(COSHH) Policy - the Royal Cornwall Hospitals Trust website...

Peninsula Community Health
Control of Substances Hazardous to Health
(COSHH) Policy
Title:
Control of Substances Hazardous to Health
(COSHH) Policy
Procedural Document Type:
Policy
Reference: GOP 19
CQC Outcome:
Outcome 10B
Version: Version 2
Approved by:
Health and Safety Committee
Ratified by:
Clinical Quality and Safety Committee
Date ratified: 7 th August 2012
Freedom of Information:
This document can be released
Name of originator/author:
Health and Safety Team
Name of responsible team:
Health and Safety Team
Review Frequency:
3 years unless a change in legislation
Review Date: 7 th August 2015
Target Audience:
All staff who may use or come into contact
with COSHH products.
Executive Signature (Hard Copy Only):
Registered in England and Wales No: 7564579
Registered office: Peninsula Community Health CIC,
Sedgemoor Centre, Priory Road, St Austell PL25 5AS
www.peninsulacommunityhealth.co.uk
Quality care, closer to you
Peninsula Community Health is a not for profit
Community Interest Company responsible for
providing NHS adult community health
services
in Cornwall and the Isles of Scilly

Contents
1. Introduction ........................................................................................................... 3
2. Definitions ............................................................................................................. 3
2.1 Terminology ................................................................................................ 4
2.3 Substance Identification .............................................................................. 4
2.4 Hierarchy Of Preferred Control.................................................................... 5
2.5 Occupational Exposure Limit....................................................................... 6
3. Duties .................................................................................................................... 6
4.0 Management of COSHH .................................................................................... 10
4.1 COSHH Risk Assessment......................................................................... 11
4.2 MONITORING........................................................................................... 12
4.3 HEALTH SURVEILLANCE........................................................................ 12
4.4 RECORD KEEPING.................................................................................. 12
5. COSHH Policy Implementation ........................................................................... 13
5.1 Implementation & Dissemination................................................................ 13
5.2 Training and Support.................................................................................. 13
5.3 Document Control & Archiving Arrangements........................................... 13
5.4 Equality Impact Assessment ..................................................................... 13
5.5 Process for Monitoring Effective Implementation ...................................... 13
6. Associated Documentation.................................................................................. 14
Please Note the Intention of this Document
This policy outlines Peninsula Community Health’s processes and protocols for the
management and control of substances hazardous to health to ensure the safety of
all staff, patients and visitors.
Review and Amendment Log
Version No Type of Change Date Description of change
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1. Introduction
The Health and Safety at Work Act 1974 requires that “every employer” shall make
arrangements for securing, so far as is reasonably practicable, safety and absence
of risk to health in connection with the use, handling, storage and transport of articles
and substances.
This duty is extended to and clarified for substances hazardous to health under the
Control of Substances Hazardous to Health Regulations 2002 (COSHH) (as
amended).
Under the COSHH Regulations, Peninsula Community Health is required to make an
assessment of heath risks created by work involving hazardous substances.
Where risks are identified, Peninsula Community Health must carry out a risk
assessment, take action to prevent or control exposure to those substances, monitor
exposure and provide information, instruction and training for those who may be
exposed.
2. Definitions
Employer is Peninsula Community Health (PCH)
Employees are persons working for PCH, to include contingent workforce / agency
/ personnel on work experience and volunteer workers.
Hazard is something with the potential to cause harm, injury, illness, disease or
loss.
Risk is the likelihood of harm, injury, illness or loss from a particular hazard is
realised. Risk reflects both the likelihood of occurrence and it’s severity of outcome,
for example, through an unexpected event happening that may either cause harm or
have an impact upon PCH patients, employees, contractors, visitors including the
general public.
Risk Assessment is the process whereby hazards are identified and the level of
risk identified is evaluated.
A hazardous substance can be defined as one which meets any of the following
criteria:
A substance that is classed as very toxic, toxic, harmful, corrosive or irritant
under the Chemical (Hazard Information and Packaging for Supply) Regulations
2009 (CHIP).
A biological agent meaning any micro-organism, cell culture or human
endoparasite which may cause or create a hazard to human health
A substance listed as carcinogenic in the regulations.
A substance which already has an allocated Workplace Exposure Limit (WEL)
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Significant quantities of any kind of dust.
Any other substances capable of creating comparable risks to health to those
listed above.
2.1 Terminology
Those persons with responsibilities for Health and Safety and the COSHH
regulations should make themselves aware of the terms used, as this will promote a
better understanding of those responsibilities.
Substance type
A substance hazardous to health can be found in any of the following forms: -
Hazard
Liquid Gas Fume Solid
Aerosols Vapour Dust Micro-organism
The hazard presented by a substance is its potential to cause harm, which can be
through:
Inhalation (through dust, vapours, fumes etc)
Ingestion (directly from swallowing or indirectly from settlement on hands
etc.)
Absorbed through the skin (directly or from contaminated surfaces or
clothing)
Injected into the body (by high pressure or contaminated sharps)
Risk
The risk from a substance is the likelihood that it will cause harm whilst being used
or stored and will depend on: -
The hazard presented by the substance
How it is used or stored
How it is controlled
Who is exposed, what they are exposed to, for how long and how much
and what activity they are doing
2.2 Substance Identification
Substances can be found in a variety of containers including drums, bottles and
packages etc. However, not all of these contain substances that are hazardous to
health.
The labels on products that have been identified as “Substances Hazardous to
Health” can be readily identified from those that are not, as they display specific
pictorial symbols indicating the hazard they pose. For example, a black cross on an
orange background, meaning that substance is Harmful or Irritant. The symbol will
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also carry the wording as appropriate. The labels will also display risk or safety
phrases that identify the hazard and risk. This is a legal requirement under the
Chemical (Hazard Information and Packaging for Supply) Regulations 2009 (CHIP).
GHS Regulation (Globally Harmonised System for the Classification and Labelling of
Chemicals) is a new European Regulation on the classification and labelling of
hazardous chemicals based on UN GHS agreement. There is a transition period up
until June 2015 and will replace the Dangerous Substances Directive and Dangerous
Preparations Directive (implemented in the UK as the Chemicals Hazard Information
and Packaging for Supply (CHIP) Regulation). This new regulation Introduces new
scientific criteria to assess the hazardous properties of chemicals, new hazard
warning symbols (called pictograms) and new hazard warning symbols.
2.3 Hierarchy Of Preferred Control
The first letter of the acronym COSHH stands for control and one of the objectives is
to improve the control of exposure. The first requisite of control is the recognition that
there is an exposure which needs to be controlled. The formal risk assessment
process will lead to this recognition, the regulations set out a hierarchy to obtain and
maintain control by:-
‣ Elimination Can the job be done without using the substance
‣ Substitution
‣ Control
Using a substance which is non-hazardous or less hazardous to
health
By mechanical means, change or modifying a system
‣ Protection
Use of Personal Protective Equipment (PPE), as a last resort
Risk phrases
These identify the hazard. For example: -
R26 Toxic by Inhalation
R36 Irritating to the eyes
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Or
Safety phases
These give advice on how to minimise the risk. For example: -
S15 Keep away from heat
S24 Avoid contact with the skin
2.4 Occupational Exposure Limit
Under COSHH, Workplace Exposure Limits (WEL) have been established for a
number of substances hazardous to health. A WEL is the maximum concentration of
an airborne substance averaged over a referenced period.
WEL’s are intended to prevent excessive exposure to specific hazardous substances
by containing exposure below a set limit.
3. Duties
The Chief Executive / Executive Board
a) The Chief Executive of the organisation, as Accountable Officer, is ultimately
responsible for health and safety.
b) The PCH Board will delegate responsibility for the implementation of safe working
practices to Managers within the organisation.
Executive Directors
a) Are responsible, delegated from the Chief Executive, for the health and safety at
work of all employees, patients, contractors, visitors and others
b) They should ensure that the organisation is fully compliant with the requirements
of the Health & Safety at Work etc. Act 1974, all other relevant legislation and
Codes of Practice, ensuring that support is given to all persons to whom
responsibility has been delegated.
Senior Managers
Senior Managers are responsible for the health, safety and welfare at work of their
managers, staff and others with regard to the risks to their health and safety
associated with substances hazardous to health and will ensure: -
That their managers and staff follow the PCH policy and procedures relating
to COSHH.
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They have detailed local health and safety documentation in place that
allocates specific responsibilities to enable them to comply with the policy on
COSHH.
Ensure that COSHH Risk Assessments are carried out, recorded and that
employees are informed of the significant risks identified; and that the
protective and preventative measures required to protect themselves and
others from risks arising from the use and storage of substances hazardous to
health are implemented.
That to support risk assessments, action plans are completed, implemented
and reviewed to ensure the elimination or reduction of the risks identified and
that any residual risks are placed on the PCH Risk Register as appropriate.
That staff are trained to the appropriate level to deal with the risks identified
through the assessment process and that records of all such training are
documented and maintained.
Involvement with the Health and Safety team in any policy amendments and
updates issued from time to time and in any programmes of inspection or
audit, bringing these to the attention of staff, as appropriate.
Line Managers and Supervisors will ensure: -
There is information available on toxicity and potential hazards for substances
in use within their area of control, which will include the Material Safety Data
sheets for each substance. This information must be available for staff, and
managers should ensure that staff are aware how to access it.
That an up-to-date register of COSHH products for their own area of control is
kept and maintained.
They undertake suitable and sufficient COSHH Risk Assessments for their
area of control; this task may be delegated, but must be undertaken by a
member of staff within the department deemed to be competent
Where Risks have been identified either through the risk assessment or
otherwise they are to ensure: -
a) That in areas which are identified as high risk, suitable warning signs are
displayed giving suitable and sufficient advice on the hazards and
appropriate safeguards to be taken.
b) That all substances are correctly labelled, that packaging is intact and the
expiry date is prominently displayed.
They seek advice and guidance and liaise with the Infection Control or
Occupational Health Department (as appropriate) on all aspects of COSHH
involving biological agents
They liaise with the Cornwall Healthcare Estates & Support Services
(CHESS) or the Medical Physics Department on all aspects of COSHH
involving the inspection, maintenance and testing of machinery and
equipment used as a control measure under COSHH.
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They arrange Health Surveillance through the Occupational Health
Department where appropriate.
Liaison with the organisation’s Health and Safety Team on environmental
monitoring where required.
That where the use of Personal Protective Equipment (PPE) is identified, the
correct type and size of equipment is selected in liaison with the Health and
Safety team.
That all persons who are provided with PPE receive instruction, training and
information considered necessary on the function, correct use and
maintenance in liaison with the Health and Safety team.
That appropriate instruction, training and information on the safe handling,
transportation, packaging, storage and use of substances or equipment used
in conjunction with substances hazardous to health is arranged or provided.
They review the risk assessments carried out in the areas under their control.
This review should be on an annual basis; when the assessment is no longer
valid, or when there has been a significant change in the work to which the
assessment relates.
They keep up to date any such records as required under the regulations for
the requisite period of time.
Employees will ensure they: -
Make themselves fully aware of the PCH COSHH Policy, COSHH risk
assessments and any safety precautions appertaining to the use, storage and
transportation of a substance hazardous to health that they use or handle at
work.
Wear Personal Protective equipment (PPE) when it is provided and ensure
that it is stored and maintained when not in use and that any defects are
promptly reported to line manager.
Attend training when it has been arranged for them.
Report to their Line Manager and following up with a report through DATIX
of:-
a) Incident of a spillage involving a hazardous substance to health
b) Failure or deterioration of a control measure
c) Shortage or inadequacy of PPE
Health and Safety Team
Will monitor and audit COSHH procedure.
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Will facilitate general training in COSHH that has been arranged through Line
Managers and/or the Education and Training Department. This will encourage
cascade training and result in greater understanding by managers and staff of
the Trust’s compliance requirements of COSHH.
Provide specialist advice and guidance as and when appropriate to individual
departments.
In liaison with managers provide advice and information to ensure the safe
packaging, handling, transportation, storage and use of substances and in the
use of equipment used in conjunction with substances hazardous to health,
for all staff or persons likely to be affected by such activities.
Assist Managers in the correct selection of Personal Protective Equipment
(PPE).
Assist line managers in carrying out environmental monitoring tasks and in the
making and keeping of all records for the appropriate period of time.
CHESS or Medical Physics Department will ensure: -
That all plant, machinery and equipment for which they have responsibility
under COSHH is inspected, maintained and tested to the appropriate
standards / time scales as set out in the regulations or other legislative or
mandatory requirements.
They notify both the Line Manager and the Health and Safety team if any
plant, machinery or equipment falls short of the standards to which it was
designed as a control measure under COSHH and that, as a result may give
rise to an exposure to a substance hazardous to health.
The Waste Department will ensure: -
They provide advice on the disposal of substances covered by COSHH
regulations and keep the Waste Management Policy up-to-date to reflect any
changes to the regulations.
Trust Dangerous Goods Safety Adviser will:-
Provide advice on safe transportation of COSHH items designated as
dangerous for carriage.
The Supplies Department will ensure: -
They provide Material Safety Data Sheets (MSDS) for use in the COSHH Risk
assessments for substances ordered through their department. All other
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They notify the Health and Safety team if a new item has been ordered that is
covered by the COSHH Regulations.
The Infection Control Department will ensure: -
They provide practical advice and guidance on microbiological agents
covered by the COSHH regulations.
In liaison with Line Managers, carry out environmental monitoring on
microbiological agents, as appropriate and in accordance with statutory and
mandatory requirements and inform the relevant line managers and the
Health and Safety team of the results.
Serious problems relating to health and safety issues will be reported to the
Health and Safety team.
Keep and maintain all such records of any monitoring carried out under
statutory or mandatory requirements.
The Occupational Health Department will ensure: -
They carry out biological monitoring and health surveillance as required and
keep all records for the specified time.
They will liaise with line managers, the Infection Control Department and
Health and Safety team, as appropriate for the protection of health of all
employees.
4.0 Management of COSHH
Peninsula Community Health is committed to protecting the Health and Safety of its
employees and others, so far as reasonably practicable, and will ensure:
The collection of information on toxicity and potential hazards, and keep and
maintain an up to date registry on substances in use within the organisation,
which will include the Material Safety Data sheets for each substance.
Risk assessments are carried out where any work is liable to expose an
employee to any substance hazardous to health and, as a result of that
assessment, take all steps necessary to eliminate, reduce, prevent or control
any exposure.
That any control measures, which exist or are introduced as a result of the
risk assessment are maintained, examined and tested to the required
timescales and that they are correctly used or applied.
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Monitoring of the workplace is carried out to ensure adequate control is
maintained for protecting the health of employees.
Information is available and accessible to employees on the risks identified as
a result of the risk assessment including any protective or preventative
measures and that staff know how to access this information.
That any personal protective equipment (PPE) that is issued is of the
approved type and is correctly maintained and worn.
Health Surveillance (where appropriate) to protect the health of employees is
undertaken through the Occupational Health Department.
Risk Assessments carried out under the regulations are reviewed on a regular
basis, or when the assessment is no longer valid or there has been a
significant change in the work to which the assessment relates.
Implementation or any changes that are required as a result of the Risk
Assessment review.
Any such records as required under the regulations are made and kept up to
date.
4.1 COSHH Risk Assessment
Line managers are responsible for carrying out COSHH risk assessments enabling
decisions to be made about the use of substances in the workplace and the handling
of clinical waste, and the use of appropriate controls to ensure safety and improve
the working environment.
The COSHH procedural documentation process consists of: -
COSHH Risk Assessment Summary
Prioritised Action Plan
Risk Matrix
(This documentation can be found at the end of this policy)
PROCEDURE FOR RISK ASSESSMENT & CONTROL
1. Initially, the staff member carrying out the assessment must compile a
Summary List of substances (see Appendix A) used in the area for which
they are responsible and obtain the Material Safety Data sheet (MSDS),
sometimes called Hazard Data Sheet for each of the substances being
assessed. See Appendix D - checklist to assist this process.
2. Taking each substance to be assessed in turn, check the MSDS and label for
that substance, to determine if it is classified as a substance hazardous to
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3. Hazards identified as Medium / High / Extreme should have a supporting
action plan to identify control measures to be implemented (see Appendix B).
4. Any new substances, which are brought into the area under the line
managers’ control, will have to be Risk Assessed by them prior to the
substance being put into use and added to the summary form as detailed
previously in the procedures.
5. Managers are to ensure that the Health and Safety team are kept informed of
any new or altered processes or new substances likely to give rise to
exposure to a substance hazardous to health.
4.2 MONITORING
Monitoring of atmospheric concentrations to which a member of staff is exposed
when undertaking a task should be carried out where: -
1. The COSHH risk assessment indicates the level of risk identified .
2. The effectiveness of environmental control measures in the work area need to
be re-evaluated
3. There is a need to demonstrate that the Workplace Exposure Limit (WEL) has
not been exceeded.
4. The effectiveness of Local Exhaust Ventilation (LEV) needs to be assessed at
regular intervals as required by statutory of mandatory requirements
Biological monitoring may be used for: -
1. Surveillance of those who are, or may be, exposed at work to substances
hazardous to health, in the normal course of their work.
2. Examination of those who are unexpectedly exposed or subjected to risk of
exposure as a result of an accident.
3. Continuing evaluation of environmental and internal dose control limits
4.3 HEALTH SURVEILLANCE
This is carried out on employees where they have been exposed to concentrates of
a substance hazardous to health that is listed in the schedule to the COSHH
Regulations. It is carried out in conjunction with the Occupational Health Department.
4.4 RECORD KEEPING
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COSHH risk assessments records and occupational hygiene/monitoring reports
along with health surveillance records should be kept for a period of not less than 40
years.
5. COSHH Policy Implementation
5.1 Implementation & Dissemination
The implementation and effectiveness of this policy will be monitored through the
Health and Safety Committee.
5.2 Training and Support
Training should include:
Chemical data and information (usually through the MSDS) on the substances
involved, their hazards, and the action to be taken should a spill or
contamination occur.
The correct use and maintenance of PPE
Information on the correct storage and safe transportation of material
Correct disposal of waste
5.3 Document Control & Archiving Arrangements
Once ratified, this policy will be loaded to the documents library. Any previous
versions will be electronically archived by the Policy Administrator in the electronic
Policy Drive Archive Folder.
A signed hard copy of the policy will be forwarded to the Policy Administrator and an
electronic copy will be saved by the Policy Administrator in the electronic Policy
Drive. Further copies of current and archived policies can be obtained from the
Policy Administrator including versions in large print, Braille and other languages.
5.4 Equality Impact Assessment
Peninsula Community Health aims to design and implement services, policies and
measures that meet the diverse needs of our service, population and workforce,
ensuring that none are placed at a disadvantage over others.
As part of its development, this strategy and its impact on equality have been
assessed. The assessment is to minimise and if possible remove any
disproportionate impact on employees on the grounds of race sex, disability, age,
sexual orientation or religious belief. No detriment was identified.
5.5 Process for Monitoring Effective Implementation
A COSHH audit will be completed at least every three years to ensure compliance
with the policy in all areas of the organisation. This audit will be carried out by the
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health and safety team. Any learning from the audits will be collated and fed back to
staff and if necessary will be incorporated within the policy by an amendment.
6. Associated Documentation / references
This document references the following supporting documents which should be
referred to in conjunction with the document being developed.
Health & Safety Management Strategy
Health & Safety Policy
Guide to Risk Assessment
Generic Waste Policy
Management of Contractors and Estates Projects Policy
Health & Safety at Work etc Act 1974
Reporting of Injuries, Disease and Dangerous Occurrences Regulation 1995
Disability Discrimination Act 1995
Control of Substances Hazardous to Health 2002 (as amended)
Chemicals (Hazard Information and Packaging for Supply) Regulations 2009
Registration, Evaluation, Authorisation and restriction of Chemicals Regulations
(REACH)
Personal Protective Equipment at Work Regulations 1992
Management of Health and Safety at Work Regulations 1999
Occupational Exposure Limits EH40
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Appendix A
CONTROL OF SUBSTANCES HAZARDOUS TO HEALTH REGULATIONS 2002
SUMMARY LIST OF COSHH ASSESSMENTS
Hospital /Health Office/Site:
Item
No
Substance Quantity Freq. Of
Use
Ward/Dept:
Ext:
Duration of
Exposure
Persons
Exposed
Assessors:
Title:
Hazards to Health
Assessment Date:
Review Date:
Overall
Risk Numerical risk
Ranking ranking
E,H,M,L Impact Likelihood
COSHH Hazard Data Sheets should accompany the COSHH Assessments
Hazards identified as Med High should have a supporting Risk assessment and action plan

Appendix B
ACTION PLAN FOR AREAS OF RISK
Hosp/Health office: Activity/topic: Ward/Dept/Area:
Ext:
Risk
Assess
ment
Item
No*
Hazard*
Action to be implemented to
improve control of risk
Responsible
Person(s)
Assessors:
Title:
Revised numerical
Timescale Risk Ranking
(to be assessed &
reviewed as action
progresses / completes **)
Action Plan Date:
Review Date:
Overall
residual
risk rating
Impact Likely E, H,
M , L
Risk
Register
ref. No.
(for use by
Managers/
RASH
Team)

Appendix C
PENINSULA COMMUNITY HEALTH: RISK MATRIX 1
TABLE 1: RISK IMPACT/CONSEQUENCE SCORE: Choose the most appropriate domain for the identified risk from the left hand side of
the table Then work along the columns in same row to assess the severity of the risk on the scale of 1 to 5 to determine the consequence score,
which is the number given at the top of the column.
Consequence score (severity levels) and examples of descriptors
Domains Negligible (1) Minor (2) Moderate (3) Major (4) Catastrophic (5)
Impact on the
safety of
patients, staff
or public
(physical/
Minimal injury
requiring no/minimal
intervention or
treatment.
No time off work
Minor injury or illness,
requiring minor
intervention
Requiring time off work
for less than 3 days
psychological
Increase in length of
harm)
hospital stay by 1-3
days
Quality/
complaints/
audit
Peripheral element of
treatment or service
suboptimal
Informal
complaint/inquiry
Overall treatment or
service suboptimal
Formal complaint
(stage 1)
Local resolution
Single failure to meet
internal standards
Minor patient safety
implications if
unresolved
Reduced performance
rating if unresolved
Moderate injury
requiring professional
intervention
Requiring time off work
for 3-14 days
Increase in length of
hospital stay by 4-15
days
RIDDOR/agency
reportable incident
Event impacts on a
small number of
patients
Treatment or service
has significantly
reduced effectiveness
Formal complaint
(stage 2)
Local resolution (with
potential to go to
independent review)
Repeated failure to
meet internal
standards
Major patient safety
implications if findings
are not acted on
1 Taken from National Patient Safety Agency “Risk Matrix for Risk Managers” (January 2008)
Major injury leading to
long-term
incapacity/disability
Requiring time off work
for over14 days
Increase in length of
hospital stay by over
15 days
Mismanagement of
patient care with longterm
effects
Non-compliance with
national standards with
significant risk to
patients if unresolved
Multiple complaints/
independent review
Low performance rating
Critical report
Incident leading to
death
Multiple permanent
injuries or irreversible
health effects
An event which impacts
on a large number of
patients
Totally unacceptable
level or quality of
treatment/service
Gross failure of patient
safety if findings not
acted on
Inquest/ombudsman
inquiry
Gross failure to meet
national standards

Human
resources/
organisational
development/
staffing/
competence
Statutory duty/
inspections
Adverse
publicity/
reputation
Business
objectives/
projects
Finance
including
claims
Short-term low
staffing level that
temporarily reduces
service quality (less
than 1 day)
No or minimal impact
or breach of
guidance/ statutory
duty
Rumours
Potential for public
concern
Insignificant cost
increase/ schedule
slippage
Small loss Risk of
claim remote
Low staffing level that
reduces the service
quality
Breach of statutory
legislation
Reduced performance
rating if unresolved
Local media coverage -
short-term reduction in
public confidence
Elements of public
expectation not being
met
Up to 5 per cent over
project budget
Schedule slippage
Loss of 0.1–0.25 per
cent of budget
Claim less than
£10,000
Late delivery of key
objective/ service due
to lack of staff
Unsafe staffing level or
competence (>1 day)
Low staff morale
Poor staff attendance
for mandatory/key
training
Single breach in
statutory duty
Challenging external
recommendations/
improvement notice
Local media coverage -
long-term reduction in
public confidence
5–10 per cent over
project budget
Schedule slippage
Loss of 0.25–0.5 per
cent of budget
Claim(s) between
£10,000 and £100,000
Uncertain delivery of
key objective/service
due to lack of staff
Unsafe staffing level or
competence (>5 days)
Loss of key staff
Very low staff morale
No staff attending
mandatory/ key
training
Enforcement action
Multiple breaches in
statutory duty
Improvement notices
Low performance rating
Critical report
National media
coverage with 3 days
service well below
reasonable public
expectation. MP
concerned (questions
in the House)
Total loss of public
confidence
Incident leading to over
25 per cent over
project budget
Schedule slippage
Key objectives not met
Non-delivery of key
objective/ Loss of >1
per cent of budget
Failure to meet
specification/ slippage
Loss of contract /
payment by results

Purchasers failing to
pay on time
Claim(s) over £1
million
Service/
business
interruption
Environmental
impact
Loss/interruption of
up to 1 hour
Minimal or no impact
on the environment
Loss/interruption of up
to 8 hours
Minor impact on
environment
Loss/interruption of up
to1 day
Moderate impact on
environment
Loss/interruption of up
to1 week
Major impact on
environment
Permanent loss of
service or facility
Catastrophic impact on
environment

TABLE 2: RISK LIKELIHOOD SCORE: What is the likelihood of the consequence occurring
The frequency-based score is appropriate in most circumstances and is easier to identify. It should
be used whenever it is possible to identify a frequency.
The probability based score may be useful when rating risks associated with the success of timelimited
or one-off project. For example, a three-year project cannot be expected to fail ‘once a
month’, and the likelihood score will need to be assessed on the probability of adverse
consequences occurring within the project’s time frame.
Likelihood
score
1 2 3 4 5
Descriptor Rare Unlikely Possible Likely
Frequency
How often
might
it/does it
happen
Probability.
Will it
happen or
not
This will
probably
never
happen/rec
ur
Less than
0.1%
Do not
expect it to
happen/rec
ur but it is
possible it
may do so
Between
0.1 %and
1%
Might
happen or
recur
occasionally
Between
1% and
10%
Will
probably
happen/rec
ur but it is
not a
persisting
issue
Between
10% and
50%
Almost
certain
Will
undoubtedly
happen/rec
ur, possibly
frequently
Over 50%
TABLE 3: RISK RATING MATRIX
Risk scoring = consequence x likelihood
Consequence/
Impact score
Likelihood
1 2 3 4 5
Rare Unlikely Possible Likely
Almost
certain
5 Catastrophic 5 10 15 20 25
4 Major 4 8 12 16 20
3 Moderate 3 6 9 12 15
2 Minor 2 4 6 8 10
1 Negligible 1 2 3 4 5
The scores obtained from the risk matrix are assigned grades as follows
1 - 3 Low risk
4 - 6 Moderate risk
8 - 12 High risk
15 - 25 Extreme risk

Peninsula Community Health
Appendix D
RISK ASSESSMENT CHECKLIST FOR
CONTROL OF SUBSTANCES HAZARDOUS TO HEALTH REGULATIONS 2002 (as amended)
(COSHH)
HOSPITAL:
CLINIC/HEALTH OFFICE:
Actual Workplace:
Assessors
Please answer the questions in the boxes provided below
Name of substance
Health and Safety Team
Recommendations/Comments
Chemical or other names (if appropriate)
Number of persons likely to be exposed
to the substance at any one time
Duration of exposure
Frequency of exposure
Aprox quantities involved in the process
(i.e. grams/ounces/litres/gallons etc)
Likely route of entry to the body:
Inoculation
Inhalation
Ingestion
Skin absorption
Hazard known/possible health effects
Is it correctly stored and labelled
(i.e. containers sealed)
What was used/handled and purpose
What control measures exist or are used:
(please tick box)
Scavenging system
Local Exhaust Ventilation (LEV)
Fume Cabinet
Window Fan
Dedicated Machine
Access Control
Personal Protective Equipment (PPE)
Is there a local Health and Safety policy
or procedure
Is there a documented safe system of
work
Is Personal Protective Equipment Used
(please tick box)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Goggles
Gloves
Respirator
Other Please state
No
No
No
No
No
No
No
No
No

RISK ASSESSMENT CHECKLIST FOR
CONTROL OF SUBSTANCES HAZARDOUS TO HEALTH REGULATIONS 2004 (COSHH)
Have you procedures in place for dealing Yes
with spillages (please tick box)
Assessors
Please answer the questions in the boxes provided below
Are waste disposal procedures in place Yes
(please tick box)
Have all your staff been trained and is it Yes
up to date (please tick box)
No
No
No
Health and Safety Team
Recommendations/Comments
Is environmental monitoring carried out
(please tick box)
If ‘yes’ last date undertaken
Enter exposure standard (if known)
Yes
No
Have you carried out this risk assessment Yes
No
using a Hazard Data Sheet (please tick
box)
Risk Assessed as (please tick box) High Medium
Low
Assessors General Comments:
Risk Confirmed as:
High Medium Low
Health & Safety Team General
Comments
DETAILS OF ASSESSOR, ASSESSMENT, DATES &
REVIEWS
Details of Health & Safety
Team Member
Forenames Surname Name
Job Title Signature Signature
Date of Assessment Date of Next Review Date

Equality and Human Rights Impact Assessment (EDHRIA)
Part One – Initial Assessment Screening Tool
Name of the policy or
methodology:
Control of Substances Hazardous to Health
Details of person completing the EDHRIA
Name
Jenny Gray
Job Title
Health and Safety Advisor
Directorate/Programme Board Governance Team
Telephone Number 07768 066915
1. Identify the policy or methodology aims
What are the main aims, purpose and outcomes of the policy or methodology
This policy outlines Peninsula Community Health’s processes and protocols for
the management and control of substances hazardous to health to ensure the
safety of all staff, patients and visitors.
Does it relate to our role as a service provider and/or an employer
Yes, it supports the recommendations laid out in the Care Quality Commissions
Essential Standards of Quality and Care, March 2010, Outcome 10, Safety and
Suitability of Premises.
Draft V1 CHS EDHRIA Form 1

2. Assess the likely impact on human rights and equality
Use this table to check if the policy or methodology:
could have a negative impact on human rights and/or on any of the equality groups, or
could have a positive impact on human rights, contribute to promoting equality, equal opportunities or improve relations.
It is not necessary to complete each box. Refer to the form guide point 2 for further details (LINK to website).
Human Rights
Equality & Diversity Protected Characteristics
General
Race
Gender
Disability
Sexual
Orientation
Religion or belief
Age
Gender
Reassignment
Marriage & Civil
Partnership
Pregnancy &
Maternity
Right to life e.g. decisions about life-saving treatment, deaths through
negligence in hospitals and care homes
Right not to be tortured or treated in an inhuman or degrading way
e.g. dignity in care, abuse or neglect of older people or people with
learning disabilities.
Right to respect for private and family life e.g. respecting lgb
relationships, confidentiality
Right to freedom of thought, conscience and religion e.g. respect for
cultural and religious requirements
Right to freedom of expression e.g. access to appropriate
communication aids
Right to freedom of assembly and association e.g., right to
representation, to socialise in residential care settings
Right to education e.g. access to basic knowledge of hygiene and
sanitation
Right to liberty e.g. informal detention of patients who do not have
capacity
Other types of discrimination e.g. employment, harassment, differential
health outcomes
Draft V1 CHS EDHRIA Form 2

3.
How does it impact on people’s Equality, diversity and human rights
Using the table above, explain anticipated impacts. If a full EDHRIA is recommended, you can
summarise the impacts at this point and in more detail in the full EDHRIA.
Could people be impacted negatively Could the policy or methodology result in inequality or
discrimination.
No the policy is applicable to all staff and other persons on PCH premises.
Could this policy or methodology result in positive impacts on people’s equality, diversity, human
rights Could it present opportunities to promote equality
Yes, this policy demonstrates that the use of COSHH products is undertaken safely by all staff and
other persons on PCH premises without discrimination.
4. Recommendations
Is a full EDHRIA recommended If not, give reasons
No- These guidelines have a positive impact on people’s equality, diversity and human rights and are
in line with the recommendations for patient care issued by CQC.
Details of person completing the EDHRIA
Name
Jenny Gray, Health and Safety Advisor
Signed ……………………………………………………… Date: …………………………………
Approval and sign-off
Head of function/business director
Name
Helen Newson, Director of Nursing & Professional Practice
Signed ……………………………………………………… Date: …………………………………
EDHRIA sign-off by CHS Equality &
Diversity Sub Committee
Name
Signed ……………………………………………………… Date: …………………………………
Draft V1 CHS EDHRIA Form 3

Full Equality and Human Rights Impact Assessment (EDHRIA)
This section is only completed if a full EDHRIA is recommended from the Initial Screening Tool
Part Two – Evidence Gathering and Involvement
Refer to form guide points 6 – 9 for further details (LINK TO WEBPAGE).
6. How does it impact on people’s rights Consider the evidence and research. Refer to
your responses under Item 2 to ensure that all aspects are covered.
Could people’s equality, diversity, human rights be impacted negatively Could the policy or
methodology result in inequality or discrimination If yes, what is the evidence
Evidence
Actions that could reduce negative
impacts
Could this policy or methodology result in positive impacts on people’s equality, diversity, human
rights Could it present opportunities to promote equality and diversity
Evidence
Actions that could increase positive
impacts
7. Gaps in evidence
Are there any gaps in the evidence If so, provide details.
Is this evidence required and if so, how can it be obtained
(e.g. consultation with specific groups)
Draft V1 CHS EDHRIA Form 4

8. Involvement of people who use services and staff
Have you involved or will you involve people who use services, staff and other stakeholders
Target group
Summary of involvement
People who use
services
Staff
Other stakeholders
9. Listening to what people say
Have you made any changes to policy or methodology as a result of involvement of staff and
people who use services List the major changes made or planned.
Draft V1 CHS EDHRIA Form 5

Part Three – Actions and Outcomes
See Guidance points 10 & 11 for help.
10. Monitoring and review of the EDHRIA
Give details of the monitoring arrangements. How will the impact of the policy or methodology be
monitored, who will do this and when
Review date
Draft V1 CHS EDHRIA Form 6

Marriage & Civil
Partnership
11. Action Plan and Outcome Report
Human Rights
Action Lead Time
scale
Success measure
Outcome
Race
Gender
Disability
Sexual Orientation
Religion or belief
Age
Gender Reassignment
Pregnancy & Maternity
Draft V1 CHS EDHRIA Form 7

Details of person completing the EDHRIA
Name
Signed ……………………………………………………… Date: …………………………………
Approval and sign-off
Head of function/business director
Name
Signed ……………………………………………………… Date: …………………………………
EDHRIA sign-off by CHS Equality &
Diversity Sub Committee
Name
Signed ……………………………………………………… Date: …………………………………
Draft V1 CHS EDHRIA Form 8