Control of Substances Hazardous

to Health (COSHH) Procedure

Ref HS-0001-013-v2
Status: Approved
Document Type: Procedure
Contents
1 Purpose .............................................................................................................3
2 Related Documents ..........................................................................................3
3 Procedure ..........................................................................................................4
3.1 COSHH – Flow Chart..........................................................................................4
3.2 COSHH Guidance Notes ....................................................................................5
3.3 COSHH Risk Assessment ..................................................................................6
3.4 Hazard Symbol Identification ..............................................................................7
3.5 COSHH Risk Assessment ..................................................................................8
3.6 Monitoring and Health Surveillance..................................................................... 9
4 Definitions ....................................................................................................... 10
5 How this Procedure will be Implemented...................................................... 10
5.1 Training Needs Analysis ................................................................................... 10
6 How the Implementation of this Procedure will be Monitored ..................... 11
7 References ...................................................................................................... 11
8 Document Control .......................................................................................... 11
9 Appendices ..................................................................................................... 12
9.1 Appendix 1........................................................................................................ 13
9.2 Appendix 2........................................................................................................ 17

Ref: HS-0001-013-v2 Page 2 of 24 Ratified date: 13 February 2020

COSHH Procedure Last amended:13 February 2020
1 Purpose

Following this procedure will assist with identifying and managing substances which have been
identified as hazardous to health.

2 Related Documents

This procedure describes what you need to do to implement the COSHH section of the Health and
Safety Policy.

This procedure describes what you need to do to complete a risk assessment for any identified
hazardous substances used within the work environment.

The Health and Safety Policy defines roles and responsibilities which you must read,
understand and be trained in before carrying out the procedure described in this document.

This procedure also refers to:

 Health & Safety Policy

 Incident Reporting and Serious Incident Review Policy
 COSHH Risk Assessment
 Personal Protective Equipment Regulations
 Transport of Dangerous Goods Act
 Hotel Services COSHH Assessments

Ref: HS-0001-013-v2 Page 3 of 24 Ratified date: 13 February 2020

COSHH Procedure Last amended:13 February 2020
3 Procedure

3.1 COSHH – Flow Chart

All hazardous substances must be purchased through Cardea.

Staff should not bring in their own COSHH substances at anytime.

Procedure Guidance/Information

Make an inventory of all hazardous Use COSHH inventory to list all substances.
substances in the department, unit or
ward.

When obtaining new substances seek Procurement – Cardea

advice from Procurement (Cardea). (0191) 333 2616

Obtain safety data sheets and information Safety data sheets should be supplied with
regarding the use, storage and disposal first order, if not contact supplies or
before using any (hazardous) substances. supplier/manufacturer./access from internet.

Carry out a written COSHH assessment Use the COSHH assessment template form.
before using any (hazardous) substances. Appendix 1.

Identify and implement control measures to

remove or reduce personal exposure.
Where engineering controls or work
procedures cannot reduce risk ensure
appropriate Personal Protective Equipment
(PPE) is ordered and signed for.
Communicate the actions and findings for
all relevant staff.

Review the COSHH Assessment on a

regular basis or if the work activities
(including products) significantly change.

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3.2 COSHH Guidance Notes

Hazard identification:

In order to control the risks associated with handling substances, it is essential to first ensure you
have identified all hazardous substances.
Reference to product labels and safety data sheets may assist with identifying which chemical
substances are harmful and the type of harm they may cause.

You should not be just thinking about the main substances involved.
The work processes may produce other hazardous substances such as intermediates in chemical
reactions, or by-products such as dusts, fumes, vapours or breakdown products. All these
substances need to be fully considered, so it is important to not just rely on the safety data sheets
alone to provide you with your list of hazards.

Hazardous substances include:

• Substances used directly in work activities (e.g. adhesives, paints, cleaning materials etc.)
• Substances generated during work activities (e.g. fumes, dusts, vapours etc.)

Examples of substances:

• Adhesives
• Cleaning products
• Degreasers
• Paints, varnishes, solvents
• Wood dust
• Cement dust
• Welding fumes
• Biological agents
• Pesticides etc.

How are these types of substances hazardous to health?

In consideration of the task, it is important to think about how workers might be exposed.
The substances described are either solid, liquid, gas, fumes or vapours and can enter the human
body through a variety of different routes:

• Inhalation – breathing in the gases, fumes, mist or dust

• Ingestion – swallowing the substances
• Absorption – through the skin by direct contact or via mucous membranes
• Eye contact – through direct contact with one or both eyes
• Injection – via skin puncture

Once harmful substances are directly on the skin or have entered into the body via inhalation,
ingestion or absorption they can lead to a range of ill-health effects.

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COSHH Procedure Last amended:13 February 2020
Some of these ill-health effects can be acute; for example immediate skin irritation.
Some of these ill-health effects can be chronic; for example they can lead to ill health a long time
after the exposure has initially occurred.

3.3 COSHH Risk Assessment

A COSHH risk assessment concentrates on hazards and risks from hazardous substances in your
workplace. See Appendix 1 for COSHH assessment template.

A risk from a hazardous substance arises when you use it.

The level of risk depends on the amount you are exposed to, how long you are exposed for and
frequency of exposure, sometimes additional personal factors (such as genetics and/or previous
exposure to the substance).

It is essential for the COSHH assessment to consider how and where during the process or task
undertaken the exposure can occur and how significant the exposure is likely to be.

Once the potential sources and points of exposure have been identified as part of the hazard
identification process an assessment should:

• Identify which substances are brought in or are produced during work activities
• Identify which substances are harmful by reading the product labels and safety data
sheets (SDS) (if in doubt contact your supplier)
• Remember to identify harmful substances that have been produced by your processes
which workers may be exposed to (e.g. fumes, dusts, vapours etc.)
• Design and operate processes and activities to minimize emission, release and spread of
substances hazardous to health
• When developing control measures take into account all relevant routes of exposure:
inhalation, ingestion, skin absorption, injection and eye contact
• Control exposure by measures that are proportionate to the health risk
• Where adequate control of exposure cannot be achieved by other means, provide, in
combination with other control measures, suitable personal protective equipment (PPE)
• Check and regularly review all elements of control measures for their continuing
effectiveness.
• Inform and train all employees affected by the hazards and risks from the substances with
which they work in, and the use of those control measures developed to minimize risk.
• Ensure that the introduction of control measures does not increase the overall risk to
health and safety
• Appropriate storage of chemicals and control of access
• Spillages/controls for accidental release
• Firefighting provisions
• Emergency provisions i.e. eye wash, drench showers etc.

Remember – The assessment should be a ‘living’ document!

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COSHH Procedure Last amended:13 February 2020
3.4 Hazard Symbol Identification

There are 9 pictograms (international symbols) as shown in the table below:

All have white background with red diamond frame and black hazard symbol inside.

Chemicals are classified into 2 broad categories:

- Physical hazards (flammables, explosives, corrosives)

- Health Hazards (acute toxicity, irritant, carcinogen and several others)

Each substance now has a ‘Danger’ or ‘Warning’ on the label, unless it is deemed of such low
hazard as to not require one.

- Danger = more severe hazards

- Warning = less severe hazards

All pictograms relating to transport are still governed by “The Transport of Dangerous Goods”
Regulations.

New
Description Hazard Class and Hazard Category
Pictogram

Acute toxicity (fatal or toxic)

Skull & Cross bones
(oral, dermal, inhalation)

Irritant (skin and eye)

Skin sensitizer / Skin irritation
Acute toxicity (oral, dermal, inhalation)
Eye irritation
Narcotic effects
Exclamation mark
Respiratory tract irritant
Skin sensitization
Specific Target Organ Toxicity
Single exposure
Hazardous to ozone layer (none mandatory)
Aquatic toxicity
Hazards to Aquatic Environment
Environment
Acute hazard
Chronic hazard
Respiratory sensitization
Germ cell mutagenicity
Carcinogenicity
Health Hazard Reproductive toxicity
Specific Target organ toxicity - single exposure Specific Target
organ toxicity – repeated exposure
Aspiration hazard

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COSHH Procedure Last amended:13 February 2020
 Skin corrosion / burns.
Corrosion Serious eye damage
Corrosive to metals

Oxidizers
Flame over circle Oxidizing gases
Oxidizing liquids

Flammables
Flammable gases
Flammable aerosols
Flammable liquids
Flammable solids
Self-reactive substances and mixtures
Flame Self-heating substances
Pyrophoric liquids
Pyrophoric solids
Substances & mixtures (that when in contact with water) emit
flammable gases
Organic peroxides

Gases under pressure

Gas Cylinder - Compressed gases
- Liquefied gases
- Refrigerated liquefied gases

Unstable explosives
Explosives of Divisions that include self-reactive substances &
Exploding Bomb
mixtures
Organic peroxides

3.5 COSHH Risk Assessment

A general generic risk assessment must highlight hazards and risks identified in the working area.
Where COSHH substances have been identified as being in use, then a COSHH risk assessment
must be completed.

Hotel Services have already identified all approved substances /chemicals they have in use.
Details of these can be found on the InTouch pages here:

• Hotel Services COSHH Assessments

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COSHH Procedure Last amended:13 February 2020
3.6 Monitoring and Health Surveillance

Monitoring

If through the risk assessment process it is identified that staff are potentially at risk from exposure
to substances hazardous to health, then monitoring of staff groups will be implemented. This will
include staff groups undertaking identical or similar tasks and being exposed to similar risks.

Monitoring will be carried out by trained and experienced staff in monitoring exposure and be:
• Familiar with monitoring standard methods
• Adequate knowledge of exposure limits and exposure strategies
• Writing professional development
• Provide sensible and proportionate advice

Monitoring records will contain the following information:

• Traceability information including name of substance (CAS number and Work Exposure
Limits (WELs), if applicable)
• Process/task description
• Date of monitoring undertaken
• Report authors name

Health Surveillance

The objective of health surveillance is to:

• Check the health of individuals by detecting, as early as possible adverse changes which
may be caused by exposure to substances hazardous to health.
• Collect, keep up to date data, and use date to evaluate hazards so that action can be taken
to prevent more serious diseases developing.
• Check control measures are working effectively and provide feedback on the effectiveness
of the risk assessments and control measures, whether further steps to manage the risk are
required.

Where health surveillance shows an employee’s health is being affected the following steps will be
implemented:
• Review of the risk assessment, if necessary modify control measures
• Check health of employees doing similar work
• Refer employer to Occupational Health who will explain:
o Results of health surveillance
o Arrange for further specialist assessment of health
o Continue with health surveillance
o Consideration of alternative employment within workplace

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COSHH Procedure Last amended:13 February 2020
4 Definitions

Term Definition
• Control of Substances Hazardous to Health
COSHH Substances that are hazardous to health which can take many
forms.
Risks which are significant are those that are not trivial in nature
and capable of creating a real risk to health and safety which any
Significant Risk
reasonable person would appreciate and take steps to guard
against
Document that summarises the performance and other technical
Safety Data Sheet (SDS) characteristics of a product which contains information to assist
with undertaking a risk assessment.

5 How this Procedure will be Implemented

• This procedure will be published on the Trust’s intranet and external website.
• Line managers will disseminate this procedure to all Trust employees through a line
management briefing.

5.1 Training Needs Analysis

Staff / Professional
Type of Training Duration Frequency of Training
Group

On Induction and
updates when
Hotel Services Local Induction varies
assessments are
reviewed

On local induction and

on introduction of new
Estates Local Induction varies
substances and
processes

On local induction and

on introduction of new
Nursing Staff Local Induction varies
substances and
processes

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COSHH Procedure Last amended:13 February 2020
6 How the Implementation of this Procedure will be Monitored

Where results and any

Associate Action Plan will be
Auditable Standard/Key Frequency/Method/Person reported to, implemented and
Performance Indicators Responsible monitored; (this will usually be
via the relevant Governance
Group)

1 Completed risk assessments Audit Programme HSS+F Group

7 References

• Health and Safety at Work Act 1974

• The Management of Health and Safety at Work Regulations 1999
• Control of Substances Hazardous to Health Regulations 2002
• Personal Protective Equipment at Work Regulations 1992 (as amended 2002)
• Working with Substances Hazardous to Health – A brief guide to COSHH
• The Control of Substances Hazardous to Health Regulations 2002. Approved Code of
Practice and guidance; L5

8 Document Control
Date of approval: 13 February 2020
Next review date: 13 February 2023
This document replaces: Ref: HS-0001-013.v1 Control of Substances Hazardous to Health
(COSHH) Procedure
Lead: Name Title
Helen Cunningham Health & Safety Manager
Members of working party: Name Title
Health, Safety Security & Fire Group
This document has been Name Title
agreed and accepted by:
Paul Foxton Director of Capital, Estates and
(Director)
Facilities Management
This document was approved Name of committee/group Date
by:
EFM DMT 13 February 2020
An equality analysis was July 2019
completed on this document
on:

Ref: HS-0001-013-v2 Page 11 of 24 Ratified date: 13 February 2020

COSHH Procedure Last amended:13 February 2020
Change record
Version Date Amendment details Status
1 08 May 2015 New document Withdrawn
1 08 Sep 2016 Full review – no changes required Withdrawn
1 26 Sep 2019 Review date extended from 08 September 2019 Withdrawn
to 31 March 2019
2 13 Feb 2020 Full Review: Published
P9: 3.5 COSHH Risk assessment with link to
InTouch pages added

P10: 4 Definitions: Safety Data Sheets added

P10: 5 Training Needs Analysis added

P13: Appendix 1 COSHH Risk Assessment

Format & Appendix 2 Example Completed
COSHH Assessment

P12: Section 9 - Appendices / Update COSHH

Assessment Form

9 Appendices

Appendix 1 – COSHH Assessment (Blank)

Appendix 2 – Example Completed COSHH Assessment

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COSHH Procedure Last amended:13 February 2020
9.1 Appendix 1
Control of Substances Hazardous to Health (COSHH) Assessment
SECTION 1
Assessment Number:
Assessment Completed
Signature:
By:

Department: Job Role:

Date Assessment
Review Date:
Conducted:

Substance(s) Used /
[image]
Present:

Irritant / Dangerous to Gases Under Health

Toxic Corrosive Flammable Oxidising Explosive
Harmful Environment Pressure Hazard

☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

Ref: HS-0001-013-V3 Page 13 of 24 Ratified date:

Procedure Template Last amended: January 2020
Activity / Process:
(including area of
activity)

Solid ☐
Amount Used: Duration: State: Liquid ☐

Frequency: Gas ☐

Staff ☐ Public ☐ Low ☐

People at Risk: Patients ☐ Others ☐ Risk of Exposure: Medium ☐
Contractors ☐ ________________ High ☐

Dusts ☐ Fumes ☐
By-Products Produced:
Vapour ☐ Other Breakdown Products ☐

SECTION 2 – Hazards & Control Measures

Absorption / Skin Contact ☐
Inhalation ☐
Routes of Exposure: Eye Contact ☐
Injection ☐
Ingestion ☐

Re-design ☐ Maintenance Controls ☐

Substitution ☐ Workplace Monitoring ☐
Control Measures
Engineering ☐ PPE ☐
Local Exhaust Ventilation ☐ Other:_________________________________

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COSHH Procedure Last amended:13 February 2020
 Full Face Visor ☐ Face Mask ☐

Personal Protective Gloves / Gauntlets (Chemical

Equipment (PPE)
Goggles / Safety Glasses ☐ Resistant)
☐

Respirator ☐ Protective Clothing ☐

Maintenance Control
Measures Identified:
Inhalation
Ingestion
First Aid Provisions: Absorption
Eye Contact
Other / Site Specific:
Fire & Emergency
Provisions:
Spillage Measures:
Information, Instruction &
Training:
Handling & Storage:
Disposal Procedures:
Has risk been adequately controlled after control
measures have been implemented? YES ☐ NO ☐

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COSHH Procedure Last amended:13 February 2020
 If no what further action is required?

Risk Group:
(After controls in place)
Please refer to guidance in Risk Management File

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COSHH Procedure Last amended:13 February 2020
9.2 Appendix 2
Control of Substances Hazardous to Health (COSHH) Assessment – EXAMPLE
SECTION 1
Assessment Number: COSHH 001
Assessment Completed
Signature:
By:

Department: Hotel Services Job Role:

Date Assessment
January 2020 Review Date: January 2021
Conducted:

Substance(s) Used /
SPOTLESS – RINSE AID FOR DISHWASHERS
Present:

Irritant / Dangerous to Gases Under Health

Toxic Corrosive Flammable Oxidising Explosive
Harmful Environment Pressure Hazard

☐ ☒ ☐ ☐ ☐ ☐ ☐ ☐ ☐

Ref: HS-0001-013-v2 Page 17 of 24 Ratified date: 13 February 2020

COSHH Procedure Last amended:13 February 2020
 Used in cleaning of utensils, crockery, cutlery etc.
Activity / Process:
Supplied in 5 litre containers
(including area of
activity) When replacing empty container, unscrew cap, insert tube from machine, screw back on cap,
container placed on floor/bracket next to machine.

Electronically regulated by machine. Solid ☐

Amount Used: Duration: Varies State: Liquid ☒

Frequency: Daily Gas ☐

Staff ☒ Public ☐
Low ☒
Patients ☐ Others ☐
People at Risk: Risk of Exposure: Medium ☐
Contractors ☐
High ☐
Catering Staff & Housekeeper
Dusts ☐ Fumes ☐
By-Products Produced:
Vapour ☐ Other Breakdown Products ☐

SECTION 2 – Hazards & Control Measures

Absorption / Skin Contact ☐
Inhalation ☐
Routes of Exposure: Eye Contact ☒
Injection ☐
Ingestion ☒

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COSHH Procedure Last amended:13 February 2020
 Re-design ☐ Maintenance Controls ☐
Substitution ☐ Workplace Monitoring ☐
Control Measures
Engineering ☐ PPE ☒
Local Exhaust Ventilation ☐ Other:_________________________________

Full Face Visor ☐ Face Mask ☐

Personal Protective Gloves / Gauntlets (Chemical

Equipment (PPE)
Goggles / Safety Glasses ☒ Resistant)
☒

Respirator ☐ Protective Clothing ☒

Maintenance Control
Measures Identified:
Inhalation Remove to fresh air
Ingestion Seek medical attention. Take Safety Data Sheet.
First Aid Provisions: Absorption Wash with soap and water.
Eye Contact Rinse with running water for 10 minutes.
Other / Site Specific:
Fire & Emergency
Fire: normal fire procedures in place
Provisions:
Small quantities: clean with cold water
Spillage Measures:
Large quantities: prevent from entering main drains – contact estates department

Ref: HS-0001-013-v2 Page 19 of 24 Ratified date: 13 February 2020

COSHH Procedure Last amended:13 February 2020
 Wear PPE
Refer to following documents:
Information, Instruction &
Training: • Work Schedules
• General Risk Assessments
• Product Safety Data Sheet
Handling & Storage: Store away from heat
Disposal Procedures: Containers can be disposed of with general waste
Has risk been adequately controlled after control
measures have been implemented? YES ☒ NO ☐

If no what further action is required?

Risk Group:
(After controls in place)
Please refer to guidance in Risk Management File

Ref: HS-0001-013-v2 Page 20 of 24 Ratified date: 13 February 2020

COSHH Procedure Last amended:13 February 2020
Equality Analysis Screening Form

Please note; The Equality Analysis Policy and Equality Analysis Guidance can be found on InTouch on the policies page
Name of Service area, Directorate/Department Estates & Facilities Management, Health Safety & Security
i.e. substance misuse, corporate, finance etc.
Name of responsible person and job title Helen Cunningham

Name of working party, to include any other Health, Safety Security & Fire Group
individuals, agencies or groups involved in this
analysis
Policy (document/service) name Control of Substances Hazardous to Health (COSHH) Procedure
Is the area being assessed a… Policy/Strategy Service/Business plan Project
Procedure/Guidance X Code of practice

Other – Please state

Geographical area covered Trustwide

Aims and objectives Following this procedure will assist with identifying and managing substances which have been
identified as hazardous to health.
Start date of Equality Analysis Screening Jan 2019
(This is the date you are asked to write or
review the document/service etc.)
End date of Equality Analysis Screening
(This is when you have completed the equality July 2019
analysis and it is ready to go to EMT to be
approved)

You must contact the EDHR team if you identify a negative impact. Please ring Sarah Jay or Julie Barfoot on 0191 3336267/3046

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COSHH Procedure Last amended:13 February 2020
1. Who does the Policy, Service, Function, Strategy, Code of practice, Guidance, Project or Business plan benefit?

All staff, patients and visitors

2. Will the Policy, Service, Function, Strategy, Code of practice, Guidance, Project or Business plan impact negatively on any of the
protected characteristic groups below?

Race (including Gypsy and Traveller) No Disability (includes physical, No Sex (Men, women and gender No
learning, mental health, sensory neutral etc.)
and medical disabilities)
Gender reassignment (Transgender No Sexual Orientation (Lesbian, Gay, No Age (includes, young people, No
and gender identity) Bisexual and Heterosexual etc.) older people – people of all
ages)
Religion or Belief (includes faith No Pregnancy and Maternity Yes Marriage and Civil No
groups, atheism and philosophical (includes pregnancy, women who Partnership
belief’s) are breastfeeding and women on (includes opposite and same
maternity leave) sex couples who are married or
civil partners)
Yes – Please describe anticipated negative impact/s
No – Please describe any positive impacts/s

Some identified substances may be a risk to new and expectant mothers and their unborn baby and therefore must be reviewed through risk
assessment.

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COSHH Procedure Last amended:13 February 2020
3. Have you considered other sources of information such as; legislation, codes of practice, best practice, Yes X No
nice guidelines, CQC reports or feedback etc.?
If ‘No’, why not?
Sources of Information may include:
• Feedback from equality bodies, Care Quality • Staff grievances
Commission, Equality and Human Rights Commission, • Media
etc. • Community Consultation/Consultation Groups
• Investigation findings • Internal Consultation
X •
• Safety Alerts Research
• Trust Strategic Direction • Other (Please state below)
• Data collection/analysis X
• National Guidance/Reports

4. Have you engaged or consulted with service users, carers, staff and other stakeholders including people from the following protected
groups?: Race, Disability, Sex, Gender reassignment (Trans), Sexual Orientation (LGB), Religion or Belief, Age, Pregnancy and
Maternity or Marriage and Civil Partnership

Yes – Please describe the engagement and involvement that has taken place

Staff engagement and consultation through Health, Safety, Security & Fire Group

No – Please describe future plans that you may have to engage and involve people from different groups

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COSHH Procedure Last amended:13 February 2020
5. As part of this equality analysis have any training needs/service needs been identified?

Training to be provided through local induction and supervision.

Yes/No Please describe the identified training needs/service needs below:

A training need has been identified for;

Trust staff Yes Service users Yes/No Contractors or other outside Yes/No
agencies

Make sure that you have checked the information and that you are comfortable that additional evidence can provided if you are
required to do so
The completed EA has been signed off by:
You the Policy owner/manager: Date: July
Type name: Helen Cunningham 2019

Your reporting (line) manager:

Type name: Linda Parsons Date: July
2019

If you need further advice or information on equality analysis, the EDHR team host surgeries to support you in this process, to book on and
find out more please call: 0191 3336267/3046

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COSHH Procedure Last amended:13 February 2020