TRUST POLICY AND PROCEDURE FOR THE MANAGEMENT OF WASTE

Transcription

1 TRUST POLICY AND PROCEDURE FOR THE MANAGEMENT OF WASTE Reference Number: FM 2014/001 Version: 3 Status: Review Author: Paul Brooks Job Title: Associate Director of Patient Experience and Facilities Management Author: Jackie Marriott Job Title: Assistant Head of Facilities Management Version / Amendment History Version Date Author Reason 1 17/07/02 Robert Ridge 2 02/11/ /07/ /08/14 Paul Brooks & Robert Ridge Paul Brooks Jackie Marriott Policy Update Policy Update Minor Revision Policy update Intended Recipients: All Trust Staff Training and Dissemination: Training Provided by Skanska Facilities services, IPCT, Health and safety, e learning. To be read in conjunction with: Trust Policy and Procedures for Manual Handling (RKM ); Trust Infection Control Policy; Trust Policy and Procedures for Incident Reporting, Analysing, Investigating and Learning (RKM ), Trust Policy and Procedure for Information Technology Security, Trust Policy For The Control Of Substances Hazardous To Health In consultation with and Date: Operational Health & Safety Steering Group, Strategic Health and Safety Committee. EIRA Stage One Completed Yes Policy for the Management of Waste Page 1

2 Stage Two Completed N/A Procedural Documentation Review Group Assurance and Date Approving Body and Date Approved Strategic Health and Safety Committee Infection Control Committee Date of Issue December 2014 Review Date and Frequency Contact for Review January 2018 (then every 3 years) Assistant Head of Facilities Executive Lead Signature Approving Executive Signature Director of Patient Experience Chief Nurse Policy for the Management of Waste Page 2

3 Section Contents Page 1 Introduction 5 2 Purpose & Outcomes 5 3 Definitions Used 5 4 Key Responsibilities/Duties Chief Executive Chief Nurse Associate Director of Patient Experience and Facilities Management DHC Facilities Services General Manager Clinical and Executive Directors/Associate Directors Waste Management Committee All Staff Waste Management Committee Strategic Health and Safety Committee Categories of Waste Means of Segregation Specification of Containers to be Used Storage Transport Handling of Waste Prior to Disposal Risk Assessment Training Needs Personal Protection Accidents and Incident Investigation Reporting Spillages Final Disposal Recycling 11 Policy for the Management of Waste Page 3

4 Section Page 6 Monitoring Compliance and Effectiveness References 14 Appendices Appendix 1 Guide to Standard Use of Generic Bags / Receptacles for Approximate Waste Containment Appendix 2 Waste Disposal Policy for the Management of Waste Page 4

5 1 Introduction TRUST POLICY FOR THE MANAGEMENT OF WASTE Derby Hospitals NHS Foundation Trust recognises that waste management is an integral part of its responsibilities under the Management of Health and Safety at Work Regulations 1992, Environmental Protection Act 1990, Hazardous Waste Regulations 2005 and Waste Management Licensing Regulations 1994 (as amended). HTM 07-01, Safe Management of Healthcare Waste and Requirements. 2 Purpose and Outcomes The Trust is committed to ensuring the safety and welfare of its employees and anyone else affected by its activities, so far as is reasonably practicable. It is the intention to comply with all statutory Health and Safety and Environmental legislation relating to the safe handling and disposal of wastes arising from these activities. Waste may be disposed of in a number of ways; each may present special challenges. Typical common methods for final disposal include registered Landfill sites, Recycling and Treatment Facilities, alternative treatments (AT) and High temperature (HT) Incineration Facilities. As time passes, opportunities for the Trust to pursue better final waste management options will be investigated to keep up with legislative obligations, improved technological efficiencies and lower carbon emissions. The Trust recognises its responsibilities to protect the environment and will take every opportunity to reduce the amount of waste generated by its activities and where appropriate recycling techniques shall be adopted. It is the duty of all management to ensure that all activities are designed to ensure the safe handling and disposal of waste is properly supervised at all times. This policy applies to all individuals working in the Trust, in whatever capacity, including those employed by the Trusts private sector partners providing Facilities Management Services. These Service Providers are therefore expected to comply with this policy, as are staff members of other organisations whose employees work within the Trust. 3 Definitions Used The definition of terms used and their meaning within the context of the document is to clarify interpretation and is not an exhaustive list. DHC PFI Municipal Waste Derby Healthcare, who are the PFI provider to the Derby Hospitals NHS Trust Private Finance Initiative Any waste that is not defined as Policy for the Management of Waste Page 5

6 Offensive waste Infectious Healthcare healthcare or confidential waste Waste that is not known or suspected to be infectious Waste that is known or suspected to be infectious Recyclable Waste Waste that can be converted into reusable materials Confidential Waste Any waste that has any personal reference to a patient, visitor or member of staff not defined as healthcare, hazardous or municipal waste Cytotoxic/ Cytostatic Hazardous Producer Cytotoxic/Cytostatic, Hazardous - The Hazardous Waste (England and Wales) Regulations 2005 deem Cytotoxic/Cytostatic waste and medicines as, A cytotoxic and cytostatic medicine is a medicinal product possessing any one or more of the hazardous properties: H6: Toxic; H7: Carcinogenic; H10: Toxic for reproduction; H11: Mutagenic. Any person handling waste prior to placing in the waste containers at the waste collection point. Waste Collection Point Wheeled Containers A secure area designated to store lockable large wheeled containers. Large lockable wheeled containers in various colours that identify waste streams. 4 Key Responsibilities/Duties 4.1 Chief Executive The Chief Executive has overall responsibility on behalf of the Trust Board for its compliance with statute law. The Chief Executive has overall responsibility for ensuring that there are effective arrangements in place for the safe management of healthcare waste. The Chief Executive will ensure that the requirements specified within this policy are resourced and implemented throughout the Trust. The Chief Executive has a statutory duty to ensure safe systems of work and a safe environment for all its employees, visitors, contractors, volunteers, members of the public and others within all its premises. 4.2 Chief Nurse Policy for the Management of Waste Page 6

7 The Chief Nurse has the delegated responsibility for reporting to the Trust Board, annually, on the effectiveness of the arrangements relating to the management of waste. 4.3 Associate Director of Patient Experience and Facilities Management. Has the responsibility of day to day compliance with this policy within the facilities Management structure, for ensuring that documentation is issued in pursuance of the safe handling and disposal of waste, reflecting legal requirements, good working practices and accepted guidance. 4.4 DHC General Manager Derby Health Care plc (DHC) General Manager is responsible for the provision of waste management services to the Trust. DHC sub contract waste management to Skanska Facilities Services as part of the PFI consortia, who in turn are responsible for ensuring arrangements for the management of waste, comply with contractual, legislative requirements and Trust policies and procedures. 4.5 Estates Manager (SFS) Responsible for the development and review of this procedure ensuring that the Trust manages all waste disposal in accordance with the Trust Waste Policy and professional advice provided by the Waste Consultant, employed on behalf of SFS. 4.6 Clinical and non-clinical Directors/Associate Directors? What the new titles It will be a line management responsibility to ensure compliance with this policy. All line managers will hold responsibility commensurate with the Trusts Risk Management Policy. Line Managers will ensure that all staff under their direct control is made aware of the details necessary to compliantly dispose of the most frequently produced waste streams within their respective work area or activity. Departmental or local waste management policies may be necessary for this to be formalised; this may include other wastes encountered, which may require some form of holding area or emergency action to be taken. Line Managers will ensure that all necessary local resources, financial or otherwise, are made available to ensure that all aspects of this policy can be met. If there are problems in meeting this expectation, then this should be escalated up the line management structure, until resolved. 4.6 Trust Employees Policy for the Management of Waste Page 7

8 The Trust, as the waste producer, is responsible for making sure waste is correctly segregated at the point of production, into relevant containers and waste receptacles. To this end, all staff has a responsibility as part of their personal Duty of Care to adhere and comply with this also. For the purpose of this policy, bank staff, agency staff and students are considered to be Trust staff. Staff is reminded that non-compliance with regulations appertaining to the Environmental Protection Act 2011 could, in certain circumstances, result in individual prosecution.. Staff will take reasonable care of themselves and others, who may be affected by their actions regarding any aspect of waste. Staff will co-operate in matters that involve waste generation, segregation and transport. Staff will correctly use all necessary PPE [personal protective equipment] and other equipment designated for the task of handling and moving waste. Staff will be responsible for correctly securing all waste bags, waste sharps and other rigid clinical waste containers with an identity [ID] waste tag that is solely issued to the ward or department the waste has originated from. Staff will report any waste hazards or deficiencies in their working environment to their line manager, as well as completing the incident on the Trusts electronic [DATIX] system, if necessary. 4.7 Contractors and Contracted Out Staff All contractors employed by or working on behalf of the Trust, in, on or adjacent to Trust property will make the necessary arrangements to comply with this policy. 4.8 Waste Management Committee A team of appropriate professionals shall provide the Trust with advice and assistance on all matters relating to waste management. 4.9 Strategic Health and Safety Committee This committee is responsible for the monitoring and reporting to the Quality Review Committee of any issues arising from incidents involving the safe handling or disposal of waste in regard to the requirements of the Control of Chemicals Hazardous to Health Regulations Categories of Waste Waste generated on Trust sites can be categorised into one of the following: Policy for the Management of Waste Page 8

9 Infectious Healthcare waste (formerly clinical waste) Offensive Waste Municipal Cytotoxic/Cytostatic Hazardous Radioactive Confidential Building Recyclable Sharps Medicines Gypsum 5.1 Means of Segregation Waste, which will be disposed of in a particular manner, shall be segregated into easily recognisable colour coded containers. The Trust has fully adopted the Department of Health s guidance on good practise for the safe disposal of healthcare waste; this being Health Technical Memorandum (HTM) 07-01: Safe Management of Healthcare Waste [current]. 5.2 Specification of Containers to be Used Adequate supplies of appropriate containers shall be provided where waste arises and shall be capable of containing waste without spillage. If they are intended for reuse they must be capable of being suitably cleaned and where required disinfected. 5.3 Storage Waste shall not be allowed to accumulate in corridors, wards or other unsuitable places, sufficient secure containers for each stream shall be provided locally. Waste collection points shall be established throughout each site. Sufficient numbers of suitably secure constructed, wheeled containers shall be sited at these points to allow waste produced locally to be removed and stored within these containers, where it shall await collection. Bulk waste secure storage compounds, which will site waste skips, and wheeled containers shall be located at various areas throughout the sites, waste collected from the waste collection points can be deposited here and in some cases containers exchanged for clean. Suitable access for service vehicles shall be taken into account when siting bulk storage containers. 5.4 Transport Internal Transport Policy for the Management of Waste Page 9

10 Dedicated trucks, trolleys and wheeled containers shall be used to transport waste from the collection points to the dedicated storage areas, where the contents may be directly transferred to a bulk storage container/skip or waste containers exchanged for empty ones. Transport Off site The contractor responsible for the removal of waste should have a safe system of work in operation to ensure that: Collectors, drivers and others are aware of and trained in the nature of the waste being carried. Such operators are familiar with the procedures to be followed in the event of spillage or accidents, and that written instructions, safety and protective clothing are provided on the vehicle where required. An emergency telephone number is provided. Provide their carrier registration certificate. 5.5 Handling of Waste Prior to Disposal Procedures for handling waste shall be established within the Trust, specialist departments will require specific procedures based on individual risk assessments. The Waste Management Committee shall publish standard procedures for handling waste including: 5.6 Risk Assessment Risk associated with the segregation, handling, storage and transport of wastes will be identified, documented and prioritised as part of the Trust risk register. Waste management control measures will be implemented and continually reviewed (see audit section). 5.7 Training Needs All employees who are required to handle and move waste should be adequately trained in the safe procedures. All procedures should be passed for approval by the Waste Management Committee. A record of such training shall be kept. This record is checked on a Monthly basis as part of the facilities management PMS process. Written local procedures should be available at all times. 5.8 Personal Protection Where a risk assessment has identified the need for personal protective equipment to be used, adequate supervision shall ensure that these items are provided, used and maintained. Policy for the Management of Waste Page 10

11 5.9 Accidents and Incident Investigation Reporting The Trust s policy on accident and incident reporting should be followed in relation to any incident involving waste. Close liaison between the Waste Management, Control of Infection and Health and Safety Committee shall ensure all incidents are properly investigated to prevent recurrence Spillages The procedure for dealing with a hazardous spillage from certain types of waste shall be agreed and circulated to all staff to which the spillage may affect. Spillage kits shall be available in areas at risk for use by the team. If a spillage occurs staff should place wet floor signs at the area and call the FM helpdesk on ext RDH LRCH Final Disposal The disposal route for each category of waste shall be clearly identified. Systems shall be in place to ensure that agreed procedures are being carried out and in particular that waste which should be incinerated, re-cyclyed or go for alternative treatment is not inadvertently sent to landfill. Waste shall only be handed over to registered waste carriers for transportation to a certified disposal point, suitable for the disposal of that category of waste Recycling The Trust will aim to reduce amounts of waste for disposal where appropriate, through effective segregation and the recovery of materials through recycling or secondary use such as:- House Hold Glass Paper ( including hand towels) Cardboard Furniture Scrap metal Printer ink cartridges Confidential waste Fluorescent tubes Batteries Computers Opportunities to further minimise production of waste streams will also be promoted through discussions with suppliers to reduce packaging etc. Policy for the Management of Waste Page 11

12 6 Monitoring Compliance and Effectiveness The Waste Management Committee and the Strategic Health and Safety Committee will provide the Trust with advice on the development, implementation and review of the waste management policy and procedures with regard to the production, movement, storage and safe disposal of waste in accordance with current appropriate legislation, best practice guidance and value for money. Both committees meet on a quarterly basis. Audit arrangements will be implemented to support the continuing practise of effective segregation and waste reduction. Audits will focus on reduction; correct segregation, handling, storage and transport of waste in accordance with both waste management legislation and Trust policy and procedures. The Trust and Project Co will actively audit and monitor the amounts of waste produced and targets will be set for waste reduction in line with Environment Agency and NHS Estates Good Practise Guidance. Monthly reports on the waste produced by the Trust are presented to the Facilities Management team during the performance monitoring meeting by the service providers. This information is also included in the monthly report from the PFI provider (Derby Hospital Company) and any issues are discussed and minuted at the monthly liaison meeting. This policy will be regularly monitored to ensure that objectives are being achieved. It will be reviewed, and where necessary amended, in the light of legislative or organisational change. Monitoring Requirement: The Trust is required to demonstrate compliance with the following legislative and industry good practice guidance. Environment Agency, Department of Health guidance (2006) and best practice requirements. The Hazardous waste (England and Wales) Regulations (2005). Management of Health and Safety at Work Regulations (1992). Control of Substances Hazardous to Health Regulations Waste Management Licensing Regulations (1994) (As amended). HTM Safe Management of Healthcare waste current. Care Quality Commission Outcome 8, regulations 12 & 13. Policy for the Management of Waste Page 12

13 Monitoring Method: Monthly reports on Management of waste produced by the Trust are presented to the Facilities Management Department as part of the Hard FM Contract performance measurement system and reported as part of the PFI provider s (Derby Healthcare) monthly service report. Trust Facilities Management undertaken unannounced due diligence inspections of all of the waste disposal contractors on an annual basis. Trust Facilities Management undertake planned and ad hoc unannounced audits of on-site waste services (including production, segregation, handling, storage and transport) to monitor compliance against Trust Policy for the Management of Waste incorporating legislative, Waste management contracts, industry best practice guidance and CQC requirements. The Trust Waste Management Committee provides advice and assistance on all matters relating to waste management and monitors compliance/actions identified through planned and ad hoc audits as reported by Facilities Management or others. Report prepared by Facilities Management Monitoring report presented to: Trust Strategic Health and Safety Committee Frequency of Report 6 monthly 7 References Environment Agency, Department of health guidance (2006) and best practice requirements Policy for the Management of Waste Page 13

14 The Hazardous Waste (England and Wales) Regulations (2005) Management of Health and Safety at Work Regulations (1992) Environmental Protection Act (1990) Hazardous Waste Regulations (2005) Waste Management Licensing Regulations (1994) (As amended) HTM Safe management of healthcare waste Guide to Standard use of Generic Bags / Receptacles for Appropriate Waste Containment Appendices Policy for the Management of Waste Page 14

15 Appendix 1 Waste Receptacle Description Clear Recycling / RDF waste bags For the disposal of household / recyclable items House Hold Glass Paper (including hand towels) Packaging No food waste No gloves and aprons No offensive waste No infectious waste Confidential waste For the disposal of All medical records. Patient letters/appointments Black waste bags For the disposal of Food items, polystrene, wax paper, Offensive [Tiger] waste bags For disposal of non-infectious healthcare waste: dressings, gloves, aprons, sanitary wear No recognisable anatomical waste No pharmaceuticals No chemicals No gypsum Policy for the Management of Waste Page 15

16 No sharps No Food waste No paper towels Orange known infectious Clinical waste bags For the disposal of known or suspected infectious clinical waste No free flowing fluids [unless solidified or absorbed] No recognisable anatomical waste No pharmaceuticals No chemicals No gypsum No sharps No food waste Yellow Clinical waste bags For the disposal of clinical wastes requiring high temperature incineration. Clinical waste contaminated with absorbed chemicals and anatomical waste [first containment] and then into red lidded / yellow body rigid container. No sharps Yellow body / yellow lid rigid sharps containers For the disposal of sharps / vials contaminated with residues of blood or medicines No Pharmaceuticals, including medicine bottles. No Chemicals Policy for the Management of Waste Page 16

17 Yellow body / orange lid rigid sharps containers FSL058 can be used for For the disposal of sharps waste that maybe contaminated with body fluids. chest drains / dialysis sets & tubing where body liquid cannot / has not been solidified. It can also be used for removed stainless steel hip / knee joints, reenforcement limb / bone plates, screws and associated items. FSL110 is ideal for the disposal of long items, such as staple guns and body probes. No pharmaceuticals, including medicine bottles No pharmaceutically contaminated sharps No recognisable anatomical waste No chemicals Yellow body / purple lid rigid sharps containers For the disposal of sharps and items contaminated with cytotoxic or cytostatic medicines, including giving sets contaminated with cytotoxic or cytostatic medicines. DD221 is for the disposal of cytotoxic & cytostatic waste pharmaceutical tablets/liquids only. No other medicines Yellow body / red lid rigid containers For the disposal of including part or full blood bags. placentas foetal remains. bone, flesh, excess body fat removal histopathology body part waste. FSW579 should be used for larger, infrequent disposal of amputated limbs. Whole legs may need to be dislocated at Policy for the Management of Waste Page 17

18 the knee, so the whole limb fits. Blue body / blue lid pharmaceutical containers For the disposal of larger pharmaceuticals, such as saline bags with a medicine content and frequent disposal of heavy pharmaceutical items, such as medicine bottles [this can include remnants and empty medicine bottles Use for tubed creams, tablets, pills, including their blister packs etc. No cytotoxic or cytostatic medicine saline bags with a medicine content and frequent disposal of heavy pharmaceutical items, such as medicine bottles [this can include remnants and empty medicine bottles Use for tubed creams, tablets, pills, including their blister packs etc. No cytotoxic or cytostatic medicines Policy for the Management of Waste Page 18

19 Appendix 2 Derby Hospitals NHS Foundation Trust WASTE DISPOSAL PROCEDURE INTRODUCTION Waste is produced in wards and most departments across the Trust. As part of the Trust's Waste Policy this procedure sets out the method to ensure that waste is handled and disposed of safely in accordance with Health and Safety, Environment Agency and best practice requirements. Producers of Bagged, Waste (Offensive, Recycled, Infectious, Cytotoxic/Cytostatic, Municipal, High incineration) In line with this procedure ensure: Waste is segregated and placed into the correct waste receptacles. The correct colour and specification of bag is used. Bags are changed when 3/4 full and at least daily, and sealed correctly using plastic sequential numbered tie wrap to identify the location of where the waste was produced. Correct PPE is worn when disposing of waste (gloves/aprons) Transfer waste bags to the Waste Collection Point and deposit into the correct coloured lockable wheeled container, safely and ensure waste bins are secure at all times. Remove gloves and aprons, and dispose of into the offensive waste stream and wash hands. Producer Cardboard waste Flatten all cardboard before disposal. Take of flattened cardboard at the waste collection point located in the service lift areas. Dispose of cardboard in the correct coloured lockable wheeled container. Ensure container is locked before leaving the location. Producer Confidential waste The producer must request a confidential waste sack by contacting the help desk on RDH/ LRCH. Locate confidential waste sack in suitable area. Ensure only confidential waste is disposed of in the waste sack. When sack is approximately ¾ full secure the top of the sack as described by the instruction on the sack. Contact the relevant helpdesk RDH/LRCH to arrange collection. Policy for the Management of Waste Page 19

20 Ensure the sack is left in a secure location for collection. All confidential waste paper shall be shredded on site in the facility provided by Derby Hospitals NHS Foundation Trust, and collected by an approved external waste contractor for final disposal means of recycling. The Estates manager is responsible for ensuring a suitable contract is established and audited. Electronically stored confidential data such as cd s dvd s, floppy discs, computer back up, video, and audio tapes are disposed of safely in accordance with health and safety, environment agency, and best practice guidelines. Producers of Household Glass & Crockery All household Glass and Crockery must be cleaned of debris before disposal. This must be then placed into clear bag, and disposed of into the white wheeled lockable containers situated in the service lifts areas on levels 1-4. Producers of Batteries Battery recycling containers are available for collection for the Skanska Facilities Office based on level 1 of the Kings Treatment Centre. Once these are full place a call to the relevant helpdesk, and the full containers will be collected by the porters and on exchange and empty one will be left on the ward/dept. Producers of Aerosols All aerosols must be disposed of in the blue wheeled lockable containers. Producer sharps waste. All sharps must be disposed of in the correct coloured rigid container. Once ¾ full or the assembly date has expired the sharps boxes must be taken to the agreed location for collection by the waste porters. Sharps boxes must never be left in an insecure location which is accessible by the patients or the general public. Producers of all other specialist waste i.e. electrical/gas items, furniture, metal etc. please contact the relevant helpdesk. Specification of bags/containers and enclosures to be used Locked wheeled, rigid containers and bags must conform to UN approved standards so designed as to prevent leakage or spillage for the containment of all waste. All waste containers must be capable of being suitable cleaned or disinfected if intended for re-use. Storage areas Policy for the Management of Waste Page 20

21 Waste shall not be allowed to accumulate in corridors or other unsuitable places, nor shall it be disposed of or stored in such a manner it may cause harm to others. Waste collection points shall be established throughout the sites these must be kept locked at all times. Sufficient numbers of lockable-wheeled containers shall be sited at these points to accommodate waste produced locally. Each container shall also be kept locked. There should be no incidents of overspill within the dedicated on site storage compounds, and compounds should remain locked when not in use, and between the hours of Transport It is the responsibility of the waste producer to manually remove waste from their area to the nearest waste collection point, and dispose of the waste into a lockable wheeled container. Internal to the building, waste porters shall manually transport lockable wheeled containers to their destination. Tow trucks shall be used to use to transport full and empty wheeled containers between collection points and dedicated storage areas. Prior to transporting lockable wheeled containers from the waste compound to the waste collection points, the general porter must ensure the containers are clean and in good repair,i.e locks and wheels in working order and faults must be reported to the estates department. All wheeled containers must be assigned with the correct label before being taken to the waste collection point. The contractor responsible for the removal of waste from site shall have a safe system of work in operation. The Estates Manager is responsible for the management of these contracts. Emergency numbers are held by the Estates Department. Policy for the Management of Waste Page 21