................................................................................................ 4
DEFINITIONS ...................................................................................................................................................... 5
DUTIES AND RESPONSIBILITIES ..................................................................................................................... 5
PROCESS ........................................................................................................................................................... 6
TRAINING REQUIREMENTS.............................................................................................................................. 7
REFERENCES AND ASSOCIATED DOCUMENTATION ................................................................................... 8
MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL DOCUMENTS .......... 8
APPENDIX 1: COSHH ASSESSMENT OF RISK………………………………………………………..........................9
APPENDIX 2: PRINCIPLES OF GOOD PRACTICE FOR THE CONTROL OF EXPOSURE TO
SUBSTANCES HAZARDOUS TO HEALTH………………………………………………………………………………...11
APPENDIX 3: LABEL CLASSIFICATION/HAZARD CATEGORY……………………………………............................12
APPENDIX 4: GLOBALLY HARMONISED SYSTEMS OF CLASSIFICATION AND LABELLING OF
CHEMICALS
13
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QUICK REFERENCE GUIDE
This policy must be followed in full when developing or reviewing and amending Trust procedural
documents.
For quick reference the guide 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.
1. Employers have a general duty under the Health and Safety at Work etc, Act 1974 to
ensure the health, safety and welfare of all their employees. The Control of Substances
Hazardous to Health Regulations (COSHH) 2002 (as amended) aim to protect
employees from health risks associated with hazardous substances.
2. The purpose of this policy is to set out the measures required by the Trust to ensure
compliance with the COSHH Regulations.
3. The COSHH regulations apply to substances (including carcinogens, mutagens,
mixtures and biological agents), which are hazardous to health in any form in which they
occur in a work activity. Exceptions include substances already covered by separate
Regulations (e.g. lead and asbestos), and substances hazardous to health solely by
virtue of radioactive, explosive or flammable properties, or solely because it is at a high
or low temperature or a high pressure; or where the risk to health is as a result of a
substance administered in the course of medical treatment.
4. WEL Workplace Exposure Standard as indicated on the material safety data
PPE Personal Protective Equipment
Risk Assessment, Minimum compliance is the completed assessment
Hazard and Risk
5. It is the managers responsibility to undertake an assessment of risk before the
substance is brought into use, Occupational Health and Safety will undertake any
necessary health surveillance and staff are required to work in such a fashion so as not
to put themselves and others at risk and in accordance with any instructions given.
6. Assessing risks to health from work with hazardous substances
Introducing appropriate measures to prevent or control the risk
Ensuring control measures are used and maintained
Monitoring employees exposure to hazardous substances and carrying out health
surveillance, where appropriate
Providing information, instruction and training to employees about the risks and the
precautions needed
7. The Trust will give sufficient information, instruction and training to ensure a good
understanding of the hazards to health posed by substances in the workplace, and the
importance of the control measures provided. A separate course is available for those
who are to be risk assessors.
8. The control of substances hazardous to health regulations 2002 (as amended)
Health and safety at work act 1974
EH 40/2005 occupational exposure limits (as amended from time to time)
9. Monitoring will be by ill heath reports through Occupational health and exposure to
hazardous substances reported through the accident system as reported in the accident
data to the Health and Safety operational and steering groups.
Compliance with Control of Substances Hazardous to Health (COSHH) Regulations 2002 Policy (as amended
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1. INTRODUCTION
Employers have a general duty under the Health and Safety at Work etc, Act 1974 to ensure the
health, safety and welfare of all their employees. This duty includes providing a safe and healthy
workplace, safe machinery and safe systems of work, together with information, instruction and
training. These duties are made explicit by the Management of Health and Safety at Work
Regulations 1992 (as amended) and in regulations that require the assessment and control of
specific types of risk, for example the Control of Substances Hazardous to Health Regulations
(COSHH) 2002 (as amended). The COSHH regulations aim to protect employees from health
risks associated with hazardous substances.
2. PURPOSE
The purpose of this policy is to set out the measures required by the Trust to ensure compliance
with the COSHH Regulations.
3. SCOPE
The COSHH regulations apply to substances (including carcinogens, mutagens, mixtures and
biological agents), which are hazardous to health in any form in which they occur in a work
activity. Exceptions include substances already covered by separate Regulations (e.g. lead and
asbestos), and substances hazardous to health solely by virtue of radioactive, explosive or
flammable properties, or solely because it is at a high or low temperature or a high pressure; or
where the risk to health is as a result of a substance administered in the course of medical
treatment.
Substances hazardous to health include:
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A substance which is classified as very toxic, toxic, harmful, corrosive or irritant
under the Chemicals (Hazard, Information and Packaging for Supply) Regulations
2002 as amended (CHIP); these carry the following symbols, a definition of the
health effects associated are listed at appendix 3 Alongside the new classification
and labeling systems guidance – appendix 4
Toxic / Very Toxic
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Corrosive
Bio Hazard
Harmful / Irritant
A substance for which a Workplace Exposure Limit (WEL) is specified
Any biological agent (micro-organism, cell culture or human endoparasite) which is
hazardous to health
Any substance or preparation classified as carcinogenic (category 1 or 2)
Any dust at a concentration in air equal to or greater tnan 10mg/m³ 8hr TWA of total
inhalable dust or 4mg/m³ 8hr TWA of respirable dust
Substances that have chronic or delayed effects e.g. mutagenic or toxic to
reproduction
Any other substance which creates a comparable hazard to health
The hazard presented by a substance is its potential to cause harm. The risk from a substance is
the likelihood that it will cause harm in the actual circumstances of use. This depends on for
example, the chance of exposure occurring, the amount of the substance people are exposed to
and for how long, the effectinvness and reliability of any existing control measures etc. There can
be substantial risk from a substance that is not particularly hazardous, if exposure is excessive.
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This document must be brought to the attention of any managers and employees working with
any chemicals that carry the designated symbols or warnings above.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that
it may not be possible to adhere to all aspects of this document. In such circumstances, staff
should take advice from their manager and all possible action must be taken to maintain
ongoing patient and staff safety’
4. DEFINITIONS
WEL Workplace Exposure Standard as indicated on the material safety data
PPE Personal Protective Equipment
Risk Assessment, Minimum compliance is the completed assessment form at appendix 1 that
considers all aspects of appendix 2 to be deemed as adequate.
5. DUTIES AND RESPONSIBILITIES
Managers:
 Ensure that COSHH assessments are carried out by competent persons
 Ensure all COSHH assessments are collated in an accessible COSHH folder
 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
 Liaise with the Health and Safety Department for advice where required, and to update
the biological agent users register as appropriate
 Liaise with the Occupational Health Department 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 Occupational Health and
Health and Safety Departments if there is a potential risk to health
Health and Safety Advisers:
 Provide advice to managers on completion of COSHH assessments
 Carry out or arrange appropriate exposure monitoring where required
 Liaise and consult with Occupational Health Department where required
 Ensure that relevant training programs are made available, including training for
nominated assessors and competent persons
Occupational Health Department:
 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 and Safety Department as appropriate
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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 Department
6. PROCESS
Complying with COSHH involves:
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Assessing risks to health from work with hazardous substances
Introducing appropriate measures to prevent or control risk
Ensuring control measures are used and maintained
Monitoring employees exposure to hazardous substances and carrying out health
surveillance, where appropriate
Providing information, instruction and training to employees about the risks and the
precautions needed
Risk Assessment:
Where work involving substances hazardous to health is carried out, a written assessment of the
risks to health arising from the work and the steps needed to meet the requirements of the
Regulations, must be carried out. The assessment should be documented and reviewed 2 yearly,
or sooner, if there is reason to suspect that it is no longer valid e.g. if there is a significant change
to the work, if new substances are introduced, new methods of manufacture are used, there is a
change in guidance, or there are changes to control measures including Personal Protective
Equipment (PPE).
Where there is exposure to substances that are hazardous to health control of that substance
shall only be treated as adequate if the principles of good practice for the control of exposure to
substances hazardous to health set out in Appendix 2 are applied.
Any substance that carries the risk phrase R42 or R42/43, or is listed as an “Asthmagen” a
greater assessment of risk should be undertaken to ensure that the circumstances in which this
occurs is eliminated e.g. through the possible mixing of chemicals that will produce the
asthmagen.
Risk Control:
Exposure to substances hazardous to health must be prevented or controlled. Prevention is by
elimination of the hazardous substance or process, or by substitution with a less hazardous
substance, or the same substance in a less hazardous form, e.g. pellet form instead of powder,
or a wet process instead of a dry one.
When exposure to a hazardous substance cannot be prevented it should be controlled by
measures designed to reduce the risk to health. Control measures fall into three broad
categories: engineering, procedural and Personal Protective Equipment (PPE). PPE should be
used only when other control measures are not feasible (except in the case of carcinogens or
biological agents when all relevant controls should be put in place). The COSHH Regulations set
out a clear, strict hierarchy of control measures:
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Totally enclosed process and handling systems
Partially enclosed process with Local exhaust ventilation (LEV)
Local exhaust ventilation
Sufficient general ventilation
Reduction of numbers of employees exposed and exclusion of non-essential access
Reduction in the period of exposure for employees
Regular cleaning of contamination from work area provision of means for safe storage
and disposal of substances hazardous to health
Suitable Personal Protective Equipment (PPE)
Prohibition of eating, drinking, smoking in contaminated areas
Provision of adequate facilities for washing, changing and storage of clothing, including
arrangements for laundering contaminated clothing)
Monitoring exposure and health surveillance:
 Where required, exposure monitoring must be carried out by a competent person, and
this should be arranged in conjunction with the Health and Safety Department
 Health surveillance is arranged in conjunction with the Occupational Health Department,
and is required when the following circumstances are met: there is a statutory duty to do
so; or 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:
(Appendix 1 gives the assessment form, which must be used for this purpose). In addition please
also refer to and use the Trust Risk Assessment Policy if appropriate.
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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 nonemployees 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 5): 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 and Safety Department re the need for occupational hygiene
measures
Liaise with Occupational Health Department 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
7. TRAINING REQUIREMENTS
The Trust will give sufficient information, instruction and training to ensure a good understanding
of the hazards to health posed by substances in the workplace, and the importance of the control
measures provided. Information will also be given to others who may be affected, such as
contractors, temporary staff and visitors and should include as a minimum,

Must be provided to employees exposed to substances hazardous to health
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Should raise awareness of all hazards, risks to health and precautions to be taken
(adopted?)
Should include control measures, LEV, PPE etc, and their proper use application, and
any user checks required before use
There must be adequate supervision by line management to ensure proper use of the control
measures provided.
For those who will be risk assessors a separate course is available through the Health & Safety
Department.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
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The control of substances hazardous to health regulations 2002 (as amended)
Health and safety at work act 1974
EH 40/2005 occupational exposure limits (as amended from time to time)
EH 40 annual supplements
A step-by-step guide to risk C. O. S. H. H. assessment
Chemicals (Hazard Information and Packaging for Supply) Regulations (CHIP)
9. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS
This policy will be monitored for effectiveness on an annual basis through the measurement of
reported ill heath reports through Occupational Health, exposure to hazardous substances
reported through the accident system and as reported in the accident data to the Health and
Safety Operational and Steering groups.
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APPENDIX 1:
COSHH ASSESSMENT OF RISK
Site:
Supplier:
Tel No:
Product Name:
Safety Data Sheet Date of issue:
Description of Use in Department
What is it used for? (Task)
How is it used? (Include PPE)
Frequency of use? (Daily, Weekly, Monthly)
How long are people exposed to the
substance?
Quantity used?
Who is exposed? (Staff, Public,
Maintenance)
Nature of Hazard (information on ingredients, exposure controls)
Hazardous Constituents
Hazard
Risk
Safety
Category
Phrase
Phrase
e.g. Methanol
Toxic(T) &
Highly
Flammable
R11,23,24,
25, 39
S7, 16,24,
36 37, 45
WorkplaceExposure
Limits
WEL (8hrs and 15min
in)
WEL 8hrs - 266mgm3 &
15min - 333mgm3
a.
b.
c.
d.
Route of entry into body – Health Effects
Inhalation
Ingestion (swallowing)
Eye contact
Skin Contact
Is there a fire or explosion risk with this substance?
Can mixture with other substances create additional risks? E.g. release of chlorine gas / asthmagens etc.
Can the substance be substituted with a safer alternative?
Yes
No
Could you reduce the amount of the substance in your dept?
Yes
No
Assessment of Risk in Department in the way it is currently used
Very Low
Low
Moderate
High
Very High
Comments:
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9.1.
COSHH Control Measures
Define the system of work
What Additional Measures can be taken to Reduce Exposure? (i.e. enclosure, mechanical control or PPE to be worn)
First Aid Procedures
Inhalation
Skin Contact
Eye contact
Ingestion
How should a spillage be dealt with?
If Substance is Flammable what Measures should be taken
Where should the Substance be Stored?
If not needed, how would you Dispose of the Substance?
Is Air Monitoring or Health Surveillance required? (If you think it is necessary contact Occupational Health)
Date of examination and test for local exhaust ventilation / respirator, if applicable.
How will information be given to staff regarding this assessment and by whom?
9.2.
Assessment of Risk with control measures in place
Very Low
Low
Moderate
High
Very High
Comments:
Name of Assessor
Signature
Date of assessment
Review date dd/mm/yy or on change of substance or supplier
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APPENDIX 2: PRINCIPLES OF GOOD PRACTICE FOR THE CONTROL OF
EXPOSURE TO SUBSTANCES HAZARDOUS TO HEALTH
a) Design and operate processes and activities to minimize emission, release and spread of
substances hazardous to health.
b) Take into account all relevant routes of exposure– inhalation, skin absorption and ingestion–
when developing control measures.
c) Control exposure by measures that are proportionate to the health risk.
d) Choose the most effective and reliable control options, which minimise the escape and
spread of substances hazardous to health.
e) Where adequate control of exposure cannot be achieved by other means, provide, in
combination with other control measures, suitable personal protective equipment.
f) Check and review regularly all elements of control measures for their continuing
effectiveness.
g) Inform and train all employees on the hazards and risks from the substances with which they
work and the use of control measures developed to minimise the risks.
h) Ensure that the introduction of control measures does not increase the overall risk to health
and safety.
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APPENDIX 3: LABEL CLASSIFICATION/HAZARD CATEGORY
HEALTH EFFECTS
Very toxic
Substances and preparations which in very low quantities cause death or acute
T+
or chronic damage to health when inhaled, swallowed or absorbed via the skin.
Toxic
Substances and preparations which in low quantities cause death or acute or
T
chronic damage to health when inhaled, swallowed or absorbed via the skin.
Harmful
Substances and preparations which may cause death or acute or chronic
Xn
damage to health when inhaled, swallowed or absorbed via the skin.
Corrosive
Substances and preparations which may, on contact with living tissues, destroy
C
them.
Irritant
Non-corrosive substances and preparations which, through immediate,
prolonged or repeated contact with the skin or mucous membrane, may cause Xi
inflammation.
Sensitising
Substances and preparations which, if they are inhaled or if they penetrate the
skin, are capable of eliciting a reaction by hypersensitization such that on
further exposure to the substance or preparation, characteristic adverse effects
are produced.
Sensitising
inhalation
by
Sensitising
skin contact
by
Carcinogenic
Xn
Xi
Substances and preparations which, if they are inhaled or ingested or if they
penetrate the skin, may induce cancer or increase its incidence
Category 1
T
Category 2
T
Category 3
Xn
Mutagenic
Substances and preparations which, if they are inhaled or ingested or if they
penetrate the skin, may induce heritable genetic defects or increase their
incidence.
Category 1
T
Category 2
T
Category 3
Xn
Toxic for reproduction
Substances and preparations which, if they are inhaled or ingested or if they
penetrate the skin, may produce or increase the incidence of non-heritable
adverse effects in the progeny and/or of male or female reproductive functions
or capacity.
Category 1
T
Category 2
T
Category 3
Xn
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APPENDIX 4: NEW SYSTEMS FOR CLASSIFICATION AND LABELLING OF CHEMICALS
New Systems for Classifying and Labelling of Chemicals
Those ordering and using hazardous chemicals will, or may already have started, to notice new
hazard warning symbols – now referred to as ‘Pictograms’ appearing on labels, as well as
changes to information given in the material Data Sheets (MSDS). This is because a new system
for the classification and labeling of hazardous substances and mixtures is in the process of
being implemented – part of the United Nations aim to globally harmonize the system for
classification and labeling of chemicals.
Why the change?
Across the world, countries have different rules on classification and labeling. For example, a
chemical could be classified as ‘toxic’ or ‘explosive’ in one country but not in another. Different
symbols are also used to indicate the same hazards.
Countries in the United Nations, including those in the European Union, have been working
together with industry representatives and others to agree a classification and labeling system
that can be used worldwide. The outcome is the Globally Harmonized System of Classification
and Labeling of Chemicals, known as the ‘GHS’. The GHS provides a single system to identify
hazards and to communicate them in transporting and supplying chemicals across the world.
Within Europe, the Globally Harmonized System (GHS) has been implemented in a set of
regulations known as the Classification, Labeling and Packaging of Hazardous Substances and
Mixtures (CLP) and In April 2009 these regulations were implemented into the UK as CHIP 4
(Chemicals Hazard Information and Packaging for Supply) Regulations.
What are the Key Changes?
 New hazard Warning Symbols know as ‘Pictograms’
Old: orange / black ‘hazard symbols’
New:
red
/
black
diamonds
called
‘pictograms’
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Terminology
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The word ‘Preparation’ has been replaced with the word ‘Mixture’
Signal Words
Each substance will now have either a ‘Danger or ‘Warning’ on the Label unless it is deemed of
such a low hazard as to not require one.
 Danger = more severe hazards
 Warning = Less severe hazards
Risk and Safety phrases
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These will be replaced by Hazard and Precautionary statements
Hazard Statements are separated into:
H200s for Physical Hazards
H300s for Health Hazards
H400s for Environmental Hazards
Hazard statements will 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’
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Precautionary Statements are separated into:
P100s for General
P200s for Prevention
P300s for Response
P400s for storage
P500s for Disposal
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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…….
Safety Data Sheets
The word ‘Material’ has been removed and these are now simply known as Safety Data Sheets.
They must include 16 set Headings:
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Identification
Hazard(s) Identification
Composition/information on ingredients
First-aid measures
Accidental release measures
Handling and Storage
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Exposure controls/personal protection
Physical and chemical properties
Stability and reactivity
Toxicological information
Ecological information
Disposal considerations
Transport information
Disposal considerations
Regulatory information
Other information
How does this affect the end user?
Although most of this emphasis is on those who manufacture, package and supply chemical end
users will notice these changes on the chemicals and substances that they receive into the
workplace.
There is a long transitional period for changeover to the harmonized system 2009 – 2015 and as
such the products that we use within the workplace may arrive from the supplier with either the
‘old’ or the ‘new’ labels and statements.
All end users should be made aware of these changes.
A point to note is that unless you are bringing a new substance into the workplace for
use, the composition of the substances that you are currently using has not changed –
what has changed is the way in which this information is given on the packaging.
Once the GHS system has reached its deadline date in 2015 there will be a need to formally
update the COSHH assessment forms and the policy to reflect these new changes. During this
transitional phase departments may need to make minor wording adjustments to their COSHH
assessment forms – for example replacing the R + S phrases with hazard and precautionary
statements to reflect any products arriving with the new labeling.
A full list of Hazard and Precautionary statements alongside details of the new pictograms can be
found on the COSHH section of the Health and Safety web pages.
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