Waste Management Policy

Post holder responsible for Policy Martin Conabeer, Facilities Operational Manager

Author of Policy Martin Conabeer, Facilities Operational Manager

Division responsible for Procedural Operations Support Division/Post & Waste Document Department

Contact details x6069

Date of original document September 2004

Impact Assessment performed Yes/ No Health and Safety Group: 22 September Ratifying body and date ratified 2016. Version 7 (addition of links to North Devon policy): H&SG Chair approval: 9th June 2017. Review date and (frequency of further April 2021 (every 5 years) reviews) Expiry date September 2021

Date document becomes live 12 June 2017

Please specify standard/criterion numbers and tick  other boxes as appropriate

Monitoring Information Strategic Directions – Key Milestones Patient Experience Maintain Operational Service Delivery

Assurance Framework Integrated Community Pathways Monitor/Finance/Performance Develop Acute Services Infection Control  CQC Fundamental Standards, Regulations: 15  Other (please specify): HTM 07-01 Note: This policy has been assessed for any equality, diversity or human rights implications

Controlled document This document has been created following the Royal Devon and Exeter NHS Foundation Trust Development, Ratification & Management of Procedural Documents Policy. It should not be altered in any way without the express permission of the author or their representative.

Waste Management Policy Ratified by: Health and Safety Group Chair approval 9th June 2017 (addition of links to North Devon policy). Review date: April 2021 Page 1 of 35

Full History: Status: Final

Version Date Author (Title not name) Reason September 1.0 Post and Waste Manager New policy 2004 Post and Waste Manager 2.0 January 2005 Review & minor amendments

Post and Waste Manager 3.0 March 2009 Updated in line with legislation

Post and Waste Manager 4.0 March 2012 Updated in line with legislation

Post and Waste Manager 5.0 April 2014 Updated in line with legislation

Facilities Operational 6.0 July 2016 Review & Minor amendments Manager Facilities Operational Addition of links to North Devon 7.0 February 2017 Manager Healthcare Trust waste policy

Associated Trust Cleaning Policy Policies/ procedural Confidentiality Policy (this is the Information Governance Policy) documents: Control of Substances Hazardous to Health (COSHH) Policy Decontamination Policy & Procedures Disposal of Waste IT Equipment Policy Incident Reporting, Analysing, Investigating and Learning Policy Infection Prevention & Control Policy Inoculation Injury Policy Radiation Safety Policy Risk Assessment Policy and Procedure

Associated Community Services procedural documents: Waste Management Policy (North Devon Healthcare Trust) Waste Management Manual (North Devon Healthcare Trust)

Key Words Waste In consultation with and date: Senior Matrons- by e-mail: 25 August 2016 Matrons- by e-mail: 25 August 2016 Waste Management Group- by e-mail: 25 August 2016 Infection Prevention and Control Team - by e-mail: 25 August 2016 Divisional Directors - by e-mail: 25 August 2016 Lead Nurses - by e-mail: 25 August 2016 Head of Governance - by e-mail: 25 August 2016 Safety & Risk Manager - by e-mail: 25 August 2016 Equality & Diversity Manager - by e-mail: 25 August 2016 Governance Leads - by e-mail: 25 August 2016 Policy Expert Panel (PEP): 15 September 2016 Health and Safety Group: 22 September 2016 Health and Safety Group Chair: 09 June 2017 (approval for minor amendments)

Contact for Review: Operational Support Manager W aste Management Policy Ratified by: Health and Safety Group Chair approval 9th June 2017 (addition of links to North Devon policy). Re view date: April 2021 Page 2 of 35

Executive Lead Signature:

Director of Nursing and Patient Care

Waste Management Policy Ratified by: Health and Safety Group Chair approval 9th June 2017 (addition of links to North Devon policy). Review date: April 2021 Page 3 of 35

CONTENTS

1. INTRODUCTION ...... 5 2. PURPOSE ...... 5 3. DEFINITIONS ...... 6 4. DUTIES AND RESPONSIBILITIES OF STAFF ...... 7 5. AUDITS ...... 11 6. TRAINING ...... 12 7. ARCHIVING ARRANGEMENTS ...... 12 8. PROCESS FOR MONITORING COMPLIANCE WITH AND EFFECTIVENESS OF THE POLICY ...... 12 9. REFERENCES ...... 13 APPENDIX 1: WASTE STREAMS ...... 15 APPENDIX 2: PROCEDURES TO COMPLY WITH WASTE LEGISLATION ...... 17 APPENDIX 3: WASTE HIERARCHY ...... 22 APPENDIX 4: PROCEDURES FOR REMOVING/HANDLING OF WASTE...... 23 APPENDIX 5: CHARTS OF COMMON TYPES OF HEALTHCARE WASTE AND RECEPTACLES ...... 25 APPENDIX 6: STANDARD COLOUR CODING SYSTEM ADOPTED BY THE TRUST ...... 30 APPENDIX 7: SEGREGATION FLOW CHART FOR HEALTHCARE WASTE ...... 31 APPENDIX 8: STORAGE OF WASTE ON SITE ...... 32 APPENDIX 9: COMMUNICATION PLAN ...... 33 APPENDIX 10: EQUALITY IMPACT ASSESSMENT TOOL ...... 34

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1. INTRODUCTION

1.1 The Royal Devon and Exeter NHS Foundation Trust (hereafter referred to as the Trust) in the provision of healthcare activities and associated support functions, produces a wide and diverse range of waste. These waste streams are set out in Appendix 1

1.2 It is the legal responsibility of all employees who dispose of waste within the Trust to ensure that risks relating to that waste are minimised for staff, patients, visitors, others and the environment.

1.3 A failure to comply with this policy could result in disciplinary action being taken against an individual or individuals(s). It should also be noted that any breach of this policy could also lead to prosecution of individuals and/or the Trust which could result in substantial fines, possible imprisonment, adverse publicity and loss of reputation. For the procedure for the disposal of healthcare waste, see Appendix 2

2. PURPOSE

2.1 The Trust is committed to disposing of its waste streams in compliance with relevant legislation and good practice guidance documents. It also aims to minimise and prevent significant risks to the health and safety of its staff, patients, public, waste contractors and the environment when disposing of that waste.

2.2 This policy applies to all Trust employees and non-Trust staff.

2.3 This policy adopts the unified colour coding policy suggested within the following Guidance on the safe management of healthcare waste (DoH, 2013) in relation to clinical waste derived from medical, nursing, dental, pharmaceutical and other clinical services, and applies the principles of assessment, segregation, packaging, and the required detailed documentation including the use of European waste codes Environmental Protection Agency (2002) European Waste Catalogue and Hazardous Waste List (EWC). Environmental Protection Agency. Available at: http://www.nwcpo.ie/forms/EWC_code_book.pdf

2.4 Waste Regulations require that the Trust and individuals working for it adhere to the Waste Hierarchy as shown in Appendix 3, where possible. The Trust is committed to reducing its environmental impact and ensuring services remain financially sustainable. When considering projects and services it is essential to review the waste hierarchy and identify how it can be implemented.

2.5 Versions of the North Devon Healthcare Trust (NDHT) Waste Management Policy and NDHT Waste Management Manual can be accessed on the Trust intranet, HUB, via the following links:  Waste Management Policy (North Devon Healthcare Trust [NDHT])  Waste Management Manual (North Devon Healthcare Trust [NDHT])

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3. DEFINITIONS

3.1 Clinical waste is defined in the Controlled Waste Regulations 2012 as:

(a) any waste which consists wholly or partly of human or animal tissue, blood or other body fluids, excretions, drugs or other pharmaceutical products, swabs or dressings, or syringes, needles or other sharp instruments, being waste which unless rendered safe may prove hazardous to any person coming into contact with it; (b) any other waste arising from medical, nursing, dental, veterinary, pharmaceutical or similar practice, investigation, treatment, care, teaching or research, or the collection of blood for transfusion, being waste which may cause infection to any person coming into contact with it

3.2 Clinical waste can be divided into three groups of materials:

(a) Any healthcare waste which poses a risk of infection. (Technical Guidance H9) (Environment Agency, 2013b)

(b) Healthcare wastes which pose a chemical risk (Technical Guidance H1 to H8, H10 to H15) (Environment Agency, 2013b)

3.3 Clinical Waste (Yellow Stream) Poses a known or suspected risk of infection

 Anatomical waste  Chemically contaminated waste  Medically contaminated infectious waste  Category A Pathogens (Health and Safety Executive [2013])

3.4 Infectious / Potentially Infectious Waste (Orange Stream) This is waste known or suspected to contain pathogens classified in Category B as specified in the Carriage of Dangerous Goods Regulations (2009)

 Category B Pathogens  Blood  Semen  Vaginal secretion  Cerebrospinal fluid  Synovial  Pleural  Peritoneal  Pericardial  Amniotic

3.5 Offensive waste (Tiger Stripe) This is non-infectious waste, which is unpleasant and may cause offence to those coming into contact with it. It includes:

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 outer dressings and protective clothing, e.g. masks, gowns and gloves that are not contaminated with body fluids  hygiene waste and sanitary protection, e.g. nappies and incontinence pads auto-claved laboratory waste.

3.6 Pharmaceutical Waste (Blue) There are two Classes of Medicine:

 Pharmaceutically active, (not Cytotoxic or Cytostatic) and  Not pharmaceutically active and possessing no hazardous properties (e.g. saline solution and glucose).

3.7 Cytotoxic and Cytostatic medicines are classified as being hazardous and they display the following hazardous properties:

 H6 Toxic  H7 Carcinogenic  H10 Toxic for reproduction  H11 Mutagenic

Additionally, if medicines are deemed not to be Cytotoxic and Cytostatic then they may still be classed as hazardous based on the following properties:

 H3B Flammable  H4 Irritant  H5 Harmful H14  Eco toxic

3.8 Radioactive waste contains radioactivity above levels defined in legislation. Radioactive waste generated in this hospital is low level waste and is usually also clinical waste. It must be held according to the permit granted by the Environment Agency. For advice on radioactive waste, please contact the radioactive waste adviser via Medical Physics. There is advice on handling radioactive waste from in-patients on the Nuclear Medicine page on the Hub.

 Radiation Safety Policy (Ionising Radiation)

4. DUTIES AND RESPONSIBILITIES OF STAFF

4.1 Chief Executive

4.1.1 The Chief Executive has overall responsibility for ensuring safe and effective waste management systems are in place and is responsible for ensuring that employees are aware of and carry out the responsibilities identified in this policy.

4.1.2 The Chief Executive has delegated this responsibility to the Head of Facilities Management of the Operations Support Division and the Deputy Director of Capital and Estates

4.2 Head of Facilities Management Operations and Support Unit & Deputy Director of Capital and Estates Will ensure compliance with this Policy and delegate day to day responsibilities for maintaining that compliance to:

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4.3 Service Manager Facilities (who on behalf of the Head of Facilities Management, Operations Support Division) and the Head of Estates (who on behalf of the Deputy Director of Capital and Estates) - Operational management responsibilities are currently divided between Operations Support unit and Estates. A breakdown of the day to day area of responsibilities can be seen on the waste streams table (Appendix 1).

4.3.1 Will be responsible for the day to day management of this policy and be jointly responsible for ensuring compliance of the policy through the Operations Support Management /Specialties Governance Group (OSM/SGG), thus ensuring that Managers with specific responsibilities comply with this policy.

4.3.2 Maintaining a current knowledge base of relevant legislation, codes of practice and issued guidance.

4.3.3 Ensuring the correct registration and licensing of the site are in place and ensuring that such registrations are known to all department heads who may dispose of waste.

4.3.4 Ensuring a training programme is in place to allow staff to have the knowledge and information required to comply with the requirements of this policy.

4.3.5 Ensuring that any amendments/alterations/additions to this policy are accurately communicated and implemented along with supporting evidence on why the changes were instigated, thus providing a pedigree of information, in case of investigation by the Environment Agency or any other investigatory body.

4.3.6 Ensuring that suitable internal and external audits (where applicable) are in place to test and verify compliance with this policy.

4.3.7 Facilities Service Manager, will submit a report from the annual work plan to the Health & Safety Group outlining the performance of the Trust against this policy, the report will detail the Trusts waste recycling position, current rates/costs of waste disposal and the environmental considerations relating thereto as well as any remedial actions taken to ensure that this policy remains effective.

4.3.8 Ensuring that suitable waste disposal and recycling contracts are in place via Procurement and that all such contracts are controlled, monitored and audited.

4.3.9 Representing the Trust in liaison with Waste Regulatory Authorities, Local Authorities and other bodies having responsibilities under environmental and waste regulations.

4.3.10 Ensure that storage and disposal areas are appropriate and maintained in a satisfactory condition.

4.3.11 Monitoring and recording the levels and types of waste produced and making necessary reports to bring trends as well as variances to the attention of relevant managers.

4.3.12 Identifying opportunities to improve adherence to the Waste Hierarchy (see Appendix 3) and implementing them where appropriate.

4.3.13 Implementing improvements in waste management, in line with guidance from the NHS Sustainable Development Unit.

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4.4 Trust Waste Manager (Operations and Support Unit)

4.4.1 The Trust Waste Manager is responsible for maintaining a current knowledge of relevant legislation, Codes of Practice and issued guidance and advising how it may affect the Trust, as well as monitoring all waste arrangements: also to identify opportunities to improve Trust adherence to the waste hierarchy.

4.4.2 Working with the Trust Estates Manager to ensure that safe and suitable management systems are in place for all the Trust’s waste streams.

4.4.3 Being responsible, together with relevant heads of departments as required, and/or other safety advisors, to investigate any major waste related incident and to act on the findings of that investigation in line with the incident, investigation, analysing and learning policy and procedure.

4.4.4 Carrying out an annual internal overview audit, in conjunction with the department head or representative and/or an Infection Control Team member, of all premises/departments whose waste is disposed of by the Trust to verify compliance with this policy and providing a report to the Head of Facilities.

4.4.5 Conducting duty of care audits/visits to all contractors involved in the removal of clinical waste, and an annual check on controlled waste disposers to provide cradle-to-grave audits of the waste streams generated by the Trust, involving as appropriate representatives of the waste producer areas.

4.4.6 Ensuring that appropriate waste transfer and consignment notes throughout the Trust are completed in a correct manner and a record of such notes are, stored for at least 3 years.

4.4.7 Monitoring and recording the levels and types of waste produced and making necessary reports to bring trends as well as variances to the attention of relevant managers.

4.4.8 Providing advice, guidance and support to managers who have day to day duties on the identification, collection, internal movement, storage of waste and its consignment.

4.4.9 The Trust Waste Manager will generate quarterly Trust Datix reports identifying breaches to the Waste Management Group,

4.4.10 Undertake annual pre-acceptance audits to ensure that the Trust meets legal requirements for compliance against waste legislation.

4.5 Energy and Sustainability Manager Will be responsible for: providing assistance and guidance to improve environmental performance, setting waste environmental improvement targets and assist in implementing schemes to achieve them. Also to support adherence to the waste hierarchy, ensuring Estates Department waste is managed appropriately, formulating and controlling the Estates waste disposal budget, and managing contractors employed under the Estates waste budget.

4.6 Dangerous Goods Safety Advisor Has the responsibility to advise on storage, package and movement on and off site, and to final disposal.

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4.7 The Non Ionising Radiation and Nuclear Medicine Clinical Scientist Has the responsibility for radioactive waste.

4.8 Head of IT Infrastructure Delivery Has the responsibility for the Disposal of Waste IT Equipment Policy.

4.9 Information Governance Manager Has the responsibility for the Confidentiality Policy (Information Governance Policy).

4.10 Head of Department / Ward Manager 4.10.1 Have the responsibility for implementing and monitoring this policy within their specific area of responsibility.

4.10.2 Ensure that waste management procedures and safe working practices resulting from them are produced, documented and implemented for their area.

4.10.3 Ensure that an adequate number of waste containers and receptacles for waste are provided and are readily accessible.

4.10.4 Is responsible for risk assessments being undertaken within their department/ward concerning waste disposal. The Waste Manager can provide guidance on risk assessments.

4.10.5 Ensure that all staff are properly trained and are competent for their duties.

4.10.6 Ensure that arrangements with regard to waste are included in the induction training of new employees.

4.10.7 Ensure all staff under their control are aware of the correct procedures for waste management, and receive appropriate on-going waste training.

4.10.8 Ensure that disposal areas are kept clean and tidy and well maintained.

4.10.9 Ensure that any personal protective equipment deemed by risk assessment to be necessary is provided and used appropriately.

4.10.10 Ensure that appropriate waste signage and instructions regarding waste streams are displayed.

4.11 Domestic Services Manager Has the responsibility for the Cleaning Policy

4.12 The Infection Control Team

4.12.1 Assist the Divisions and departments to ensure that the staff are aware of the Trust’s control of infection/BBV (Blood borne viruses, e.g. Infection Prevention & Control Policy - also the Inoculation Injury Policy detailing how to deal with a sharps injury and how the safe and correct segregation of health care related waste will reduce the risk to other groups of staff within the waste chain.

4.12.2 Provide advice on the day-to-day management of infection control operational issues with other named officers within this policy to ensure a coordinated approach to the safe storage, transport and management of waste. Waste Management Policy Ratified by: Health and Safety Group: 22 September 2016 Review date: April 2021 Page 10 of 35

4.12.3 Along with the Operations Support Division Management and other staff with a direct responsibility for waste management monitor compliance with the policy through a process of audit and exception reporting.

4.12.4 Assist with or instigate investigations into incidents and/or injuries related to waste or sharps as necessary. Sharps related injuries caused within waste should be reported via Datix and monitored by the Health and Safety Group.

4.13 The Procurement Department Has the responsibility to develop standard contract clauses and tender criteria which improve adherence to the waste hierarchy with the aim of aiding the Trust in reducing waste disposal costs and improving its sustainability (this will be supported by the sustainable procurement policy which they are preparing).

4.14 The Health and Safety Group Has the responsibility for endorsing this policy.

4.15 The Waste Management Group This Group will monitor and oversee all aspects of waste management within the organisation (IMT and MEM are responsible for looking after their own elements of waste) and ensure compliance with relevant legislation and standards providing assurance to the Health and Safety Group.

4.16 Operations Support Division Audit Team and the Ward Housekeepers Carry out waste audits in all areas to ensure compliance with the Guidance on the safe management of healthcare waste (DoH, 2013) and Hazardous Waste: Interpretation of the definition and classification of hazardous waste (Environment Agency, 2013b)

4.17 All Staff 4.17.1 Although the Trust Management has primary responsibility for the safe management and disposal of waste, each employee has an individual and legal responsibility to:

1. Attend Waste training. 2. Comply with the Trust Management in the implementation of this policy. 3. Ensure that their waste is segregated and properly secured.

4.17.2 Ensure their compliance where a requirement for the wearing /use of Personal Protective Equipment (PPE) has been established for the handling of waste (see Appendix 4.)

4.17.3 Report any problems that arise regarding waste disposal to their supervisor/manager and complete a Datix incident form as per the Trust Incident Reporting, Analysing, Investigating and Learning Policy and Procedure.

5. AUDITS 5.1 Waste auditing is a legal requirement and is an essential tool in assessing that waste contractors are registered and approved, assessing composition of waste streams for the purpose of compliance: and ensuring that duty of care visits are undertaken.

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5.2 Waste audits will be carried out to monitor the effectiveness of waste segregation and minimisation to demonstrate compliance.

5.3 Audit reports are issued via the CCW (Cleaning Catering & Waste) software. Feedback will be given to wards/departments on outcomes of audits.

5.4 Respective managers or Ward Housekeepers on non-compliant wards/departments will be responsible for any follow-up action required to rectify non-compliance.

6. TRAINING Training will be given at local induction, refresher training by use of E-learning, paper version and face to face sessions are available to meet the requirements of all staff levels. This training has been added to the list of essential training reported monthly and compliance measured, minimum compliance figure Trust wide is 75% Training updates are required two yearly, for all staff.

7. ARCHIVING ARRANGEMENTS The original of this policy will remain with the author, the Post and Waste Manager, Operations Support Unit. An electronic copy will be maintained on the Trust intranet (A-Z) – P – Policies (Trust-wide) – W – Waste Management. Archived electronic copies will be stored on the Trust's “archived policies” shared drive, and will be held indefinitely. A paper copy (where one exists) will be retained for 10 years.

8. PROCESS FOR MONITORING COMPLIANCE WITH AND EFFECTIVENESS OF THE POLICY 8.1 In order to monitor compliance with this policy, the auditable standards will be monitored as follows:

No Minimum Requirements Evidenced by

1. Operations Support Division Audit Team Weekly Audit Log CCW report 2. Departmental Waste Reports Quarterly Datix Breach Figures Report 3. Service Manager Annual Audit Annual Report

Waste Management Annual Pre-acceptance Annual Report 4. Audits Journey & waste facility Duty of Care Inspections 5. observation documentation 6. External Auditor (HTM07-01) Annual Report 7. Monitor for trends in waste related incidents Datix reports quarterly Monitor Trust compliance with waste essential 8. Monthly ESR Reports training

8.2 Frequency In each financial year, the Operations Support Division Service Manager will present the annual waste audit to ensure that this policy has been adhered to and a formal report will be written and presented at Operations Support Management / Specialties Governance Group (OSM/SGG). 8.3 Undertaken by Waste Management Policy Ratified by: Health and Safety Group: 22 September 2016 Review date: April 2021 Page 12 of 35

Operations Support Division Service Manager

8.4 Dissemination of Results The Waste Management Group is held quarterly. Any resulting actions will be disseminated to OSM/SGG (if operational) or Health & Safety Group if related to legislation compliance.

8.5 Recommendations/ Action Plans Implementation of the recommendations and action plan will be monitored by the Waste Management Group, which meets quarterly

8.6 Any barriers to implementation will be risk-assessed and added to the risk register.

8.7 Any changes in practice needed will be highlighted to Trust staff via the Governance Managers cascade system.

9. REFERENCES

Environmental Protection Act 1990 (c.43). (Duty of Care – Para 34(1). London: Stationary Office. Available at: http://www.legislation.gov.uk/ukpga/1990/43/section/34

The Environmental Protection (Duty of Care) Regulations 1991.London Stationary Office. Available at: http:/www.opsi.gov.uk/SI/si1991/UKsi_19912839_en_1.htm Regulations 1991

The Controlled Waste (Registration of Carriers & Seizure of Vehicles) Regulations 2012. (SI 2012/811). London: Stationary Office. Available at: http://www.legislation.gov.uk/uksi/2012/811/contents/made

Environment Agency (2013a). Hazardous Waste – Interpretation of the definitions and classification of hazardous waste. Available at: https://brand.environment- agency.gov.uk/mb/CVSM33

Environment Agency (2013b) Hazardous Waste: Interpretation of the definition and classification of hazardous waste. Environment Agency. (Technical Guidance H1 to H8, H10 to H15) Available at: http://a0768b4a8a31e106d8b0- 50dc802554eb38a24458b98ff72d550b.r19.cf3.rackcdn.com/LIT_5426_acd22f.pdf

Environment Agency (2013c). Duty of Care regulations. Available at: http://www.environment-agency.gov.uk/business/topics/waste/40047.aspx Environment Agency (2013d) European Waste Catalogue (EWC) Available at: http://www.environment-agency.gov.uk/business/topics/waste/31873.aspx

Environmental Protection Agency (2002) European Waste Catalogue and Hazardous Waste List (EWC). Environmental Protection Agency. Available at: http://www.nwcpo.ie/forms/EWC_code_book.pdf

The Hazardous Waste (England and Wales) Regulations 2005 as amended 2009. (SI 2009/507). London: Stationary Office. Available at: http://www.legislation.gov.uk/uksi/2009/507/contents/made

The Waste Electrical and Electronic Equipment (Amendment) Regulations 2010. (SI 2010/1155) London: Stationary Office. Available at: Waste Management Policy Ratified by: Health and Safety Group: 22 September 2016 Review date: April 2021 Page 13 of 35

http://www.legislation.gov.uk/uksi/2010/1155/note/made

The Waste (England and Wales) Regulations 2011. (SI 2011/988). London: Stationary Office. Available at: http://www.legislation.gov.uk/uksi/2011/988/made

The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2004 (SI 2004/568). London: Stationary Office. Available at: http://www.legislation.gov.uk/uksi/2004/568/contents/made

The Control of Substances Hazardous to Health Regulations 2002 (SI 2002/2677). London: Stationary Office. Available at: http://www.legislation.gov.uk/uksi/2002/2677/contents/made

Health and Safety at Work Act 1974. (c.34). London: Stationary Office. Available at: http://www.legislation.gov.uk/ukpga/1974/37

Radioactive Substances Act 1993. (c.12). London: Stationary Office. Available at: http://www.legislation.gov.uk/ukpga/1993/12/contents

The List of Wastes (England) Regulations 2005. (SI 2005/895). London: Stationary Office. Available at: http://www.legislation.gov.uk/uksi/2005/895/contents/made

Department of Health (2013): Guidance on the safe management of healthcare waste Publications. London: Department of Health Publications. Available at: https://www.gov.uk/government/publications/guidance-on-the-safe-management-of- healthcare-waste

NHS (2016). And next available NHS Sustainability Day. Available at: http://www.nhssustainabilityday.co.uk/toolkits/

The Controlled Waste Regulations 1992 (SI 1992/588). London: Stationary Office. Available at: http://www.legislation.gov.uk/uksi/2012/811/contents/made

The Environmental Permitting (England and Wales) (Amendment) Regulations 2012. (SI 2012/630). London: Stationary Office. Available at: http://www.legislation.gov.uk/uksi/2012/630/contents/made

Health and Safety Executive (2009) Chemical warehousing: The storage of packaged dangerous substances. London: HSE. Available at: http://www.hse.gov.uk/pubns/books/hsg71.htm

The Health and Safety Executive (2013). The Approved List of biological agents. 3rd Edition, 2013. London: HSE. Advisory Committee on Dangerous Pathogens. Available at: http://www.hse.gov.uk/pubns/misc208.pdf

WasteCare (2011). The Waste (England and Wales) Regulations 2011. WasteCare. Available at: http://www.wastecare.co.uk/regulations/the-waste-regulations-2011/

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APPENDIX 1: WASTE STREAMS

Waste Contractual Specialist Description Physical Is waste Method of Operational Handlers of Waste Responsibilities Advisor/Key (Alphabetical Form Hazardous? Disposal Responsibilities Stakeholder order) Service Manager Aerosols Mixed Yes / No Recycled/Recovery Waste Team Waste Manager Head of Estates Facilities Service Manager Amalgam Solid Yes Recovery/recycling Waste Team Waste Manager Head of Estates Facilities, Inf. Control Service Manager Anatomical Solid Yes Incineration Waste Team Waste Manager Head of Estates Facilities, Inf. Control Service Manager Batteries Solid No Recycled Waste Team Waste Manager Head of Estates Facilities Builders Solid No Landfill/recycled Estates Estates Head of Estates Cardboard Service Manager Solid No Landfill Waste Team / Estates Waste manager Head of Estates (black bag) Facilities Service Manager Cardboard Solid No Recycled Waste Team Waste Manager Head of Estates Facilities Cartridges Waste Team & Service Manager Solid Yes Recycled/Recovery Waste Manager Head of Estates (Toner) - empty Contractors Facilities Service Manager Chemicals Mixed Yes Reprocessed Waste Team Waste Manager Head of Estates Facilities Service Manager Clinical Solid Yes Incineration Waste Team Waste Manager Head of Estates Facilities, Inf. Control Information Confidential Solid No Recycled Waste Team Waste Manager Head of Estates Governance Lead Service Manager Cytotoxic Solid Yes Incineration Waste Team Waste Manager Head of Estates Facilities, Inf. Control Fluorescent Service Manager Solid Yes Recycled Estates Estates Head of Estates Lamps Facilities Waste Team / Service Manager Food waste Solid No Landfill Waste manager Head of Estates Catering Facilities Furniture Service Manager broken or re- Solid No Recycled Waste Team Waste Manager Head of Estates Facilities usable Service Manager Glass Solid No Recycled Waste Team Waste Manager Head of Estates Facilities Grounds Solid No Mulched Estates Estates Head of Estates Grounds (green Solid No Composted Estates Estates Head of Estates waste) Gypsum Reused, Recycled Solid No Estates Estates Head of Estates (Builders) other disposal Gypsum Service Manager Solid Yes Incinerated Waste Team Waste Manager Head of Estates (Clinical) Facilities Service Manager Offensive Waste Solid No Incineration Waste Team Waste Manager Head of Estates Facilities Energy & Recycled or Catering Oils (cooking) Solid No Catering Department Head of Estates Sustainability reprocessed Manager Manager Oils (non-edible Solid Yes Recycled Estates Estates Head of Estates machine) Service Manager Service Manager Paper Solid No Landfill Waste Team / Estates Waste manager Facilities Facilities Service Manager Paper (Office) Solid No Recycled Contractor Waste Manager Head of Estates Facilities Pathology Head of Solid Yes Reprocessed Contractor Path Lab Head of Pathology chemicals Pathology Service Manager Service Manager Pharmaceutical Mixed Yes Incineration Pharmacy Manager Waste Manager Facilities, Pharmacy Facilities Manager, Inf. Control Plastics Solid No Landfill Waste Team Waste manager Head of Estates (black bag) Plastics Service Manager Solid No Recycled Waste Team Waste Manager Head of Estates (clear bag) Facilities Service Manager Radiation Radioactive Solid Yes Incineration Waste Team Head of Estates Facilities, Medical Advisor Physics, Inf. Control Porters & Waste Service Manager Scrap Metals Solid No Recycled Porters, Waste Team Head of Estates Team Facilities Service Manager Sharps Solid Yes Incineration Waste Team Waste Manager Head of Estates Facilities, Inf. Control

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Estates are responsible for waste they generate in their activities; Facilities are responsible for waste generated by all other activities.

Estates do not handle furniture unless it is part of a specific project.

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APPENDIX 2: PROCEDURES TO COMPLY WITH WASTE LEGISLATION

1. PROCEDURES TO COMPLY WITH WASTE LEGISLATION

Managers and departments heads will comply with the following procedures and guidance, developing local procedures where required.. Whilst many of the examples quoted are for healthcare waste (clinical) the same procedures/principles apply to all waste types.

1.1 Segregation

1.1.1 The correct segregation of waste at point of production into suitable packaging, colour coded for healthcare waste is vital to good waste management. Health and safety, carriage and waste regulations require that waste is handled, transported and disposed of in a safe and effective manner. Waste may be basically divided into the three streams:

1.2 Waste from Direct Patient related care

1.2.1 Will be segregated as shown by Appendix 5, Appendix 6 and Appendix 7 which incorporates the Safe Management of Healthcare Waste unified colour coding policy.

1.2.2 If the waste does not match any of these categories, a risk assessment must be carried out to establish the appropriate disposal treatment. If this is a re-occurring waste, a copy of the assessment and the codes used, will be sent to the Waste Manager to ensure it is added to the relevant Appendix., see:- Guidance on the safe management of healthcare waste (DoH, 2013) pages 75 -112). The Department Manager must check with the Waste Manager that there is not already a Trust approved disposal route before committing to a waste contractor.

1.3 Waste from Non-direct patient related care

1.3.1 Waste which may be derived from activities not associated with direct patient care will be segregated as shown by Appendix 7

1.4 Waste not identified in Appendix(s)

1.4.1 This policy and associated documents cannot cover every single waste stream. Any wastes which are not shown must be correctly assessed for their hazards and correct means of disposal by referring to either:

1.4.2 Guidance on the safe management of healthcare waste (DoH, 2013) pages 75 - 112,

Or 1.4.3 List of Waste codes which provide information on how to code waste correctly for anyone producing, carrying or managing waste in England and Wales

Or 1.4.4 Seeking the advice of a specialized disposer qualified in that waste disposal.

Waste Management Policy Approved by Health and Safety Group Page 17 of 35 Re view date: September 2016

1.4.5 Notes of any conversation and arrangements agreed to this unidentified waste shall be recorded. The manager shall ensure that any arrangements relating to the waste are written into any local procedures and made known to staff including any safe handling and storage criteria. If this is a re-occurring waste, a copy of the assessment and the codes used and consignment notes arising from that waste will be sent to the Waste Manager.

2. Handling

2.1 See Appendix 4

3. Primary storage Waste will be collected in the following primary receptacles:

3.2 Waste Sacks

3.2.1 Only those waste sacks supplied by the Supplies Department or Domestic Services will be used for the collection of material. These will be to the relevant NHS specification for the waste concerned. In addition infectious waste sacks will be UN 3291 approved

3.2.2 They shall be tied and identified in accordance with the waste sack handling advice. (See Appendix 4)

3.3 Sharps Containers

3.3.1 Shall be BS 7320 and UN 3291 approved: European Waste Catalogue and Hazardous Waste List (EWC). http://www.nwcpo.ie/forms/EWC_code_book.pdf (Environmental Protection Agency [2002])

3.3.2 They shall be assembled, used and identified in accordance with the Inoculation Policy (Sharps) and manufacturer’s instructions.

3.3.3 Sharps containers are not leak proof and should contain no more than 5% of free liquid.

3.4 Rigid Containers (Leak-proof)

3.4.1 Shall be BS 7320 and UN 3291 approved. European Waste Catalogue and Hazardous Waste List (EWC). http://www.nwcpo.ie/forms/EWC_code_book.pdf (Environmental Protection Agency [2002])

3.4.2 They shall be assembled, used and identified in accordance with the manufacturer’s instructions.

3.4.3 The receptacles shall carry the following information in the form of a label or written in indelible black ink on the receptacle: the department name, date, and name of person dispatching the waste, the waste type and European Waste Catalogue

Waste Management Policy Approved by Health and Safety Group Page 18 of 35 Re view date: September 2016

http://www.nwcpo.ie/forms/EWC_code_book.pdf (Environmental Protection Agency [2002]) code and associated hazards.

3.5 Other Containers

3.5.1 Waste shall be stored in original containers prior to collection by disposal companies. The final packaging shall meet all the requirements for safe packaging and storage as directed by the Trust‟s Dangerous Goods Safety Advisor. For further information contact The Waste Management Team on ext 6056

3.5.2 Chemical storage on site awaiting disposal shall comply with the requirements of safe separation as required by the Control of Substances Hazardous to Health Regulations 2002.

4 Internal (intermediate) storage (See Appendix 8)

4.1 Are those classed as belonging to the ward/department generating the waste, e.g. dirty utility/ward sluice rooms.

4.2 The Hazardous Waste Regulations 2005, List of Wastes Regulations 2005, EPR 5.07 Environment permit (Clinical Waste) and Duty of Care regulations, (Environment Agency, 2013c) places several obligations on producers of waste namely that:

4.3 Waste must not be mixed – Mixing hazardous and non-hazardous waste is illegal. Keep waste(s) as separate as possible and do not place sharps containers on top of sacked waste within sluices. Internally transport differing waste types separately. Hazardous wastes cannot be mixed and any hazardous waste placed within non- hazardous waste renders all that consignment/load as hazardous waste. E.G. one sack of Infectious waste placed with sacks of domestic waste within a 5 tonne load of domestic waste from the Trust renders all that waste infectious.

4.4 The Trust or the individual concerned may be prosecuted or fined, in addition to the Trust having to remove all the consignment and dispose of it as infectious waste.

4.5 Waste must be secure – All rooms/areas where waste is kept should be secure and not accessible to members of the public. 770 litre collection containers (large yellow wheelie bins on the corridors) are deemed suitably secure provided that they are locked when not attended. They will only be left within agreed areas, internally to the hospital, at agreed times.

4.7 Loose waste, in sacks or sharps boxes must not be stored, kept or allowed to accumulate within corridors and public areas.

5 Main Storage (see Appendix 8)

5.1 The majority of waste, apart from those wastes who Department Heads retain responsibility for and consign separately, e.g. IT equipment, Pharmacy chemicals, pathology chemicals, Estates oils, will be removed to the Facilities waste recycling area, where:

5.2 All waste streams will be identified, kept separate and secure.

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6. Transport

6.1 All waste must be removed from the Trust premises by an approved and registered carrier; the Trust has a duty of care to ensure that the carrier is properly registered/licensed to transport waste and that the waste is transferred to a proper registered/licensed site. Registration is undertaken by the Environment Agency. Checks on carriers/sites may be undertaken at the Environment Agency public register website.

6.2 The Carriage of Dangerous Goods Regulations (2011) covers the movement of all dangerous (hazardous) goods not just waste. The appropriate UN number should appear on the waste consignment note. The relevant UN numbers for clinical waste types are:

Dangerous Goods (UN Number) Description Category A; UN 2814 (Highly) Infectious substance, affecting humans Category B; UN 3291 Infectious Clinical waste N.O.S UN1851 Medicines, liquid, toxic, N.O.S UN 3248 Medicines, liquid, flammable, toxic, N.O.S UN 3249 Medicine, solid, toxic, N.O.S UN 2025 (Dental amalgam) Mercury compound, solid, N.O.S

6.3 It is the responsibility of the waste producer to ensure that waste is packaged safely and securely and conforms to “The Carriage of Dangerous Goods” (2011).

6.4 If the waste is outside the definitions of clinical waste, specialist advice should be sought from an accredited and authorised waste disposal company and/or the Trusts Dangerous Goods Advisor.

7. Documentation

7.1 Apart from knowing that the person who removes the waste is authorized to carry it and that it must go to a proper site, documentation which gives an accurate description of what is being carried, has to be passed to the carrier, and others within the waste chain. This documentation follows a set form and is more onerous for hazardous waste than controlled wastes.

7.2 These notes are:

Hazardous waste consignment notes – where the waste is hazardous. It is a requirement that each and every transfer of waste from the Trust is covered by either of the above, as appropriate. These must be retained for 3 years minimum by the department who authorised the transfer of the waste.

Waste transfer notes When waste, not hazardous waste, is transferred from one party to another, the person handing it on (the “transferor‟) must complete a Waste Transfer Note. These are retained for 2 years.

The transferee and the recipient (the “transferee‟) sign the note and both keep a copy. To save on administration, it is possible to have a Waste Transfer Note issued annually. This is for regular and similar non-hazardous collections. Waste Management Policy Approved by Health and Safety Group Page 20 of 35 Re view date: September 2016

Hazardous waste consignment notes These notes must be completed for every transfer of waste which is hazardous. There is a requirement to give a full description of the waste, its EWC code, along with its associated hazards.

It is the producer’s responsibility to fill in the section of this note, but in many cases the specialist disposer will assist on your behalf.

This enables the carrier of the waste to appropriate measures to ensure the wastes are packaged, labelled and handled correctly and that the person who receives the waste for final disposal (the “consignee‟) is able to take it.

The Environment Agency have a fully descriptive website concerning the standard procedure required for hazardous waste consignment notes.

Where possible for clinical waste, notes are pre-printed by the disposer and filled in at every visit. (This may not be possible at SDRU and in the case of community sites).

7.3 Returns

The waste collection company is required to send back a return each quarter, or a copy of the consignment note with “Part E” filled in. This return is a record of what has happened to your waste and must be placed with the other waste records.

These vary company to company, but they must describe the quantity, nature, origin, destination, and frequency of collection, mode of transport, waste carrier and the disposal or recovery operation applied, to the waste received.

The Estate’s Energy & Sustainability Manager will request each disposal company to provide a quarterly waste return.

Copies of the returns should be sent to the Operational Support Division

8 EWC Code

European Waste Catalogue (EWC) (Environment Agency, 2013d) codes must be

included on the waste transfer note and the hazardous waste consignment notes. The European waste codes have been translated into domestic legislation and are called “List of Waste codes”. Environmental Protection Agency (2002) European Waste Catalogue and Hazardous Waste List (EWC). Environmental Protection Agency.

Available at: http://www.nwcpo.ie/forms/EWC_code_book.pdf

9 Premises Registration Code

9.1 There is a generic ROYALD code across all trust sites.

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APPENDIX 3: WASTE HIERARCHY

Waste Hierarchy

The Trust is endeavouring to adhere to the waste hierarchy. To assist in this please consider how you can follow this structure when disposing of your waste.

1.1 Try not to procure items which result in lots of waste

1.2 Identify where items can be reused, especially furniture

1.3 The Trust is increasing the amount of waste it sends for recycling, look for recycling bins and contacts the Waste department if you have a waste stream that can be recycled.

What is the waste Hierarchy

The waste hierarchy refers to the "3 R’s" reduce, reuse and recycle, which classify waste management strategies according to their desirability. The 3 R’s are meant to be a hierarchy, in order of importance.

The revised Waste Framework Directive introduced a changed hierarchy of options for managing wastes. It gives top priority to preventing waste in the first place. When waste is created, it gives priority to preparing it for re-use, then recycling, then other recovery such as energy recovery, and last of all disposal.

The Waste (England and Wales) Regulations 2011 (WasteCare, 2011) apply the requirements for the waste hierarchy. Regulation 12 says that businesses that import or produce, collect, transport, recover or dispose of waste, or who operate as dealers and brokers, must take all reasonable measures to apply the waste hierarchy when the waste is transferred.

Also, if you hold or require an environmental permit for an operation that generates waste, you will have to comply with a permit condition concerning the application of the waste hierarchy. Waste Management Policy Approved by Senior Operational Group: 16 April 2014 Page 22 of 35 Re view date: September 2016

APPENDIX 4: PROCEDURES FOR REMOVING/HANDLING OF WASTE

1. All waste containers/receptacles will be clearly marked with the source of the waste.

2. All personal protection equipment provided for the task, as identified within risk assessments will be maintained and worn by the operative. Any defective equipment will be brought to the attention of the operative’s line manager.

3. When the waste sacks are two thirds full or not exceeding 11 kilos, twist the neck of the sack firmly, double it back to form a “swan neck”. Secure with the correct black numerical tag. The use of a black numerical tag ensures that the Trust maintains a clear and auditable waste trail in the event of investigations or incidents around clinical waste.

4. Sacks shall be held away from the body; they shall not be thrown or compressed within any containers

5. If a sack splits, place the split sack and contents inside another of a same colour.

6. Differing waste types, sacks and containerised must not be stored or transported together. This applies from the point of primary storage onwards.

7. Sharps containers, must be fully labelled and the aperture housing closed and locked. They should be stored in the waste disposal room on the Ward/department awaiting collection by the waste staff. They should not to be placed within sacks or on top of sacks. They will be moved by the handle and not by being clasped around the container body.

8. Waste collection staff are obliged to return the container for labelling if sacks or containers have not been labelled correctly, and an incident reported on Datix.

9. Sharps containers, when being transported, shall be placed in an upright position to prevent any loss of free liquid.

10. Any spillages noted before collection will be brought to the attention of manager for that area.

11. Only those containers and cages authorised for the transportation of waste shall be used. Any defects found shall be reported to the line manager for rectification.

12. All spillages in transportation, within the container or floor, will be promptly cleaned in accordance with the spillage procedure, which is part of the Decontamination Policy and procedures (unless it is a COSHH spill, which falls within the COSHH Policy).

13. Any incident or accident shall be brought to the attention of the line manager and Trust in accordance with the Trust Incident and Reporting Policy. (See Appendix 1)

14. Any containers/cages used in the movement of waste shall not be used for transportation of food, clean linen, etc.

15. All transportation containers used for the internal transport of waste shall be kept clean and must be pressured washed every 3 months or sooner if a spillage occurs. This will be undertaken/organised by the department who transfer the waste.

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16. Training

16.1 All staff required to handle and / or move waste must be adequately trained in safe procedures of dealing with all types of waste. The level of training will be dependent on the staff’s involvement with waste. Specific staff, i.e. general services, housekeeping, nurses, doctors, will require greater depths of training.

16.2 Employees required to handle clinical waste will be trained in:

Manual Handling Training Risks associated with clinical waste Waste segregation Spillages Accidents / incidents

16.3 Specific training for General Services (Waste) staff would include:

Clinical waste handling procedures Electric tow vehicle training (licensed) Procedure for dealing with mercury spillages

17. Personal Protective Equipment (PPE)

17.1 Staff involved in the collection of waste will wear personal protective clothing at all times.

17.2 Where personal protective equipment / clothing are provided, employees are obliged to wear it. Any damage / defects must be reported as soon as possible.

17.3 Waste Collections Staff whom handle waste constantly throughout their working day will be provided with:

Protective turtle skin gloves (anti needle stick) Ballistic trousers (anti needle stick) Safety shoes Polo shirts (green) Sweatshirt (green) Light weight jacket (green) Water proof clothing

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APPENDIX 5: CHARTS OF COMMON TYPES OF HEALTHCARE WASTE AND RECEPTACLES

CHARTS OF COMMON TYPES OF HEALTHCARE WASTE AND RECEPTACLES

SHEET 1 SACKED HEALTHCARE WASTE

SHEET 2 CHART OF (SHARPS) CONTAINERS FOR HEALTHCARE WASTE

SHEET 3 CHART OF OTHER CONTAINERS FOR HEALTHCARE RELATED WASTE

SHEET 4 SHEET 4 – CHART OF OTHER WASTE STREAMS ASSOCIATED WITH HEALTHCARE ACTIVITIES

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SHEET 1 – CHART OF SACKED HEALTHCARE WASTE APPENDIX 5

BLACK TIGER STRIPE (YELLOW/BLACK) ORANGE YELLOW PURPLE

Use Use Use Use Use General Household/municipal waste Offensive waste – does not meet the Low Risk Infectious waste (such as For Recognizable tissue, For the disposal of soft items including: Food Soiled newspaper, definition of infectious waste or MRSA, HIV, C. Diff) including items diagnostic specimens etc. which contaminated with Cytotoxic and flowers, including plastic drinks bottles possess any hazardous properties such as dressings, gloves, aprons and require incineration. Also Cytostatic medicinal products only and Tins. Any tin which has sharp edges but may cause offence due to plasters, contaminated with blood or chemically contaminated clinical and their residues, or items must be wrapped in newspaper, to presence of recognizable healthcare other bodily fluids and teeth without waste such as Pathology slides. contaminated by them. prevent injuries during transport, before waste items. fillings, empty blood sacks. being placed within the sack Used for: nappies, plaster casts, incontinence pads, stoma sacks, empty. Special notes Special notes Special notes Special notes Special notes Closure: secure a knot at top No infectious waste or waste Large metallic objects should not be This waste stream is NOT for Category Sharps waste must be placed in to a rigid contaminated with medicines placed within this waste stream. A infectious waste, as listed within sharps bin – soft waste only No anatomical waste or medicines Appendix 4 Closure: secure a knot at top or liquid waste Closure: secure a knot a top with Closure: secure a knot a top with Closure: secure a knot a top with numerical tag numerical tag numerical tag

Final Disposal Methods Final Disposal Methods Final Disposal Methods Final Disposal Methods Final Disposal Methods Landfill/ materials reclamation Deep Landfill Alternative Treatment Incineration at 850⁰C Incineration at 1150⁰C EWC Code EWC Code EWC Code EWC Code EWC Code 20 01 01 18 01 04 18 01 03* 18 01 03* 18 01 03* & 18 01 09* Hazard code Hazard code Hazard code Hazard code Hazard code N/A N/A HP9 HP9 HP9

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SHEET 2 – CHART OF (SHARPS) CONTAINERS FOR HEALTHCARE WASTE APPENDIX 5

ORANGE LID YELLOW LID PURPLE LID BLUE LIDDED YELLOW BODY YELLOW YELLOW BODY YELLOW BODY BODY (Pharmi-bin)

Used for Used Used for Used for For the disposal of sharps, excluding Sharps waste contaminated with medifcorine s. For the disposal of partially or fully For the disposal of sharps Pharmacy Use Only those contaminated with any discharged sharps contaminated with medicinal products and their residues. contaminated with Cytotoxic and medicinal products and their Medicine Blister packs, Medicine Bottles Cytostatic medicinal products only residues. Phlebotomy Use Only No Cytotoxic and/or Cytostatic medicines and their residues, or items contaminated by them.

Special notes Special Special notes Special notes No pharmaceutical Do not inject flnouidst esinto bin or sewer. Extremely hazardous due to dermal Use rigid leak proof contaminated items to be Use granules to absorb any liquids. absorption. container if free liquid placed within this 5% free fluid maximum. content may be above 5% container. Treat needle and syringe as one unit. Closure: secure by closing lid (See Sheet 4, Appendix 5) Do not inject fluids into bin Do not dispose of or sewer. Closure: secure by closing lid medicines in sinks/sluices. Treat needle and syringe Closure: secure by closing lid as one unit. Closure: secure by closing lid Final Disposal Methods Final Disposal Methods Final Disposal Methods Final Disposal Methods Alternative Treatment, Incineration at 850⁰C Incineration at 1150⁰C Incineration at 850⁰C Non-Incineration EWC Code EWC EWC Code EWC Code 18 01 03* C18o de01 18 01 03* 18 01 09 03* 18 01 08* Hazard code H18az 0ard1 Hazard code Hazard code HP9 HP3, HP4c,o0 HP5,d9e HP9, HP6,HP7,HP9,HP10,HP11 HP4, HP14 HP14 Waste Management Policy Approved by Senior Operational Group: 16 April 2014 Page 27 of 35 Review date: September 2016

SHEET 3 – CHART OF CONTAINERS FOR HEALTHCARE RELATED WASTE APPENDIX 5

RED LIDDED YELLOW LID YELLOW PHARMACY PHARMACY DENTAL YELLOW YELLOW LIDDED PURPLE PACKAGING AMALGAM BODY BODY YELLOW LIDDED IV PRODUCTS RED LIDDED LEAK PROOF BODY YELLOW BODY

ANATOMICAL LEAK WASTE PROOF

Used for Used for Used for Used for Used for Used for For the disposal of placentas. Rigid 60ltr containers (Griff Rigid 30ltr containers (Griff Wiva For the disposal of cytotoxic Giving sets with IV’s Rigid screw top containers Limb bins) for the disposal of bin for the disposal of all IV fluid and Cytostatic medicines, tablets, Medicate & non medicated for the disposal of anatomical waste – recognizable sacks. medicine bottles, within Pharmacy IV’s Dental Amalgam & teeth human body parts, internal organs Whether pharmaceutically active or Pharmacy Use Only Blood Sacks containing Amalgam Large Syringes 50ml and body tissue or to prevent leakage not and other potentially infectious waste. Glass Medicine bottl’s Blister packs Pharmacy packaging

Special notes Special notes Special notes Special notes Special notes Special notes Label to be attached: Label to be attached: For All IV fluid sacks and To be disposed of with No sharp items Approved disposal Contact “ Anatomical waste for “ Anatomical waste for incineration” giving sets Cytotoxic sharps stream waste department for collection incineration” Not for specimens soaked in Closure: secure by tying when full Must be refrigerated before formaldehyde Closure: secure by closing lid Closure: secure by closing lid a knot in plastic sack and disposal. Closure: secure by closing lid folding cardboard into Closure: secure by place (forming a box) Closure: secure by closing lid closing lid Final Disposal Method Final Disposal Method Final Disposal Method Final Disposal Method Final Disposal Method Final Disposal Method Incineration at 850⁰C Incineration at 850⁰C Incineration at 850⁰C Incineration at 1150⁰C Incineration at 1150⁰C Recovery/Recycling EWC CODE EWC Code EWC Code EW1150C8 C50o⁰deC EWC Code 18 01 02 18 01 02 18 01 09 18 01 08* 18 01 09 18 01 10* 18 01 03* 18 01 03* Hazard code Hazards Code Hazard codes Hazard codes Hazard codes Hazard codes HP9 HP9 HP4, HP9, HP14 HP6,HP7,HP10,HP11 HP4,HP9,HP14 HP6 HP9

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SHEET 4 – CHART OF OTHER WASTE STREAMS ASSOCIATED WITH HEALTHCARE ACTIVITIES APPENDIX 5

WHITE PLASTIC CONFIDENTIAL WHITE PAPER SACK CLEAR CARDBOARD SACK

Used for Used for Used for Used for Confidential waste to be shredded within the Non-Confidential paper or locally Glass Bottles (non Pharmaceutical) Packaging material recycling area. shredded paper and broken Crockery Also used for other recycling Special notes Special notes Special notes Special Notes Sacked must be secured with tie- Paper Chain replenish & dispose of the paper To be flat packed by producer. wrap before internal transportation If contaminated by blood or infectious waste to be treated as “Clinical” See Appendix 10 & 11 Final Disposal Methods Final Disposal Methods Final Disposal Methods Final Disposal Methods Pulping and re-use Pulping and re-use Recycling if appropriate Recycling EWC Code EWC Code EWC Code EWC Code 20 01 01 20 01 01 20 01 01 if remerged with domestic 20 01 01 waste 20 01 99 if separate collect waste stream

Hazard code Hazard code Hazard code Hazard code NR NR NR NR

* Any waste marked with an asterisk (*) is considered to be a Hazardous waste and an Absolute entry on a consignment note

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APPENDIX 6: STANDARD COLOUR CODING SYSTEM ADOPTED BY THE TRUST

The Trust has adopted the unified colour coding system advocated within Safe Management of Healthcare Waste, to aid healthcare professionals to segregate the waste and as listed below:

This colour coding system has been standardized throughout the Trust for sacks and receptacles and is shown in: * Offensive / hygiene waste sacks will be introduced to the Trust in a staged approach, with each area being risk assessed for suitability Appendix 5 – Sheet 1 Chart of sacked healthcare waste. Appendix 5 – Sheet 2 to 4 Charts of (sharps) containers for healthcare waste

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APPENDIX 7: SEGREGATION FLOW CHART FOR HEALTHCARE WASTE

PURPLE LID

Is the waste sharp i.e. SHARPS WASTE Cytotoxic / cytostatic can it cause a cut or a YES contaminated sharps YELLOW LID

puncture wound? Scalpel / Razor Needles Stitch cutters Syringes and needle Medicinally contaminated must be disposed of as one Sharps (un-discharged / partially

NO unit discharged / fully discharged syringe) Broken glass ampoules

Infusion sets (the sharp part) YELLOW LID NO Is the waste a medicinal tablet, Is it a Cytotoxic medicine in a bottle etc., which YES or cytostatic is not required to be returned to medicine? YES PURPLE LID Pharmacy?

Offensive Waste

NO NO incontinence pads, catheter and stoma sacks, nappies, sanitary waste, nasal secretions, sputum, condoms, urine, vomit and soiled human bedding from a non-infectious source;

Is the waste INFECTIOUS WASTE Is the waste contaminated YES likely to pose a Dressings (heavily blood stained or from infected wounds) with a body fluid? risk of YES Any soiled waste from a patient in isolation in bedded areas infection? Any waste item soiled with an infected body fluid (i.e. continence pad from patient with a known UTI or infected diarrhoea) Used disposable instruments (non sharp)

Is the waste contaminated with a disease Does the waste have to be incinerated causing pathogen included within category NO because it is recognizable e.g. limbs, A. anatomical waste etc.

RECYCLING DOMESTIC WASTE

YES Cardboard Paper towels YES Glass Packaging (no medical details) NO Plastics Food Waste Paper Flowers Metals Magazines Refer to: SEEK FURTHER HAZARDOUS INFECTIOUS Place in INFECTIOUS WASTE GUIDANCE FROM INFECTION yellow sack & rigid yellow bin OR Refer to Place in Orange sack CONTROL TEAM Local Pathology Policies

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APPENDIX 8: STORAGE OF WASTE ON SITE

STORAGE OF WASTE ON SITE

1. All bins in clinical areas should be lidded and foot or sensor operated and must be rigid sided, to reduce the risk of infection. All new bins purchased should be of a hands free type, for further information contact the procurement team on ext. 5412.

2. All waste within the organisational areas shall be stored in secure strategic locations away from food preparation and general storage areas, and from routes used by the public.

3. The external storage areas should be large enough to ensure that different types of waste can be stored separately i.e. domestic, offensive, infectious and sharps. This should be in separate steel containers, pallets, cages, trunks or wheelie bins. The area shall be well-lit and ventilated and sited on well drained, impervious hard standing. The employees will be provided with washing facilities and showering facilities.

4. The internal ward / department disposal rooms are the responsibility of each ward / department and are to be clean and tidy. They are to be well maintained, any faults or damages are to be reported to Estates, preferable by using the online tool or via the Hotline on Ext 3113.

5. The collection containers and areas will be kept secure from unauthorised persons and entry by animals and free from infestation by rodents and insects. The containers must be kept locked at all times, and wheeled containers must be kept secure. Keys will be kept by the Waste Manager and the operatives within the Waste Recycling area.

6. All clinical waste sacks must be sealed by swan necking and identified with the area location tape. Sacks shall be no more than two thirds full or 11 kilos in weight.

7. All sharps containers shall have the aperture housing closed and locked. All details on the container shall be completed regarding area, date closed off etc.

8. All rigid bins shall have the appropriate label attached indicating the nature of the waste and any associated hazards.

9. Bulk waste 770 litre containers (large yellow wheelie bins) must be kept secure and locked at all times when in use.

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APPENDIX 9: COMMUNICATION PLAN

COMMUNICATION PLAN

The following action plan will be enacted once the document has gone live.

Staff groups that need to have All staff knowledge of the strategy/policy

The key changes if a revised More waste streams. policy/strategy Colour coding changes in many areas.

The key objectives To make staff aware of all aspects of waste management.

How new staff will be made aware of Cascade by email from manager, induction the policy and manager action process

Specific Issues to be raised with staff All staff should be made aware of the policy/strategy. Particular attention should be drawn to the waste streams and colour coding.

Training available to staff Support available from O.S.U. Waste Management Department.

Any other requirements

Issues following Equality Impact No negative impacts. Assessment (if any)

Location of hard / electronic copy of Appendix of the policy/ procedural document on the document etc. the Trust intranet

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APPENDIX 10: EQUALITY IMPACT ASSESSMENT TOOL

Name of document Waste Management Policy

Division/Directorate and service area Operations Support Division / Trust Wide

Name, job title and contact details of Martin Conabeer person completing the assessment Facilities Operational Manager

Date completed: 27th July 2016

The purpose of this tool is to:

 identify the equality issues related to a policy, procedure or strategy  summarise the work done during the development of the document to reduce negative impacts or to maximise benefit  highlight unresolved issues with the policy/procedure/strategy which cannot be removed but which will be monitored, and set out how this will be done.

1. What is the main purpose of this document? This policy ensures the Trust is committed to disposing of its waste streams in compliance with relevant legislation and good practice guidance documents. It also aims to minimize and prevent significant risks to the health and safety of its staff, patients, public, waste contractors and the environment when disposing of that waste

2. Who does it mainly affect?

Carers ☒ Staff ☒ Patients ☒ Other (please specify) Visitors / Environment

3. Who might the policy have a ‘differential’ effect on, considering the “protected characteristics” below? The policy is assessed as having a neutral impact on the protected characteristics below

Protected characteristic Relevant Not relevant

Age ☐ ☒

Disability ☐ ☒

Sex - including: Transgender, ☐ ☒

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and Pregnancy / Maternity

Race ☐ ☒

Religion / belief ☐ ☒

Sexual orientation – including: ☐ ☒ Marriage / Civil Partnership

4. Apart from those with protected characteristics, which other groups in society might this document be particularly relevant to… (e.g. those affected by homelessness, bariatric patients, end of life patients, those with carers etc.)?

None

5. Do you think the document meets our human rights obligations? ☒

Feel free to expand on any human rights considerations in question 6 below.

A quick guide to human rights:  Fairness – how have you made sure it treat everyone justly?  Respect – how have you made sure it respects everyone as a person?  Equality – how does it give everyone an equal chance to get whatever it is offering?  Dignity – have you made sure it treats everyone with dignity?  Autonomy – Does it enable people to make decisions for themselves?

6. Looking back at questions 3, 4 and 5, can you summarise what has been done during the production of this document and your consultation process to support our equality / human rights / inclusion commitments? We are aware that people with the disability of colour blindness might have difficulty in discerning the colour of the disposal bags. We ensure, therefore, that bags have text on them, in as much as this is legally permissible, to indicate the type of waste to be placed in them and that, as of September 2016, the bins will have text on them, to indicate the types of waste which can be placed in them.

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