1. What the regulation says
The primary legal duties for this policy sit in the Health and Safety at Work etc. Act 1974, the Management of Health and Safety at Work Regulations 1999 and the Control of Substances Hazardous to Health Regulations 2002. For CQC-registered providers, the same arrangements are also tested through Regulation 12 (safe care and treatment) and Regulation 15 (premises and equipment), quoted verbatim below.
Care and treatment must be provided in a safe way for service users. (Reg 12(1) (the headline duty))
assessing the risks to the health and safety of service users of receiving the care or treatment, (Reg 12(2)(a) (risk assessment))
doing all that is reasonably practicable to mitigate any such risks, (Reg 12(2)(b) (risk mitigation))
ensuring that the premises used by the service provider are safe to use for their intended purpose and are used in a safe way, (Reg 12(2)(d) (premises safety))
ensuring that the equipment used by the service provider for providing care or treatment to a service user is safe for such use and is used in a safe way, (Reg 12(2)(e) (equipment safety))
Regulation 15 adds the premises and equipment duty this policy operationalises:
All premises and equipment used by the service provider must be ... clean, secure, suitable for the purpose for which they are being used, properly used, properly maintained, and appropriately located for the purpose for which they are being used. (Reg 15(1): the six criteria)
The full text is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/12 and https://www.legislation.gov.uk/uksi/2014/2936/regulation/15. The Health and Safety at Work etc. Act 1974 is at https://www.legislation.gov.uk/ukpga/1974/37 and the COSHH Regulations 2002 are at https://www.legislation.gov.uk/uksi/2002/2677. Where this policy and the regulation diverge, the regulation wins.
2. Plain-English summary
Care and treatment must be provided in a safe way. Regulation 12 lists the areas a provider must address, including risk assessment, risk mitigation, staff competence, safe premises, safe equipment, sufficient equipment and medicines, medicines safety, infection prevention and shared-care planning. Regulation 15 requires premises and equipment to be clean, secure, suitable for purpose, properly used, properly maintained and appropriately located. Alongside these, health and safety law and the COSHH Regulations require the service to assess and control workplace risks and hazardous substances, train staff, and report certain accidents and dangerous occurrences.
3. Purpose
The purpose of this policy is to make sure that [Service Name] manages health, safety and hazardous substances in a safe, lawful and proportionate way.
Health and safety is not separate from care quality. Unsafe premises, unsafe equipment, poor chemical control, poor maintenance, poor training or poor incident response can place people using the service, staff and visitors at risk.
This policy supports safe care and treatment, good governance, infection prevention and control, staff safety and compliance with health and safety law.
4. Policy warning
The service must not carry out work that exposes people to avoidable risk where the risk has not been assessed and controlled.
Hazardous substances must not be used, stored, mixed, decanted or disposed of unless staff have been trained and the COSHH assessment and safety data information are available.
If a hazard presents immediate risk, staff must stop the activity where safe to do so, make the area safe, escalate to the person in charge and record the concern.
5. Scope
This policy applies to:
- health and safety risk assessments
- premises safety
- equipment safety
- slips, trips and falls hazards
- manual handling risks
- work at height
- electrical safety
- fire safety links
- cleaning chemicals
- disinfectants
- clinical products
- medicines and hazardous medicines where relevant
- bodily fluids and biological substances
- sharps and contaminated materials
- oxygen or medical gases where relevant
- contractors and maintenance work
- staff welfare facilities
- incident reporting
- RIDDOR reporting where applicable
6. Principles
The service will:
- identify hazards before harm occurs
- assess risks to people using the service, staff, visitors and others
- remove risks where possible
- reduce risks where they cannot be removed
- provide safe premises and equipment
- train staff in safe systems of work
- consult staff about risks
- record and investigate accidents and near misses
- act on health and safety findings without delay
- keep evidence of checks, maintenance and actions
7. Responsibilities
The provider is responsible for ensuring that suitable health and safety arrangements, resources and competent advice are in place.
The Registered Manager is responsible for day-to-day implementation, risk assessment, escalation, audit and action tracking.
Managers and senior staff are responsible for ensuring that safe systems are followed.
All staff are responsible for following procedures, using equipment safely, reporting hazards and not taking unsafe shortcuts.
Contractors are responsible for working safely and following the service's site rules.
8. Health and safety risk assessment
The service must maintain health and safety risk assessments proportionate to the service type.
Risk assessments must consider:
- who may be harmed
- what could cause harm
- existing controls
- further controls required
- person responsible
- due date
- review date
- whether the risk needs escalation to the risk register
Risk assessments must be reviewed after incidents, near misses, service changes, premises changes, new equipment, new substances, new procedures or changes in law or guidance.
9. Premises and equipment
The service must ensure that premises and equipment are clean, suitable, maintained, secure and used correctly.
This includes:
- planned maintenance
- daily or routine environmental checks where needed
- equipment servicing
- electrical safety arrangements
- safe storage
- safe access and exit
- suitable lighting
- safe flooring
- temperature and ventilation where relevant
- safe waiting and treatment areas
- suitable welfare facilities
- contractor management
Faulty or unsafe equipment must be removed from use, labelled clearly and escalated.
10. COSHH: hazardous substances
The service must identify substances hazardous to health and complete COSHH assessments where required.
This may include:
- cleaning products
- disinfectants
- sterilising agents
- clinical chemicals
- laboratory or diagnostic substances
- medicines or cytotoxic/cytostatic products where relevant
- bodily fluids
- contaminated waste
- aerosols, fumes, vapours or dust
- latex or other sensitising products
- mercury or amalgam where relevant
- oxygen or medical gases where relevant
The service must not assume that a household or commonly used product is safe in a care or clinical environment.
11. COSHH assessment
A COSHH assessment must consider:
- substance name
- task or process
- how exposure may occur
- who may be exposed
- possible harm
- route of exposure
- existing controls
- safer alternatives
- PPE required
- storage requirements
- spill response
- first aid response
- disposal route
- staff training required
- review date
Safety data sheets must be available where relevant, but a safety data sheet alone is not a COSHH assessment.
12. Control measures
The service must prevent exposure where possible.
Where exposure cannot be prevented, the service must reduce it using suitable controls, such as:
- substituting a safer product
- using safer methods
- limiting quantities
- ventilation
- closed containers
- safe storage
- safe dilution systems
- spill kits
- personal protective equipment
- training
- signage
- restricted access
- safe disposal routes
PPE must not be the only control where safer controls are reasonably available.
13. Storage and labelling
Hazardous substances must be stored safely and securely.
The service must ensure:
- original labels are retained where possible
- decanted substances are labelled
- incompatible substances are not stored together
- substances are kept away from unauthorised people
- flammable substances are controlled
- expiry dates are monitored where relevant
- cleaning cupboards and clinical storage areas are secure
- staff know what to do in a spill or exposure
Unlabelled substances must not be used.
14. Staff training
Staff must receive training appropriate to their role.
Training must cover:
- health and safety responsibilities
- hazard reporting
- safe use of equipment
- COSHH awareness
- use of PPE
- safe storage
- spill response
- incident reporting
- RIDDOR awareness where relevant
- manual handling where relevant
- infection prevention and control links
- emergency procedures
Staff must not use hazardous substances or equipment unless trained and authorised.
15. Contractors
Contractors must be managed safely.
The service must consider:
- contractor competence
- insurance and certification where relevant
- work permits where needed
- risk assessments and method statements
- infection control impact
- access controls
- safeguarding risks
- service disruption
- waste or hazardous materials generated
- completion records
The provider remains responsible for ensuring that contracted work does not place people at risk.
16. Accidents, near misses and unsafe conditions
Accidents, near misses and unsafe conditions must be reported immediately.
The Registered Manager must consider:
- immediate safety action
- first aid
- incident record
- investigation
- RIDDOR reporting
- safeguarding referral
- CQC notification
- contractor action
- risk assessment update
- risk register entry
- staff briefing
- training or competency action
Repeated health and safety concerns must be reviewed through governance.
17. RIDDOR
The Registered Manager must consider whether an accident, dangerous occurrence or work-related illness is reportable under RIDDOR.
The decision to report or not report must be recorded.
RIDDOR reporting does not replace CQC notification, safeguarding referral, incident review, duty of candour or internal learning processes where these also apply.
18. Monitoring and audit
The Registered Manager must audit health and safety and COSHH arrangements at least quarterly.
The audit must check:
- risk assessments
- COSHH assessments
- safety data sheets
- staff training
- storage and labelling
- equipment checks
- maintenance records
- incident records
- RIDDOR decisions
- action completion
- contractor records
- repeated hazards
- risk register links
Findings must be added to the action plan or risk register where required.
19. Related records
The service must keep:
- health and safety risk assessments
- COSHH assessments
- safety data sheets
- equipment maintenance records
- premises checks
- contractor records
- accident and near-miss records
- RIDDOR decisions
- staff training records
- action plans
- audit records
20. Related policies
This policy should be read with:
- Safe Care and Treatment Policy
- Premises and Equipment Policy
- Infection Prevention and Control Policy
- Clinical Waste and Sharps Safety Policy
- Water Safety and Legionella Policy
- Fire Safety Policy
- RIDDOR Policy
- Incident Reporting, Investigation and Learning Policy
- Risk Management and Risk Register Policy
- Training, Competency and Mandatory Training Policy
- Business Continuity and Emergency Preparedness Policy
21. Review
This policy will be reviewed annually, or sooner following an incident, RIDDOR report, CQC finding, health and safety audit failure, new hazardous substance, premises change, equipment change or change in legal or regulatory guidance.
22. Sources and further reading
This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.
- Health and Safety at Work etc. Act 1974 (https://www.legislation.gov.uk/ukpga/1974/37)
- Management of Health and Safety at Work Regulations 1999
- Control of Substances Hazardous to Health Regulations 2002 (COSHH) (https://www.legislation.gov.uk/uksi/2002/2677)
- HSE health and safety guidance
- HSE COSHH guidance
- Safety data sheets
- HSE RIDDOR guidance and the HSE incident reporting portal
- CQC Regulation 12: Safe care and treatment
- CQC Regulation 15: Premises and equipment
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/12)
23. When to seek further advice
Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.
24. Document control
| Version | Date | Author | Changes |
|---|---|---|---|
| v1 | 2026-06-10 | Verivius (sample) | Initial sample template, conformed to the Verivius policy standard. |
This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.