Standards › Standard 2E › Policies
Policy · WRK-POL-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 2E.3
At a glance
- The organisation protects the health and safety of its staff while they work.
- Required vaccinations are checked at appointment and kept up to date.
- Exposures to blood or body fluids are reported and followed up the same day.
- Personal protective equipment is provided, fitted and replaced.
- Stop and get help straight away if: a staff member has been exposed to a blood-borne risk and no follow-up has started.
1. Purpose
To protect the health, safety and wellbeing of every workforce member in the course of their duties [EC].
2. Scope
| Applies to | All workforce members, locums, volunteers and students on placement |
| Locations | All premises and outreach work of the facility |
| When | Always, including on outreach and in the community |
| Does not apply to | Personal health care outside work |
3. Definitions
| Term | Meaning |
|---|---|
| Exposure | Contact with blood, body fluid or a sharp object that may carry an infection |
| Occupational health | The health service that looks after staff health at work |
| PPE | Personal protective equipment such as gloves, gowns, masks and eye protection |
4. Background
Health workers face physical, infectious and psychological risks. Criterion 2E.3 asks for protection in practice, with records, not only a written statement.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Chief executive | Accountable for staff health and safety | Executive |
| Occupational health lead | Runs vaccination, exposure follow-up and fitness-for-work checks | Occupational health |
| Line managers | Make sure PPE is available and used | Management |
| All staff | Report exposures and hazards at once | Own role |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| PPE stock | As set in the PPE list for each area | Checked weekly |
| Vaccination record for each staff member | Current | Reviewed each year |
7. Safety
- No staff member works in a clinical area without the vaccinations required for that area, unless exempted by occupational health in writing.
8. Before you start
- Confirm the vaccination schedule and the PPE list for each service are current.
9. Procedure
Step 1. Check status at appointment.
- Check vaccination status before the first shift.
- Record any missing vaccination and the plan to complete it.
Key point: No one starts clinical work without a recorded status.
Step 2. Respond to an exposure.
- Follow WRK-SOP-002 at once: first aid, reporting and post-exposure care.
- Record the exposure on the incident system the same day.
Key point: The first hour matters.
Step 3. Support the staff member.
- Occupational health reviews the exposure and arranges follow-up tests.
- Staff are told the result and what happens next.
Key point: A staff member is never left without follow-up.
Step 4. Review the cause.
- Review each exposure at the monthly safety meeting.
- Change practice or equipment where the cause is found.
Key point: Each exposure should lead to a change or a recorded reason for no change.
10. Decision points
- If a staff member is not fit for a task, occupational health decides on a temporary change of duties, with a review date.
11. Special situations
| Situation | Action |
|---|---|
| Outbreak or epidemic | Occupational health issues updated PPE and vaccination guidance to all staff within 24 hours. |
12. Escalation
- Any exposure with a missed follow-up, or any staff member without a required vaccination, is reported to the chief executive.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Staff with required vaccinations recorded | 100% | Yearly | Occupational health lead | Escalate to chief executive |
| Exposures followed up within 24 hours | 100% | Monthly | Occupational health lead | Escalate to chief executive |
| PPE checks completed | At least 70% | Monthly | Line managers | Restock and review |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| WRK-FRM-002 or the incident system: exposure records | Occupational health file | Employment plus 40 years |
| Vaccination records | Occupational health file | Employment plus 40 years |
15. Training
- All staff are trained in PPE use and exposure reporting at induction, and refreshed every year.
16. Related documents
| ID | Title | Use |
|---|---|---|
| WRK-SOP-002 | Occupational exposure and needlestick response | Steps for an exposure |
| WRK-SOP-003 | Staff vaccination and immunisation | Vaccination schedule |
| WRK-SOP-004 | Support after distressing events | Wellbeing after incidents |
17. Evidence
| Reference | Note |
|---|---|
| E-001 | WHO Guidelines on Hand Hygiene in Health Care (2009). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
- World Health Organization (2009). WHO Guidelines on Hand Hygiene in Health Care. Geneva: WHO. Open source (E-001)