Document name:
Control of Substances Hazardous to Health (COSHH)
Policy & Guidance
Document type:
Policy and Guidance
What does this policy replace
Update of previous policy and replaces COSHH Policy
Staff group to whom it applies:
All staff within the Trust
Distribution:
The whole of the Trust
How to access:
Intranet and line managers
Issue date:
January 2016
Next review:
November 2018
Approved by:
Executive Management Team
Developed by:
Roland Webb, Health & Safety Manager
Director leads:
Director of Human Resources & Workforce Development
Contact for advice:
 Roland Webb; Health & Safety Manager
01924 327475
 Steve Amos; Emergency Planning and Safety Adviser
07798 534580
 Richard Galliford; Fire & Health and Safety Advisor
01226 435 601
 Alan Ryding; Facilities Risk Assessment Officer
07881 835537
Contents
Page
3
1.
Introduction
2.
Purpose
3
3.
The Risks of not having this Policy in place
4
4.
Definitions
4-5
5.
4.1
Employees
4.2
COSHH & CHIP
4.3
Substances
4.4
Hazard
Principles
4
4
5
5
5-6
6.
Roles and Responsibilities
6 - 13
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10
6.11
6.12
6.13
6.14
6.15
The Trust Board
Chief Executive
Director of Human Resources and Workforce
Development
Directors
Head of Estates and Facilities
Heads of Service, General Service & Line
Managers
Departmental/Ward/Team Managers
Employees
Health & Safety Manager/Specialist Advisers
Health & Safety Team
Occupational Health Service
Infection Prevention and Control Department
Principle Pharmacist
Procurement Department
Contractors
6
7
7
7
7-8
8-9
9
9 - 10
10
11
11
12
12
12 – 13
13
7.
Arrangements
13 -15
8.
Procedures
8.1
Training
8.2
Risk Assessment
15
15
15
9.
Monitoring the Compliance and Effectiveness of this
Policy
15
10.
References
11.
Review of this Policy
15 - 16
Page 1 of 34 - COSHH Policy & Guidance 2016
16
Appendices
Appendix 1
Appendix 2
Health & Safety Consultation Process
Equality Impact Assessment Tool
Appendix 3
Checklist for the Review and Approval of Procedural
Document
Appendix 4
Policy Procedures
Appendix 5
COSHH Assessment Procedure
Appendix 6
COSHH Assessment Request Form (CARQ)
Appendix 7
CARQ/SYPOL Procedure
Appendix 8
General Information & CLP pictograms
Appendix 9
Version Control Sheet
Page 2 of 34 - COSHH Policy & Guidance 2016
Control of Substances Hazardous to Health (COSHH) Policy
1.
Introduction
The policies, procedures, guidelines, clinical protocols and local work
procedures of South West Yorkshire Partnership Foundation Trust
(SWYPFT) are intended to provide a framework that ensures that the
work of SWYPFT is conducted in such a manner as to enable the
organisation to fulfil its statutory and contractual obligations and meet its
vision, values and goals in a consistent and coherent manner.
The Control of Substances Hazardous to Health Regulations 2002 (As
amended) (COSHH) provides a legal framework to protect people against
health risks arising from hazardous substances used or encountered at
work. This Policy details SWYPFT’s approach to meeting its legal and
moral obligations relating to hazardous substances.
SWYPFT has a ‘Duty of Care’ to its employees and those who might be
adversely affected by its activities, and must comply with the requirements
of:








2.
The Health and Safety at Work etc. Act 1974;
The Control of Substances Hazardous to Health (COSHH) Regulations
2002 (as amended)
The Classification, Labelling and Packaging Regulations 2009
The Management of Health and Safety at Work Regulations 1999;
The Personal Protective Equipment Regulations 1992;
RIDDOR - Reporting of Injuries, Diseases and Dangerous
Occurrences Regulations 2013;
NHS compliance standards;
Other relevant statutes/directives as they relate to substances
hazardous to health.
Purpose
The purpose of this policy is to:

Identify training needs for staff involved in COSHH arrangements.

Describe Trust wide COSHH arrangements.

Provide information and guidance to all staff relating to hazardous
substances and COSHH in general.

Specify sources of COSHH expertise and support available to staff.

Identify appropriate products that can be used safely.
Page 3 of 34 - COSHH Policy & Guidance 2016
3.
The Risks of not having this policy in place
Failure to comply with this policy may result in the following corporate
risks arising:
4.

The health and welfare of staff, service users and visitors may not
be adequately managed and controlled.

Health and safety arrangements may not be achieved and
implemented in a consistent manner across the organisation.

SWYPFT may not meet its legal obligations and standards set by
such organisations as the Health & Safety Executive (HSE), Care
Quality Commission (CQC) and Monitor etc.

Potential loss of reputation both as a provider of care and
employer.
Definitions
4.1
Employees
Employees are:

Direct employees of SWYPFT.

Employees of other organisations but directly managed by
SWYPFT.
N.B. Direct employees of SWYPFT that are directly managed
by another organisation (e.g. Local Authority) will work to that
organisation’s policy and procedures, unless specific
agreement is reached to the contrary.

4.2
Agency staff, apprentices, cadets, volunteers and any other
staff on placement with SWYPFT.
COSHH - the ‘Control of substances hazardous to health
regulations 2002 (as amended)’.
N.B. COSHH does not apply to: drugs, lead, asbestos, and
substances whose hazard is due to their explosive, radioactive,
flammable, temperature (high or low) or high-pressure
characteristics.
CHIP - Chemicals (Hazard Information and Packaging for Supply)
Regulations 2002
Page 4 of 34 - COSHH Policy & Guidance 2016
4.3
COSHH covers substances that are hazardous to health.
Substances will be present in the working environment in many
forms and concentrations. Substances are any natural or
artificial materials, whether in the form of a solid, liquid, gas or
vapour, including micro-organisms and include:








Chemicals
Products containing chemicals
Fumes
Dusts
Vapours
Mists
Gases and asphyxiating gases and
Biological agents (germs).
Germs that cause diseases such as leptospirosis or
legionnaires disease and germs used in laboratories.
If the packaging has any of the hazard symbols then it is classed
as a hazardous substance.
4.4

A hazard in a COSHH context is a substance which is classified as
one of the following:










Carcinogenic
Corrosive
Dangerous to the environment
Explosive
Harmful
Irritant
Flammable
Mutagenic
Oxidising
Toxic
All of the above can be identified on product labelling and their
safety data sheets. Other information may also be shown including
substances that may result in sensitisation, or could be a
microbiological hazard such as clinical waste.
5.
Principles
SWYPFT will take all steps, so far as is reasonably practicable, to pursue
the following principles:

To ensure, as far as is reasonably practicable, that no individual is
exposed to avoidable risks to their health resulting from hazardous
substances used or encountered through the activities of SWYPFT.
Page 5 of 34 - COSHH Policy & Guidance 2016

To ensure that the least hazardous substances are purchased and
used within SWYPFT.

To ensure that COSHH Risk Assessments are carried out for all
substances or groups of substances, to which a person may be
exposed as a result of the activities of SWYPFT.

To implement a control of hierarchy of hazardous substances that
includes:
Eliminate
Reduce
Isolate
Control

To ensure that reasonable steps are taken to prevent or control
exposure to hazardous substances.

To ensure that employees exposed to substances with known
adverse health effects are identified to the relevant Occupational
Health Department who will determine the requirement for health
surveillance.

To ensure that Information, Instruction and Training (IIT) will be
provided for all employees on:






6.
The hazardous substances to which they may be exposed;
The results of COSHH Risk Assessments;
The methods of controlling exposure;
The use of Personal Protective Equipment (PPE), and
The safe systems of work to be followed.
To ensure that all persons, other than SWYPFT employees, who,
in the course of their work, may be exposed to substances on
SWYPFT premises, will be provided with suitable and sufficient
information on the likely hazards within the area.
Roles & Responsibilities
6.1
The Trust Board
The Trust Board will ensure, so far as is reasonably practicable:
Ensure that all steps are taken to ensure the health, safety and
welfare of all stakeholders including, staff, partners, service users,
visitors and others.
6.2
Chief Executive
As accountable officer for SWYPFT, the Chief Executive has
Page 6 of 34 - COSHH Policy & Guidance 2016
overall responsibility for all health, safety and welfare matters of
SWYPFT.
6.3
Director of Human Resources and Workforce Development
It is the responsibility of the Director of Human Resources and
Workforce Development, so far as reasonably practicable to:
6.4

Manage Trust Health & Safety matters and be responsible for
informing the Trust Board of any health and safety matters,
including pertinent COSHH management issues.

Ensure a fit for purpose COSHH policy that reflects all
COSHH aspects of the SWYPFT organisation is in place.

Report to the Trust Board on an annual basis the Health and
Safety performance of SWYPFT, including COSHH.
Directors
It is the responsibility of Directors, so far as reasonably practicable
to:
6.5

Be responsible for all aspects of health, safety, security and
welfare of any person who could be affected by activities over
which the Director has management responsibility.

Ensure any COSHH related matters which are of concern are
brought to the attention of the Director of Human Resources
and Workforce Development.

Ensure their areas of responsibility fully participate in the
annual health and safety monitoring programme that allows
Business Development Units to assess and review COSHH
arrangements in place.

Establish local arrangements for consultation on COSHH
within their areas of responsibility.
Head of Estates and Facilities
It is the responsibility of the Head of Estates and Facilities to:
Ensure competent advice and support is provided to
employees in meeting the requirements of this and related
policies.

Ensure a database is maintained of incidents concerning the
use, storage and disposal of hazardous substances and
report on trends.
Page 7 of 34 - COSHH Policy & Guidance 2016
6.6

Ensure incident data is retained for a minimum of 3 years, but
where health surveillance is necessary may extend this to 40
years after consultation with Occupational Health.

In the absence of action by Directors and/or managers, and
after appropriate consultation, the Health and Safety Managers
is empowered to advise the Chief Executive and/or the Trust
Board that they should stop any use of hazardous substances
under COSHH arrangements if in their opinion it gives rise to
imminent risk of serious personal injury. In the event of a
decision to cease such activities, they will not be allowed to
restart until such time as the cause of the danger is removed or
rectified.

Manage budget performance for the provision of the COSHH
Management System, SYPOL CMS, and ensuring value for
money.
Heads of Service, General Service, Line Managers and those
with staff management responsibilities
It is their responsibility, so far as reasonably practicable to:

Ensure appropriate COSHH assessments are reviewed
annually and when job functions or working practices change.

Ensure COSHH Information is provided to staff groups and
individual staff members assessed as being at risk, including
other agencies involved.

Ensure appropriate Personal Protective Equipment (PPE) is
provided to staff using COSHH products.

Ensure appropriate training and/or information relating to
identified risks is provided as necessary and in line with
corporate and national guidance.

Ensure appropriate arrangements are in place to periodically
monitor the COSHH safety performance of the SWYPFT
organisation. Would they?

Ensure appropriate procedures are developed and reviewed
to minimise the risks related to COSHH for lone workers,
including inter agency working.

Be responsible for the management of COSHH risks within
premises or workplaces under their management or control,
ensuring appropriate risk assessments are undertaken and
appropriate lone working arrangements are in place.

Ensure systems are available to offer appropriate prevention
Page 8 of 34 - COSHH Policy & Guidance 2016
and post incident support, including referral to Occupational
Health where necessary, in regard to COSHH arrangements.
6.7

Ensure requirements relating to employees with disabilities or
pregnant employees and nursing mothers who may need to
work in identified risk areas have separate risk and COSHH
assessments as appropriate.

Liaise with the Health & Safety Team as necessary.
Departmental/Ward/Team Managers
It is their responsibility, so far as reasonably practicable to:
6.8

Undertake an appropriate assessment of risks to the work of
employees which will determine the necessary procedures
and training for staff.

Identify the assessed risks to their line managers and
developing procedures to address identified COSHH risks.

Make every effort to ensure that business premises visited by
their staff have adequate COSHH provision on site and to
address any reported shortfalls.

Ensure staff within their area of control are aware of this
policy and guidance, comply with it and carry out their
responsibilities identified within it, including attendance for
training.

Any staff nominated to become COSHH assessors for a
particular work area will need suitable training which is
provided as part of the Trust’s annual Health & Safety
programme of courses.

Ensure appropriate First Aid and COSHH spillage kits are
available within departments.

Ensure action plans support staff in learning from adverse
COSHH incidents, which in turn reduce risk.

Ensure action plans in the respect of COSHH arrangements
are effectively implemented, monitored and reviewed.

Liaise with Health & Safety Department as necessary.
Employees
It is their responsibility, so far as reasonably practicable to:
Page 9 of 34 - COSHH Policy & Guidance 2016
6.9

Work to SWYPFT Health & Safety policies and procedures.

Co-operate and assist with COSHH Risk Assessments as
required, and bring to the notice of management, any
changes in labelling, packaging or physical properties of
substances they use at work.

Attend for Health Surveillance when required, and are
encouraged to participate in relevant vaccination
programmes.

Promptly report all incidents even where they consider it to be
a minor incident, including ‘near misses’ to enable
appropriate follow up action to be taken, via the Datix system.

Report any adverse ill health effects arising from exposure to
hazardous substances to both the Health & Safety
Department and Occupational Health department.

Observe safe methods of work and safety procedures as laid
down in departmental policies, protocols, work instructions,
safe systems of work or procedures.

Look after any personal protective equipment provided.

Attend appropriate health and safety training as required by
risk assessment, policy, statutory directive, appraisal or
agreement.
Health & Safety Manager/Specialist Advisers
It is their responsibility to:

Assist in investigating incidents when requested to do so.

Monitor COSHH incidents and provide specialist advice to
Managers on appropriate control measures following an
incident.

Inform the relevant Occupational Health department of any
adverse health reports and exposure incidents.

Inform Infection Control of any reported incident relating to
exposure to biological agents.

Liaise with the local Health & Safety Executive (HSE) Officers
as required.

Liaise with the Head of Estates and Facilities on COSHH
matters.
Page 10 of 34 - COSHH Policy & Guidance 2016
6.10
Health and Safety Team
It is the responsibility of the Health & Safety Team to:-
6.11

Frequently monitor and audit the use of COSHH products
within the Trust, identifying safer products where appropriate.

Provide trends and analytical information to the Health &
Safety Trust Action Groups and the Health & Safety Steering
Group including details of COSHH incidents.
Occupational Health Service
It is their responsibility to:

Ensure that competent advice and support relating to health
surveillance and ill-health arising from incidents involving
hazardous substances is provided to employees.

Provide a health surveillance service programme.

Ensure that appropriate health surveillance is provided to
employees directly employed by SWYPFT.

Provide the collective results of any health surveillance to
individual’s relevant manager by written report.

Ensure that individuals are monitored for health surveillance
as required.

Maintain individual, confidential health surveillance records
for 40 years.

Ensure that Managers are made aware of any relevant
occupational health advice required to enable continued safe
working practice.

Advise the Health and Safety Department and Manager
accordingly of any identified Reporting of Injuries, Diseases
and Dangerous Occurrences Regulations (RIDDOR) 2013
reportable diseases or ill health.
Page 11 of 34 - COSHH Policy & Guidance 2016
6.12 Infection Prevention and Control Department
It is their responsibility to:

Ensure competent advice and support, in relation to control of
infection arising from hazardous substances, are provided to
employees.

Ensure that Managers are made aware of any relevant advice
required to enable continued safe working practice.

Assist in investigating incidents relating to biological agents
on request.

Monitor accidents/incidents involving hazardous substances
and provide specialist advice and support to managers where
necessary.

Inform and liaise with appropriate competent staff or other
specialist advisers as necessary.
6.13 Principle Pharmacist
It is their responsibility to:

Ensure competent advice and support, in relation to health
hazards arising from pharmaceutical substances, are
provided to employees.

Ensure Managers are made aware of any relevant advice
required to enable continued safe working practice.

Monitor
accidents/incidents
involving
pharmaceutical
substances and provide specialist advice and support to
managers where necessary.

Assist in investigating incidents relating to pharmaceutical
substances on request.

Inform and liaise with appropriate Competent Advisers as
necessary.
6.14 Procurement Department
It is their responsibility to:
Supply on request, copies of substance data sheets for
products supplied to departments.
Page 12 of 34 - COSHH Policy & Guidance 2016

Ensure only standard COSHH products are purchased
through the Trust procurement systems, where the
Procurement Department have knowledge of products being
ordered.

Liaise with the Health & Safety Department when requests for
non-standard stock products are requested.
6.15 Contractors
Contractors are expected to share upon request all safety data
sheets and subsequent COSHH assessments with Trust Staff and
to properly control substances in use when working for the Trust.
Contractors shall not permit unauthorised disposal of any
substance, nor leave substances unattended or otherwise insecure
where third parties can tamper with these.
7.
Arrangements
SWYPFT will, from time to time, produce policies and procedures
to deal with specific health and safety situations.
Where such a policy document has been produced employees will
adhere to the requirements of that document. If a specific policy
document has not been produced employees will adhere to the
general principles of this policy.
Policies and guidance to support the Risk Assessment process
including documentation to be used are published on the SWYPFT
Intranet site (nww.swyt.nhs.uk) and are available from the Health &
Safety Department.
Consultation with employees will take place on matters of health
and safety. Where a group of employees is represented by a
recognised trade union, and that union has appointed Safety
Representatives, they can represent those employees in
consultations.
7.1
Competent Health & Safety Advice & Assistance
SWYPFT has a legal obligation to:

“…appoint one or more competent persons to assist
[SWYPFT] in undertaking the measures [it] needs to take to
comply with the requirements and prohibitions imposed upon
[it]…”
(Regulation 7 (1) of the Management of Health & Safety at
Work Regulations 1999), and

“…nominate a sufficient number of competent persons to
Page 13 of 34 - COSHH Policy & Guidance 2016
implement [serious and imminent danger] procedures in so
far as they relate to the evacuation from the premises of
persons at work…”
(Regulation 8 (1) (b) of the Management of Health &
Safety at Work Regulations 1999).







7.2
SWYPFT has appointed the following to provide competent
advice:Head of Estates and Facilities
Health & Safety Manager
Health & Safety Advisers
Infection Prevention & Control Service
Occupational Health
Principle Pharmacist
Co-operation and co-ordination between Employers and
Others:
Where employees are based at non-SWYPFT premises,
arrangements for the co-operation and co-ordination of health and
safety provision between SWYPFT and the controller of the
premises will be established. Managers must facilitate this,
involving SWYPFT competent advisers.
Where employees directly employed by SWYPFT are integrated
into another employer’s organisation, and vice versa, they shall
enter into a formal ‘partnership agreement’ whereby the health and
safety provision of each employer shall be harmonised so far as is
reasonably practicable. The ‘Controlling Mind’ principle shall then
apply and employees will comply with the Policies and Procedures
of the host organisation. These arrangements must be included in
any contract. Joint working protocols covering integrated teams in
Barnsley, Kirklees, Calderdale & Wakefield have been agreed and
should be referred to.
The competent advisers of SWYPFT must be consulted at all
stages of developing such arrangements.
If SWYPFT considers that the health and welfare of its directly
employed employees, clients or others to whom it owes a direct
duty of care, is being compromised by the actions or inaction of the
partnering organisation, then it shall have the right to withdraw from
the services causing concern. Such withdrawal shall be a last
resort and shall only occur on authorisation of the SWYPFT Board
who shall seek advice from SWYPFT Clinical Governance and
Clinical Safety Committee prior to making such a decision. The
withdrawal shall remain in force until SWYPFT is satisfied that the
partnering organisation has undertaken appropriate steps and
measures to redress the matters of concern to SWYPFT.
Page 14 of 34 - COSHH Policy & Guidance 2016
8.
Procedures
8.1
Training
The health and safety training needs of employees will vary
depending upon their role and responsibilities and when exposed
to new risks and will be determined in line with the Trust Training
Policy and associated legislation, forming part of the annual Staff
Development Review.
The Learning & Development Department will maintain records of
the majority of training, but managers and supervisory staff need to
ensure records are maintained where local policies and procedures
have to be adhered to and understood by staff.
New employees must attend Welcome Day induction training,
which will include basic health and safety information including
COSHH awareness, as soon as practicable after commencing
work.
This will be supplemented by appropriate training at their place of
work.
8.2
Risk Assessment
Formal risk assessments will be completed by suitably trained
supervisors and managers supported by the Trusts Competent
Advisers, on COSHH risks relevant to their work activities.
9.
Monitoring the compliance and effectiveness of this policy
This will be achieved by:

10.
The Head of Estates and Facilities and the Health & Safety
Manager will provide reports to the SWYPFT Clinical Governance
& Clinical Safety Group and Health and Safety Trust Action Groups
detailing serious incidents/accidents and identifying trends and
exceptions when appropriate.
References





The Control of Substances Hazardous to Health Regulations 2002 (as
amended)
The Control of Substances Hazardous to Health - Guidance for the
Initial Assessment in Hospitals, the Institute of Occupational Health,
the University of Birmingham.
INDG352(rev1); Read the label - How to find out if chemicals are
dangerous, HSE.
HS (G) 97; Step by Step guide to COSHH assessment, HSE.
RIDDOR - Reporting of Injuries, Diseases and Dangerous
Page 15 of 34 - COSHH Policy & Guidance 2016






11.
Occurrences Regulations 2013;
(The Dangerous Substances and Explosive Atmospheres Regulations
2002) DSEAR
The CLP Regulation 2009EH40/2005 Workplace exposure limits
publication
Health and Safety at Work Act 1974
HSE Guidance INDG136(rev5) revised 10/12
HSE publication Asthmagen? Critical assessments of the evidence for
agents implicated in occupational asthma;
Workplace (Health, Safety and Welfare) Regulations 1992
Review of this policy
This policy will be reviewed three years from the date of Board and
Executive Management Team approval or sooner if there is a requirement
to meet legal, statutory or good practice standards.
Page 16 of 34 - COSHH Policy & Guidance 2016
Appendix 1
Trust COSHH Guidance
Policy Procedures
1.
COSHH Risk Assessment – MUST BE COMPLETED BEFORE USING ANY
HAZARDOUS SUBSTANCE
1.1
The core function to all control measures shall be COSHH Risk
Assessment. COSHH Risk Assessments shall be conducted following
SWYPFTs Risk Assessment procedures and utilising the risk
assessment tools provided.
1.2
Management and Employees will:
a) Conduct operational and individual Risk Assessments identifying
any
COSHH
risks.
b) Complete pre-employment ‘Job Risk Profile’ forms.
1.3
Occupational Health will:
a) Advise on completing ‘Job Risk Profile’ forms.
b) Carry out pre and in-employment health assessments in order to
ensure that employees are fit and placed in appropriate work. In
cases where employees are found to have a notifiable disease,
Occupational Health will notify Public Health.
2.
Information, Instruction and Training (IIT)
2.1
IIT will be provided as necessary to ensure practice matches the best
and is compliant with current legislation/compliance standards.
2.2
SWYPFT will use manufacturer’s Data Sheets and the SYPOL CMS
system to inform its own Risk Assessments.
2.3
Guidance on how to undertake a COSHH Risk Assessment will be
provided, in the first instance by the Health & Safety Department.
Page 17 of 34 - COSHH Policy & Guidance 2016
Appendix 2
COSHH Assessment Procedure

Any substance that has not been previously assessed and approved for use
within SWYPFT must be notified to the Health & Safety Department for referral to
the SYPOL assessment system.

Once notified, the Health & Safety Department shall request certain relevant
information about the product such as amount used, location, frequency.

The substance will then be evaluated using SYPOL and the results returned to
the requesting person.

The Health & Safety Trust Action Groups will periodically review activity
regarding COSHH Assessments and/or when notified of concerns by Health &
Safety
Advisers
overseeing
the
SYPOL
COSHH
system
Page 18 of 34 - COSHH Policy & Guidance 2016
Appendix 3
COSHH Assessment Request Form (CARQ)
Name of person completing form:
Directorate
Service/Function:
Product Information
Trade Name:
Supplier/Manufacturer:
Material Usage Information
Approximately how much of the substance/product is used in one
working day (e.g. 500 ml, few sprays)?
Approximately how long is the product in use
during the working day?
Where is the product used?
Up to 30 minutes
Outside
30 minutes to 2 hours
Inside well ventilated
2 to 4 hours
Inside poorly ventilated
4 to 8 hours
Confined space
Over 8 hours
Work Practices Information
Please give general method of use (e.g. brushed onto woodwork, sprayed onto cooker, or poured
into mould), continue over if necessary:
Page 19 of 34 - COSHH Policy & Guidance 2016
Appendix 4
CARQ/SYPOL PROCEDURE
CARQ/SYPOL PROCEDURE
Member of staff notifies Health
& Safety team, ensuring all
requested
information
is
provided.
Staff
to
Review
Risk
Assessments annually or if any
significant changes occur.
Where
possible
a
manufacturer’s Safety Data
Sheet is to be provided, or
supplier/company details for the
product to be risk assessed.
All risk assessments identified
are saved within a ‘work area’
created within SYPOL and
person requesting information
notified or login instructions
given to appropriate person.
Once received in Health &
Safety, identifiable products
are entered into the SYPOL
system within 10 working days
and
risk
assessments
produced.
Product details updated into
SYPOL within 10 working days
and notification sent to Health &
Safety. Risk assessment then
created.
Page 20 of 34 - COSHH Policy & Guidance 2016
Appendix 5
General COSHH, CLP and CHIP Information
Workplace Exposure Limits (WEL)
Certain substances have already been assessed by a number of UK based
Advisory Committees working with the Health and Safety Executive. These
bodies may have set Workplace Exposure Limits (WEL) for a limited number
of substances and reference should be made to the EH40 Workplace
exposure limits publication issued periodically by the HSE
In accordance with the regulations any Workplace Exposure Limit (WEL),
approved for a substance hazardous to health should not be exceeded and
managers must;
Reduce exposure so far as is reasonably practicable by the reading of:
Hazard statements
A hazard statement is a phrase that describes the nature of the hazard in the
substance or mixture. A hazard statement will be determined by the
application of the classification criteria.
Examples of hazard statements include:




Causes serious eye damage
Toxic if swallowed
Toxic to the aquatic life with long lasting effects
May cause allergy or asthma symptoms or breathing difficulties if
inhaled
It replaces the ‘risk or R-phrase’ used in CHIP.
Precautionary statements
A precautionary statement is a phrase that describes recommended
measure(s) to minimise or prevent adverse effects resulting from exposure to
a hazardous substance or mixture due to its use or disposal.
Examples of precautionary statements include:
 Wear eye protection
 Do not eat, drink or smoke when using this product
 Avoid release to the environment
 In case of inadequate ventilation wear respiratory protection
Suppliers determine the appropriate precautionary statements (usually no
more than six) based on the required hazard statements. It replaces the
‘safety or S-phrase’ used in CHIP.
Page 21 of 34 - COSHH Policy & Guidance 2016
WEL’s are likely to show on some manufacturer’s hazard data sheets as
Time Weighted Averages (TWA’s) or Short Term Exposure Limits (STEL’s).
Some of these substances may be a constituent part of the overall product
being purchased and careful consideration of hazard and risk issues are
required for products with WEL’s.
For example shaving foam may have a product in it with a WEL. This could
be the propellant in the can, but when used correctly it is likely to be present
in such small amounts that there is no problem from this. A similar product
can be observed in some highlighter pens which is not a problem given the
legitimate use of such pens, but could result in difficulties with substance
abusers if access to these pens is not adequately controlled. Careful
interpretation and common sense is therefore required for such WEL type
products.
Managers may also want to bear in mind that some products with WEL’s etc
may require more advanced protection techniques, or health surveillance to
be provided for staff that are using them or exposed to their hazardous
products.
Where there is any doubt about whether the product will cause harm and
where managers wish to order/purchase those with WEL’s etc they can
contact the Health and Safety Manager for advice.
Dust
Dust of any kind can also become a substance hazardous to health under
COSHH when it is present at concentrations in the air equal to or greater than
10 mg/m3 (as a time-weighted average over an 8-hour period) of inhalable
dust or 4 mg/m3 (as a time-weighted average over an 8-hour period) of
respirable dust. Good occupational hygiene practice recommends that those
levels should be the highest concentrations of dust to which employees
should be exposed.
Asthma
Control of substances that cause occupational asthma ACOP Interpretation
'Asthma' is characterised by periodic attacks of wheezing, chest tightness or
breathlessness resulting from constriction of the airways. A substance is
considered to cause occupational asthma if, as a result of exposures in the
workplace, it both:
(a) Produces the biological change known as the hypersensitive state in the
airways; and;
(b) Triggers a subsequent reaction in those airways.
'Cause' does not, in this context, mean triggering an asthmatic attack in a
person who has asthma due to another, unrelated cause (occupational or non
Page 22 of 34 - COSHH Policy & Guidance 2016
occupational). Occupational asthma may be caused by manufactured
chemicals or naturally occurring materials, such as fungal spores.
All substances which cause occupational asthma are within the definition of
substances hazardous to health for the purposes of COSHH. Therefore
COSHH and the main COSHH ACOP, published by the HSE apply and must
be observed by Trust managers.

Substances listed in Section C of the HSE publication Asthmagen? Critical
assessments of the evidence for agents implicated in occupational
asthma;
Included are:(a) substances listed in Section C of the HSE publication Asthmagen? Critical
assessments of the evidence for agents implicated in occupational asthma;
(b) any other substances assigned the risk phrases ‘May cause sensitisation
by inhalation’ (R42) or ‘May cause sensitisation by inhalation and skin contact’
(R42/43) under the Chemicals (Hazard Information and Packaging for Supply)
Regulations 2002 (CHIP); and
(c) any other substance which the Trust’s risk assessments have shown to be
a potential cause of occupational asthma.

Any other substance which the employer's (Trust) risk assessment has
shown to be a potential cause of occupational asthma.
Latex Allergies
Allergic reactions to exposure to natural rubber latex (NRL) have increased
significantly over the years, particularly within healthcare occupations.
The Health & Safety At Work Act 1974 places a general duty upon Trust’s to
keep employees, and others (such as service users & visitors), healthy & safe
at work.
The Control of Substances Hazardous to Health Regulations 2002 specifically
requires managers to undertake an assessment of any substances used at
work that are hazardous to health.
With respect to natural rubber latex, risk assessments must balance the risk
of allergic reaction caused by natural rubber gloves against any risks
associated with the use of gloves manufactured from alternative materials. As
one of the central risks to consider is the potential for transmission of
pathogenic organisms and viruses. Involvement of the Infection Prevention
and Control Team and Occupational Health Department is of central
importance and further detailed information can be obtained from the Trust’s
standard Infection Control Precautions Policy and Occupational Health.
Page 23 of 34 - COSHH Policy & Guidance 2016
Hierarchy of Control for Hazardous Substances
As an employer the Trust deals with a large number of hazardous substances
as part of normal day to day business. Managers can therefore use the
framework within the Regulations and their associated guidance to provide a
hierarchy of controls, which they need to consider. These are as follows:

Is it possible to eliminate the hazardous substance from use?

If not, is it possible to substitute the hazardous substance with a safer
alternative;

If not, is it possible to control exposure to the substance;

If not, does personal protective equipment need to be provided for use
with the substance

Is the substance one for which there is a health surveillance requirement
(These will be few and far between for products used within this Trust);

Has sufficient information, instruction and supervision been provided
by line managers?

Waste disposal has to be considered as part of this process;

All of this requires training.
The highlighted words above are further clarified below:Eliminate
Elimination of hazardous substances removes the problem.
Managers need to bear in mind that substances can only be eliminated if they
are no longer required, or if there is a safer alternative available.
If the hazardous substance still needs to be used and there is no safer
alternative then its use has to be managed effectively; controls applied to the
exposure of patients; staff and visitors to a level which is reasonably
practicable; personal protective equipment provided, used and maintained
where the assessment shows this to be necessary and the waste disposed of
wisely.
Substitute
Substitution of hazardous products with safer alternatives will allow the Trust
to run more effectively by creating the least possible risk to service users;
staff, visitors and the environment.
Less hazardous substances could be cheaper to purchase, or dispose of.
Less hazardous substances may require the provision of less protective
equipment, resulting in reduced cost for its provision/disposal and reduced
down time in terms of that taken to put the protective clothing on, or take it off.
Page 24 of 34 - COSHH Policy & Guidance 2016
Substituting substances for a less hazardous alternative is therefore an
important way of making sure business risks are reduced.
Control
Recognising that it is not possible to totally remove all hazardous substances
from everyday activities, the Trust and Service Managers need to institute
control mechanisms for those products which continue to be used.
Other control mechanisms e.g. local exhaust ventilation systems etc will arise
out of the COSHH assessments that need to be undertaken. Alternatively, by
restricting the number of people who can be affected.
Personal Protective Equipment (PPE)
In certain circumstances exposure to hazardous substances necessitates the
provision; use and maintenance of PPE.
PPE has to be suitable for the hazardous substance necessitating its
provision. It has to be suitable for the wearer, bearing in mind the conditions
under which it is to be used. The wearer may need training in its use
(probably not in all circumstances, but certainly with complicated equipment)
and there may be cleaning/maintenance and storage requirements for non
disposable products.
Waste Disposal
Whenever substances are used there will inevitably be waste produced and
possibly spilled substances that need to be disposed of correctly.
Much of this waste will be plastic containers; tins; cardboard; glass bottles
etc. If it cannot be recycled then it can be readily disposed of in the municipal
refuse disposal facilities when empty don’t think this is allowed, always
provided that the waste product has not held liquid medication, or other
controlled products.
Some substances will however be “Hazardous Waste” which has to be
disposed of in a particular way and cannot be disposed of other than by a
licensed waste disposal contractor.
It will need a link to correct procedures putting in
Office Type & “Low Risk” Products not relevant now
There are a limited amount of assessments that are available from the Trust
Intranet, but the responsibility for ensuring these remain suitable and
sufficient remains with the local manager.
Domestic Type Products
Because of some of the rehabilitation type services offered by the Trust it is
known that domestic products e.g. hair shampoo; denture tablets/powders;
nail polish; sprays; detergents/cleaners etc are purchased from a number of
Page 25 of 34 - COSHH Policy & Guidance 2016
retail sources within and outside the Trust area. The responsibility for
ensuring these remain suitable and sufficient remains with the manager as
above to ensure they have been assessed.
New hazard pictograms
New hazard pictograms, will eventually be replacing all the Chemicals
(Hazard Information and Packaging for Supply) Regulations 2009 – CHIP.
From 1st June 2015, - The European Regulation (EC) No 1272/2008 on
classification, labelling and packaging of substances and mixtures (CLP
Regulation) will be becoming more prevalent and staff should be aware of
CLP hazard pictograms. A brief description is given here for purely illustrative
purposes.

Acute toxicity, Very toxic (fatal), Toxic etc.

Gasses under pressure

Harmful skin irritation, serious eye irritation

Flammable gasses, flammable liquids, flammable solids,
flammable aerosols, organic peroxides, self-reactive,
pyrophoric, self-heating, contact with water emits
flammable gas

Explosive, self reactive, organic peroxide
Page 26 of 34 - COSHH Policy & Guidance 2016

Harmful to the environment

oxidising gases, oxidising liquids, oxidising solids

Respiratory sensitiser, mutagen, carcinogen, reproductive
toxicity, systemic target organ toxicity, aspiration hazard

Corrosive (causes severe skin burns and eye damage),
serious eye damage
Page 27 of 34 - COSHH Policy & Guidance 2016
Appendix 6
Health and Safety Consultation Process
Trust Board & Executive Management
Team
Clinical Governance & Clinical Safety
Committee
Approves the main policies on health and safety; for
Trust wide implementation
Approves all subordinate policies relating to health
and safety; control of hazardous substances; fire
safety; security and occupational health
Trust Health & Safety, Emergency
Preparedness Trust Action Group (TAG)
and associated sub-groups
Formal consultation mechanism on corporate
policies relating to health and safety; COSHH; fire;
security and occupational health issues. Issues of
health and safety concern are also raised from a
Staff Side perspective
Trade Union Safety Representatives
And The Health And Safety Manager
Meet with the Trust Health and Safety Manager to
consider the issues raised and identify the correct
forum for them to be discussed
Examples Of Other Meetings
1
2
3
4
5
Regular meetings with the Health and
Safety Executive
Meetings with Environment Agency
Regular meetings with West or South
Yorkshire Fire Service
Specialist Advisers Forum
Site/Business Delivery Unit meetings
with other organisations
Deals with matters of importance to the areas
covered by the group concerned and refer
appropriate concerns upwards to the Trust Health &
Safety, Emergency Preparedness Trust Action
Group (TAG) for progression or response
Page 28 of 34 - COSHH Policy & Guidance 2016
Appendix 7
Equality Impact Assessment Tool
As a trust wide policy, the assessment includes demographics’ for the four
areas covered by the trust as below.
Race Equality
England % av.
Kirklees
% average
Barnsley
% average
Calderdale
% average
Wakefield
% average
White
85.5
Asian
5.1
Black
3.4
Mixed
2.2
Chinese & Other
1.7
79.1
15.7
1.9
2.3
0.7
97.9
0.7
0.5
0.7
0.2
89.6
7
0.9
1.3
0.6
95.4
2.6
0.77
0.9
0.29
Taken from Census 2011 for each area
Assessment of The Trust COSHH Policy & Guidance has not highlighted any
Equality Impact issues
Date of Assessment: December 2015
1
2
3
4
5
Equality
Impact
Assessment Evidence based Answers & Actions:
Questions:
Name of the document that you COSHH Policy and Guidance
are Equality Impact Assessing
Describe the overall aim of your The overall aim of the policy is to describe the
Trust’s approach to COSHH management and
document and context?
Health & Safety, covering service users, all staff,
Who will benefit from this visitors and contractors.
policy/procedure/strategy?
All stakeholders
Who is the overall lead for this Alan Davis
assessment?
Who else was involved in Roland Webb.
conducting this assessment?
Have you involved and consulted H&S TAG’s & Sub-Groups
service users, carers, and staff in
developing
this
policy/procedure/strategy?
What did you find out and how
have you used this information?
N/A
Page 29 of 34 - COSHH Policy & Guidance 2016
Evidence based Answers & Actions:
6
Equality
Impact
Assessment
Questions:
What equality data have you used
to inform this equality impact
assessment?
7
What does this data say?
N/A
8
Taking into account the Yes/No
information gathered
above,
could
this
policy
/procedure/strategy
affect any of the
following
equality
group unfavourably:
Evidence based Answers & Actions. Where
Negative impact has been identified please
explain what action you will take to remove or
mitigate this impact.
8.1
Race
No
N/A
8.2
Disability
No
8.3
Gender
No
Reasonable adjustments, for people affected by
any impairment or special needs will be covered
by risk assessments and work procedures to
ensure their safety needs are met
N/A
8.4
Age
No
N/A
8.5
Sexual Orientation
No
N/A
8.6
Religion or Belief
No
N/A
8.7
Transgender
No
N/A
8.8
Maternity & Pregnancy
No
8.9
Marriage
Reasonable adjustments for pregnant/nursing
mothers will be covered by processes covering
COSHH risk assessments and work procedures.
N/A
&
Civil No
Had discussion with Zahida Mallard to ensure
relevant issues considered as far as reasonably
practicable before Policy & Guidance approved
partnerships
8.10
Trust No
Carers*Our
N/A
requirement*
Page 30 of 34 - COSHH Policy & Guidance 2016
9
9a
This policy covers purely covers safety with
measures covering people of all faiths,
characteristics and both genders. Regular
Health & Safety EP TAG and Sub-Group
meetings will pick up any reported areas of
concern. Any difficulties later found that are
related to an Impact Equality will be addressed.
Promotes equality of opportunity All Trust Safety Policies provide equality of
and
promote
personal
for people who share the above opportunity,
responsibilities
for
everyone,
including
anyone
protected characteristics;
with a protected characteristic.
What monitoring arrangements are
you implementing or already have
in place to ensure that this
policy/procedure/strategy:-
All Trust Safety Policies, including the COSHH
Policy and Guidance contribute to the
elimination, discrimination, harassment and
bullying for everyone including anyone with a
protected characteristics
9b
Eliminates
discrimination,
harassment and bullying for
people who share the above
protected characteristics;
9c
Promotes good relations between All Trust Safety Policies contribute to good
relations between different equality groups
different equality groups;
9d
Public Sector Equality Duty – “Due We are confident that the Trust COSHH/SYPOL
approach contributes to the effective Public
Regard”
Sector Equality Duty – “Due Regard”
Have you developed an Action No
Plan
arising
from
this
assessment?
10
11
Assessment/Action Plan approved
by
Signed:……………..Date:………..
Title: AD
12
Once approved, you must forward
a copy of this Assessment/Action
Plan to the Equality and Inclusion
Team:
inclusion@swyt.nhs.uk
Please note that the EIA is a public
document and will be published
on the web.
Failing to complete an EIA could
expose the Trust to future legal
challenge.
Page 31 of 34 - COSHH Policy & Guidance 2016
Appendix 8
Checklist for the Review and Approval of Procedural Document
Title of document being reviewed:
1.
2.
4.
5.
Comments
Title
Is the title clear and unambiguous?
Yes
Is it clear whether the document is a
guideline, policy, protocol or standard?
Yes
Is it clear in the introduction whether this
document replaces or supersedes a
previous document?
Yes
Rationale
Are reasons for development of the
document stated?
3.
Yes/No/
Unsure
Yes
Development Process
Is the method described in brief?
Yes
Are people involved in the development
identified?
Yes
Do you feel a reasonable attempt has been
made to ensure relevant expertise has been
used?
Yes
Is there evidence of consultation with
stakeholders and users?
Yes
H&S TAGs
Content
Is the objective of the document clear?
Yes
Is the target population clear and
unambiguous?
Yes
Are the intended outcomes described?
Yes
Are the statements clear and unambiguous?
Yes
Evidence Base
Is the type of evidence to support the
document identified explicitly?
Yes
Are key references cited?
Yes
Are the references cited in full?
Yes
Are supporting documents referenced?
Yes
Page 32 of 34 - COSHH Policy & Guidance 2016
Title of document being reviewed:
6.
7.
8.
9.
10.
11.
Yes/No/
Unsure
Approval
Does the document identify which
committee/group will approve it?
Yes
If appropriate have the joint Human
Resources/staff side committee (or
equivalent) approved the document?
N/A
Dissemination and Implementation
Is there an outline/plan to identify how this
will be done?
Yes
Does the plan include the necessary
training/support to ensure compliance?
Yes
Document Control
Does the document identify where it will be
held?
Yes
Have archiving arrangements for
superseded documents been addressed?
Yes
Process to Monitor Compliance and
Effectiveness
Are there measurable standards or KPIs to
support the monitoring of compliance with
and effectiveness of the document?
Yes
Is there a plan to review or audit compliance
with the document?
Yes
Review Date
Is the review date identified?
Yes
Is the frequency of review identified? If so
is it acceptable?
Yes
Overall Responsibility for the Document
Is it clear who will be responsible
implementation and review of the
document?
Yes
Page 33 of 34 - COSHH Policy & Guidance 2016
Comments
Appendix 9
VERSION CONTROL SHEET
Version
Date
Author
V1.1
February
2012
V1.2
March 2012
V1.3
July 2015
V1.4
December
2015
V1.4
January 2016
Status
Comment / changes
Roland Webb,
Health & Safety
Manager (West)
Martin Brandon,
Head of Health,
Safety & Security
(South)
Roland Webb,
Health & safety
Manager/Steve
Amos Emergency
planning & Safety
Advisor
Roland Webb,
Health & safety
Manager
Draft
First Draft
Draft
Transfer into template, incorporating
comments and final draft.
Draft
Updated policy reflecting new legislation
and Trust Management Structures
Draft
Sent for comment
Roland Webb,
Health & safety
Manager
Approval
Policy sent to EMT for approval
Page 34 of 34 - COSHH Policy & Guidance 2016