Beechdale Health Centre
Control of Substances Hazardous to Health (COSHH) Policy
& Risk Assessments
Document Control
A.
Confidentiality Notice
This document and the information contained therein is the property of Beechdale Health
Centre.
This document contains information that is privileged, confidential or otherwise protected from
disclosure. It must not be used by, or its contents reproduced or otherwise copied or disclosed
without the prior consent in writing from Beechdale Health Centre.
B.
Document Details
Classification:
Author and Role:
Organisation:
Document Reference:
Current Version Number:
Current Document Approved By:
Date Approved:
C.
Document Revision and Approval History
Version
1
1.1
Jane Smith, Practice Nurse
Beechdale Health Centre
COSHH
1.1
JANE SMITH
22.03.2013
Date
22.03.2013
01.04.2014
Version Created By:
Version Approved By:
JANE SMITH
Arun Venugopal
ARUN VENOGUPAL
Arun Venugopal
Comments
Reviewed from Initial
Document
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Contents:
Page 3
-
General Statement
Page 3
-
Risk Assessments
Page 4
-
Recording Hazardous to Health Substances
Page 5
-
Prevention or Control of Exposure
Page 5
-
Health Surveillance
Page 6
-
Monitoring Exposure
Page 6
-
Health Records
Page 6
-
Information, Instruction and Training
Page 7
-
Procedure for dealing with Health and Safety Issues
Page 7
-
Summary Policy Statement
Pages 8 & 9
-
Appendix A – COSHH Record of Activity Assessment Template
Pages 10 & 11 -
Appendix B – COSHH – Activity / Situation Risk Assessment Record
Page 12
Appendix C – COSHH – Risk Assessment Action Plan
-
Pages 13 > 15 -
Appendix D – COSHH – Hazardous Substance Risk Assessment Record
Page 16
-
Appendix E – COSHH – Record of Audit
Page 17
-
Appendix F – COSHH Index of Safety Data Sheets
Page 18
-
Appendix G – COSHH – List of Hazardous Substances in use
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General Statement
Beechdale Health Centre acknowledges that no substance can be considered completely safe.
All reasonable steps will be taken to ensure that all exposure of employees to substances
hazardous to health is prevented or at least controlled to within statutory limits.
The Practice will not supply or use those substances prohibited by law.
The Practice will undertake that prevention or adequate control of exposure of employees to a
substance hazardous to health shall be secured by measures other than the provision of personal
protective equipment.
Where exposure cannot be adequately controlled by engineering means the Practice will provide
appropriate personal protective equipment (PPE) free of charge.
The Practice will ensure all control measures meet the relevant regulatory requirements.
All employees will be provided with comprehensive information and instruction on the nature
and likelihood of their exposure to substances hazardous to health.
The people responsible for the implementation of this policy are Arun Venogupal, Practice
Manager and Jane Smith, Practice Nurse.
Risk Assessments
The Practice will carry out written risk assessments of work activities to assess the risks of
substances hazardous to health to employees and other persons affected by the Practice. (See
Appendix A for a COSHH Record of Activity Assessment Template)
Any new product / substance to be introduced into the Practice workplace will be subject to the
Practice’s normal risk assessment procedures prior to being used. (See Appendix D – COSHH –
Hazardous Substance Risk Assessment Record).
The Practice’s risk assessments will be carried out by persons who are competent and who have
been trained to do so (See Appendix B - COSHH – Activity / Situation Risk Assessment Record).
The Practice will then take all reasonable steps to minimise all the risks founds from the
assessments (See Appendix C – COSHH – Risk Assessment Action Plan).
Practice manager and practice nurse are responsible for arranging the assessments.
Risk assessments will be reviewed regularly and the practice manager is responsible for arranging
these.
The practice nurse is responsible for retaining the records of assessments.
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Recording Hazardous to Health Substances
An index will be kept of all substances hazardous to health within the workplace. The cleaning
company, officlean limited (01902 895533) is responsible for maintaining this. (See Appendix G –
COSHH – List of Hazardous Substances in use).
This index shall also contain the manufacturers’ health and safety data sheets (See Appendix F
for a Safety Data Sheet Index Template).
Safety Data Sheets
If a substance is dangerous for supply, the supplier must send a data sheet when the product is
first ordered, if the formulation changes, or if asked for a sheet. If it is not dangerous for supply
the supplier should include instructions for safe use with the package.
Safety Data Sheets will always be specific to the product in use and will, in all cases, be updated
annually.
Where an original supplier data sheet is not available, the Practice will ensure that the product is
immediately withdrawn from use and an alternative sourced.
Where a new product / substance is being considered for use or is to be obtained, the relevant
data sheet will be obtained prior to the product / substance being brought on-site.
The Practice will maintain a library of Safety Data Sheets for all substances that are used which
bear a hazard symbol (See Appendix F for a Safety Data Sheet Index Template).
A copy of the Safety Data Sheet which specifies emergency treatment will be held for each
substance:
 In the central health and safety file.
 In the possession of the cleaning staff.
 Adjacent to the storage location of the substance.
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Prevention or Control of Exposure
Local Exhaust Ventilation / Other Engineering Controls
Appropriate control measures will be taken where elimination or substitution of the hazardous
substance is not possible. Where engineering controls, such as Local Exhaust Ventilation (LEV) are
in use, Practice equipment will be properly maintained and monitored to ensure its continued
effectiveness.
If the Practice uses LEV this will be thoroughly examined and tested at least once in every 14
months. This will be arranged by the practice manager who will also retain records of these tests.
Any other engineering controls that we use will be thoroughly examined at suitable intervals and
where appropriate, will also be tested. The practice manager (Arun Venogupal) is responsible for
arranging these and retaining all associated records.
The Practice will ensure that all employees and others who work in areas where engineering
controls are provided, are aware of the purpose and safe operation of the equipment. All
changes to engineering control measures will be properly assessed.
Personal Protective Equipment (PPE)
PPE will only be used by employees as a last resort or as a back-up measure during testing or
modification of other controls. The type and use of PPE will be carefully assessed and PPE will be
maintained according to the manufacturers’ instructions.
The practice nurse is responsible for the issue of PPE and retaining records of its issue. Officlean
are responsible for the domestic staff.
All changes of PPE will be properly assessed.
Health Surveillance
When the risk assessment identifies the need for health surveillance of employees or identifies a
process / substance specified under schedule 6 of COSHH, this will be carried out by qualified
professionals at intervals of not more than 12 months (in the case of schedule 6 Substances) or at
such shorter intervals as the employment medical advisor or appointed doctor may require. The
practice manager is responsible for arranging the health surveillance for employees.
We must:
 Allow employees to have access to their own personal health records;
 Bear the costs of any health and / or medical surveillance programmes;
 Allow employees to attend any health and / or medical surveillance programmes during
normal working hours;
 Maintain health records or a copy thereof in a suitable form for at least 40 years from the
date of the last entry made in it;
 If the Practice ceases to trade it shall notify the Health & Safety Executive in writing and offer
those records to them.
Employees must:
 Make themselves available for any health and / or medical surveillance programmes;
 Provide the qualified doctor with information concerning their health that the qualified
doctor may require.
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The qualified doctor may require the Practice to allow them to inspect the employees’ workplace
and any records associated with the health surveillance. The qualified doctor may suspend,
absolutely or conditionally, those employees who, in their opinion should not continue to be
exposed to the hazardous substances concerned. In such cases the Practice must abide by any of
the conditions imposed upon it.
A decision on suspension may be the subject of a review by a procedure approved the Health and
Safety Commission.
To invoke this procedure an employee or the employer must make a written application to the
Health and Safety Executive within 28 days of being notified of the decision.
Monitoring Exposure
Where employees (or non-employees where they are on Practice premises carrying out work)
are exposed to hazardous substances and it is necessary to ensure that adequate control of their
exposure is maintained, the exposure will be monitored by a suitable procedure.
The practice manager is responsible for arranging this.
The practice manager is responsible for retaining monitoring records and these will be kept for a
minimum of 5 years.
Health Records
The practice manager is responsible for keeping employee health records and is aware of the
employees right to access their own personal records. Records of health surveillance for each
employee will be retained for 40 years.
Information, Instruction and Training
All employees and other people on the premises will be given sufficient information and training
to ensure full understanding of the hazards to health posed by the substances with which they
are working, any emergency procedures and the importance of the control measure(s) provided.
They will be kept informed about any monitoring and their individual health surveillance results.
If the Practice undertakes work which may expose any employees to substances hazardous to
health it shall provide them with such information, instruction and training as is suitable and
sufficient for them to know the risks to health created by such exposure and the precautions
which should be taken.
If employees discover any defect in the control measures provided, they should report this
immediately to the practice manager. Employees are trained in how to recognise defects and the
implications of these.
In the case of any substance hazardous to health for which a maximum exposure limit has been
approved, the employee or their representatives shall be informed forthwith if the results of
such monitoring show that the maximum exposure limit has been exceeded. Information on the
collective results of any health surveillance undertaken will be kept in a form calculated to
prevent it from being identified as relating to any particular person.
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Employees will be trained in the use of any PPE and will ensure that it is kept clean and stored
appropriately.
If employees are provided with respiratory equipment, the Practice will ensure that it is
examined at suitable intervals and, where appropriate, that it is tested.
The practice manager and practice nurse is responsible for arranging the provision of
information, instruction and training and retaining any training records.
Procedure for Dealing with Health and Safety Issues
If an employee raises a point relating to the use of substances hazardous to health the Practice
will:
 Ensure that the hazard associated with the substance has been correctly identified;
 Ensure that the assessment of the use of the substance is correct and up to date;
 Ensure that the controls in place are adequate;
 Correct any observed deficiencies in the control of the hazards;
 Inform the employee of the results of the investigation and the actions taken.
Summary Policy Statement
The Practice will:
 Conduct risk assessments and ensure that they are reviewed regularly and re-assessed at
suitable intervals when there are changes in the Practice’s workplace activities – See
Appendix B – COSHH – Activity / Situation Risk Assessment Record;
 Eliminate, prevent or control the risk – See Appendix C – COSHH – Risk Assessment Action
Plan
 Ensure that controls are maintained and monitored;
 Ensure that hazard information is kept up to date and ensure all documentation is
comprehensive and comprehensible;
 Where appropriate, monitor the health of the workforce;
 Ensure that employees are trained in the nature of the hazards and in the use of the control
measures provided on an annual basis, or on recruitment as appropriate;
 Encourage employees to report faults and problems;
 Ensure Staff do not bring substances on-site without permission;
 Ensure Staff do not move substances into different storage or use locations unless authorised
to do so;
 Use substances which will generally be in regular supply unless an alternative or a new
substance has been approved;
 Audit COSHH items at least on an annual basis as part of the annual Health & Safety joint
inspection – See Appendix E – COSHH – Record of Audit
 Ensure substances bearing a hazard symbol will not be used by staff unless they are
authorised and trained to do so;
 Instruct Temporary staff likely to come into contact with hazardous substances as to their
use;
 Ensure Personal Protective Equipment (PPE) of the required grade is available for use in
accordance with the requirements and recommendations stated on the Safety Data Sheets;
 Maintain COSHH substances at a minimum stock level;
• Carry out a risk assessment on all COSHH substances prior to use – See Appendix D – COSHH
– Hazardous Substance Risk Assessment Record
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Reporting Incidents to the CQC that stop or may stop the registered person from
running the service safely and properly .
The practice manager at the Practice is responsible for notifying the CQC without delay about
events that stop or may stop the registered person from running the service safely and properly,
including:
• A level of staff absence or vacancy, or damage to the service’s premises that mean that
people’s assessed needs cannot be met.
• The failure of a utility for more than 24 hours.
• The failure of fire alarms, call systems or other safety-related equipment for more than 24
hours.
• Any other circumstances or events that mean the service cannot – or may not be able to –
meet people’s assessed needs safely.
Where the Registered Person is unavailable, for any reason, the practice nurse or doctor will be
responsible for reporting the incident to the CQC.
There is a dedicated Notification form for this type of incident. The form is contained in the
Outcome 20 document “Notification of Other Incidents – Outcome 20 Composite Statements
and Forms”
Notifying the CQC of Serious Injury to a person who uses the Service
The practice manager at the Practice is responsible for notifying the CQC without delay about
events that lead to:
 Serious injury to any person who uses the service.
 An injury requiring treatment by a healthcare professional to avoid death or serious injury.
These serious injuries include:

Injuries that lead to or are likely to lead to permanent damage – or damage that lasts or is
likely to last more than 28 days – to:
 A person’s sight, hearing, touch, smell or taste
 Any major organ of the body (including the brain and skin)
 Bones
 Muscles, tendons, joints or vessels
 Intellectual functions, such as
 Intelligence
 Speech
 Thinking
 Remembering
 Making judgments
 Solving problems.

Injuries or events leading to psychological harm, including:
 Post-traumatic stress disorder
 Other stress that requires clinical treatment or support
 Psychosis
 Clinical depression
 Clinical anxiety
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 The development after admission of a pressure sore of grade 3 or above that develops
after the person has started to use the service (European Pressure Ulcer Advisory Panel
Grading)
 Any injury or other event that causes a person pain lasting or likely to last for more than
28 days
 Any injury that requires treatment by a healthcare professional in order to prevent:
 Death
 Permanent injury
 Any of the outcomes, harms or pain described above.
Where the Registered Person is unavailable, for any reason, ***Insert Name*** will be
responsible for reporting the serious injury to the CQC.
There is a dedicated Notification form for this type of incident. The form is contained in the
Outcome 20 document “Notification of Other Incidents – Outcome 20 Composite Statements
and Forms”
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Appendix A
COSHH Record of Activity Assessment Template
What is a COSHH Activity Assessment?

A COSHH activity assessment is a systematic examination of an activity, task or process that
involves using a potentially hazardous substance. See Appendix B – COSHH – Activity /
Situation Risk Assessment Record;
A COSHH Assessment is carried out for the purpose of;
 Identifying the substances that the Practice uses that are potentially hazardous (a hazard is
something that has the potential to cause someone harm or ill health).
 Deciding whether the precautions the Practice has already taken reduces the risk of someone
being harmed to an acceptable level, and if not;
 Deciding on what further control measures the Practice must take to prevent or control the
exposure to an acceptable level. – See Appendix C – COSHH – Risk Assessment Action Plan
Process
The Practice will monitor and control all substances in the Practice with the potential to cause
harm to ensure the safe usage and storage of these items, and that staff are aware of them, and
trained in their use See Appendix D – COSHH – Hazardous Substance Risk Assessment Record
These procedures will include, but will not be limited to:
 Clinical substances
 Clinical Waste
 Cleaning materials
 Chemicals
 Gases
 All substances with a hazard identification symbol
Hazardous Substances
Hazardous substances include;
 Substances used directly in work activities
 Substances generated during work activities
 Naturally occurring substances
 Biological agents such as bacteria and other micro-organisms.
Effects of Hazardous Substances
Examples of the effects of hazardous substances include;
 Skin irritation or dermatitis as a result of skin contact;
 Asthma as a result of developing allergy to substances used at work;
 Losing consciousness as a result of being overcome by toxic fumes;
 Cancer, which may appear long after the exposure to the chemical that caused it;
 Infection from bacteria and other micro-organisms (biological agents).
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What COSHH requires
To comply with COSHH, the Practice will follow these eight steps:
Step 1. - Assess the risks;
The Practice will determine what the risks to health are from hazardous substances used or
created by the Practice’s activities.
Step 2. - Decide what precautions are required;
The Practice will not carry out work which might expose its staff to hazardous substances.
Step 3. - Prevent or control the exposure.
The Practice will initially try to prevent exposure to hazardous substances; if this is not possible
the Practice will control the exposure to defined limits.
Step 4. - Make sure any control measures are used and maintained
Step 5. - Monitor the exposure of the substance to Practice Staff where a risk assessment has
deemed it necessary
Step 6. - Health surveillance.
The Practice will carry out health surveillance when a risk assessment has shown it to be
necessary.
Step 7. Prepare an emergency plan.
The Practice will draw up plans to deal with emergencies such as spillages etc.
Step 8. Make sure Practice Staff are properly informed, trained and supervised
These eight steps involve completing the following Appendices:
Pages 10 & 11 -
Appendix B – COSHH – Activity / Situation Risk Assessment Record
Page 12
Appendix C – COSHH – Risk Assessment Action Plan
-
Pages 13 > 15 -
Appendix D – COSHH – Hazardous Substance Risk Assessment Record
Page 16
-
Appendix E – COSHH – Record of Audit
Page 17
-
Appendix F – COSHH Index of Safety Data Sheets
Page 18
-
Appendix G – COSHH – List of Hazardous Substances in use
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Beechdale Health Centre
Appendix B
COSHH – Activity / Situation Risk Assessment Record – Page 1
Assessment
Ref. No.:
HOW TO USE THIS FORM:
LIST OF HAZARDOUS SUBSTANCES INCLUDES: Substances labelled corrosive, irritant, harmful, toxic or very toxic; pesticides and other
chemicals; products or by-products (dust, fumes etc.); micro-organisms (viruses, bacteria etc.); carcinogens (cancer causing agents).
1. Once you have identified an activity/situation involving hazardous substances complete this side of the form except for the signature box below.
2. In consultation with your staff identify the substances used in this activity/situation by printing its name vertically in the space provided at the top of the reserve side of this form.
3. For each substance identified tick the statements that best describe it. Use the supplier’s data sheet for the substance to help you and attach the data sheet to this assessment.
4. Also identify the control measures: recommended by the data sheet, presently being used and what will be required to make the activity safer.
5. Upon completion, sign the form and identify a date on which to review this assessment.
6. Transfer the items identified for action on to your department health and safety action plan.
Note: This document should be retained as a record of the assessment carried out.
ACTIVITY / SITUATION BEING ASSESSED, INCLUDING BRIEF DESCRIPTION:
HOW OFTEN IS THE ACTIVITY CARRIED OUT? DAILY  1 / 2 TIMES A WEEK  1 / 2 TIMES A MONTH 
IDENTIFY STAFF INVOLVED IN THIS ACTIVITY/SITUATION AND OTHERS WHO MAY BE AFFECTED:
LESS OFTEN
WHAT ARE THE ARRANGEMENTS FOR STORAGE AND DISPOSAL OF THE SUBSTANCES USED IN THIS ACTIVITY/SITUATION?
REASON FOR ASSESSMENT
ASSESSMENT
CARRIED OUT BY:
Name:
Mandatory Initial
Assessment:

Periodic
Review:
Job
Title:

Change in Manual
Handling Procedure:

On
Date:
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Other
(State Reason):
Signed:

OTHER: __________________
COSHH – Activity / Situation Risk Assessment Record – Page 2
Put an X in each Cell where the criteria above applies to the Hazardous Substance being used
Assessment Considerations
Identified Risk Level:
NO RISK
– Manage by routine procedure
LOW RISK
– Risk Action Plan or manage by routine procedure
Precautions already in force
Precautions needed
Insert X in
Risk Level
COMMENTS:
MODERATE RISK – Risk Action Plan within one month
SIGNIFICANT RISK – Immediate action if required – Risk Action Plan within 2 weeks
VERY HIGH RISK – Immediate action if required – Risk Action Plan within 7 days
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Other
Health Surveillance
Environmental Monitoring
Other protective clothing
Respiratory Protection
Eye Face protection i.e. goggles
Specified method of waste
disposal
Provide Info training
supervision to staff
Hand / arm protection i.e.
gloves
Good Housekeeping
Provide improved ventilation
Use a specified safe system of
work
Use less harmful substance
CONTROL MEASURES
Are any of the following precautions required?
Most of the day
Less than 1 hour per day
Harmful by inoculation
Harmful by absorption
Harmful by ingestions
Harmful by inhalation
Harms on contact with skin
Harms on contact with eyes
Less than 5 mins per day
Time
Used
Route of entry
Other
Flammable
Irritant
Corrosive
Harmful
Very Toxic
Hazard
Classification
Power / Dust
Liquid
Enter the name of the substance
in each row below:
Solid
Identify the
Hazardous Substances used.
Gas / Vapour / Aerosol
Physical
State
Beechdale Health Centre
Appendix C
COSHH – Risk Assessment Action Plan
A plan of remedial action required, as identified by carrying out a COSHH Risk Assessment
ASSESSMENT
REF. No.:
ASSESSMENT
DATE:
Identified Risk Level:
Control Measures –
Precautions Needed
Low Risk:
ACTIVITY / SITUATION
RISK ASSESSED:
Moderate Risk:
Remedial Action Required
Significant Risk:
Very High Risk:
Staff
Responsible
Progress
Review Date
Initial Plan
Compiled by:
Print
Name:
Date:
Signature:
Plan Verified
Complete by:
Print
Name:
Date:
Signature:
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Target
Completion Date
Actual
Completion Date
Beechdale Health Centre
Appendix D
COSHH – Hazardous Substance Risk Assessment Record – Page 1
Compiled By:
COSHH Risk
Assessment No.
Date:
Product / Substance Name:
Formulation:
Manufacturer:
Supplier:
How is it handled in use?
What are the specific risks
when it is being handled?
Which Staff are authorised to
handle & use it?
What control measures /
precautions need to be in
place when it is being
handled?
Where is it used?
What is it used for?
How frequently is it used?
What quantity is used each
time?
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COSHH – Hazardous Substance Risk Assessment Record – Page 2
What are the specific hazards
when it is in use?
Who is at risk when it is in
use? (e.g. Staff / Patients /
Visitors)
What are its key health
effects when it is in use?
What is its route of entry into
the body?
What control measures /
precautions need to be in
place when it is in use?
What immediate first-aid
responses are required should
spillage or exposure occur?
Does it pose a risk of fire /
ignition?
Where is it stored?
How is it stored?
What are the specific hazards
when it is stored?
Are current storage facilities
adequate?
Who is at risk when it is
stored?
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COSHH – Hazardous Substance Risk Assessment Record – Page 3
What control measures /
precautions need to be in
place when it is being stored?
How is it disposed of?
Are there any specific hazards
when it is disposed of?
What control measures /
precautions need to be in
place when it is being
disposed of?
What alternatives are there
which are safer?
Are there any other relevant
comments not previously
mentioned?
Identified Risk Level:
(Select One Level)
Action Required:
No Risk:
Product
Substitution?
Low Risk:
YES / NO
Moderate
Risk:
Risk Elimination?
Significant
Very High
Risk:
Risk:
Control Measure(s)
YES / NO
YES / NO
Required
Action(s) to be taken
to mitigate risk:
Overall Assessment
&
Recommendations
Signature:
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Date:
Beechdale Health Centre
Appendix E
COSHH – Record of Audit
Date of Audit:
Name of Person Undertaking Audit:
Criteria
Comments
All hazardous substances in use have been listed in
Appendix C
All hazardous substances have a Data Sheet in the Library
All data sheets are current / up to date
All Data Sheets are Manufacturer / Supplier originals
All relevant hazardous substances have a Data Sheet
available to the Cleaning staff
All hazardous substances have a Data Sheet available
that is adjacent to its storage / use location
No new hazardous substances are received without a
Data Sheet prior to the substance arrival
Users of hazardous substances are aware of the specific
handling and safety requirements of each of the specific
hazardous substance(s) they use
No hazardous substances are located in unauthorised
areas
Staff training has been carried out in the last 12 months
Essential PPE (as specified in the Data Sheets) is always
available
Essential PPE is always worn by staff
Contractors are not permitted to bring hazardous
materials on site without authority
A Risk Assessment is available for all hazardous
substances
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Action Plan
Beechdale Health Centre
Appendix F
COSHH Index of Safety Data Sheets
Library
Page Ref
No.
Product
Data Sheet
Date
Date Risk
Assessment
Completed
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Beechdale Health Centre
Appendix G
COSHH – List of Hazardous Substances in use
Hazardous
Substance
Category
Location
Maximum
Quantity in Stock
Training
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