Executive or Associate Director lead Christina Woolston, Estates and Facilities Support Officer. Officer

Transcription

1 Policy: Waste Management Executive or Associate Director lead Policy author/ lead Feedback on implementation to Clive Clarke Christina Woolston, Estates and Facilities Support Officer Christina Woolston, Estates and Facilities Support Officer Date of draft 24 th June 2014 Dates of consultation period 8 th September 2014 to 29 th September 2014 Date of ratification 23 rd Ratified by Executive Directors Group Date of issue Date for review September 2017 Target audience All staff Policy Version and advice on document history, availability and storage Version 4 of the Waste Management Policy. This policy is stored and available through the SHSC intranet. This policy replaces the previous waste policy /2010, - on ratification of this policy previous copies of this policy should be destroyed. Waste Management Policy Page 1 of 46

2 Contents Section Page 1 Introduction 4 2 Scope of this policy 4 3 Definitions 4 4 Purpose of this policy 5 5 Duties 6 6 Specific details Waste Types Waste Descriptions Handling and Disposal Procedures Domestic Waste Recyclable Waste Offensive/Hygiene Waste Clinical Waste Sharps Pharmaceutical Waste (Pharmacy Department only) Sharps and discarded/refused medicines in ward/bedded 14 areas only 6.11 Confidential Waste Waste Electronic and Electrical Equipment (WEEE) Furniture and Equipment Medical Devices Mattresses Asbestos Mercury Florescent lights/tubes Batteries Paints Bottled gas Protection of Staff Spillages Reporting of Incidents Documentation 19 7 Dissemination, storage and archiving 20 8 Training and other resource implications 20 9 Audit, monitoring and review Implementation plan Links to other policies, standards and legislation (associated 23 documents) 12 Contact details References 25 Appendix A Version control and amendment log 26 Appendix B European Waste Catalogue Codes 27 Supplementary Sections: Section A Equality impact assessment form 28 Section B Human rights act assessment checklist 31 Waste Management Policy Page 2 of 46

3 Section C Development and consultation process 33 Section D Ward Managers/Building Managers Audit Tool Section E Wards/sites to undertake the 6-monthly audits 39 Section F Waste Management Training Guide for Caretakers and Housekeeping staff Section G Waste Description (for display/print out) Waste Management Policy Page 3 of 46

4 1. Introduction This policy has been revised and updated to incorporate the changes in legislation governing the management of waste. It also incorporates the recommendation s made in the Department of Health, Health Technical Memorandum (HTM) Safe Management of Healthcare Waste Guidance. The Hazardous (England and Wales) Regulation 2005, supersede the Special Waste Regulations that had been in place since 1980, and require a new methodology for identifying and classifying infectious and medical waste. The previous waste classification groups A - E have been removed and replaced with the new European Waste Catalogue (EWC) codes which are mandatory for waste transfer documentation. 2. Scope of this policy This policy is Trust-wide and applies to other agencies covered by agreements with the Trust. All staff/tenants based within Sheffield Health and Social Care NHS Foundation Trust (SHSC) premises must comply with this policy. Trust staff located within other organisations/trust premises must adhere to whichever policy has the higher level of compliance. 3. Definitions UN Tested approved containers, Sharps boxes and bags are containers, boxes and bags which are obtained from the NHS Supply Chain via our Procurement Department. Cytotoxic and Cytostatic medicines are medicinal products possessing any one or more of the following hazardous properties: - H6: Toxic - H7: Carcinogenic - H10: Toxic for reproduction - H11: Mutagenic Hazardous Waste and Non-Hazardous Waste the table below shows examples of the types of waste produced by the healthcare sector that are classified as hazardous and non hazardous: Hazardous Waste Non Hazardous Waste Infectious waste Fluorescent tubes Laboratory chemicals Cleaning chemicals Photo chemicals Domestic waste (black bag) Food waste Offensive/hygienic waste Packaging waste Recyclable (paper, plastic, cardboard, glass, Waste Management Policy Page 4 of 46

5 Oils Batteries Waste electronics Asbestos Paints Solvents and gases Contaminated land aluminium) Furniture Construction and demolition waste Grounds waste Confidential waste The term Healthcare Waste is defined in HTM Safe Management of Healthcare Waste, as waste from natal care, research diagnosis, treatment or prevention of disease in humans/animals, and can be classified as Hazardous or Non-Hazardous Waste. 4. Purpose of this policy SHSC attaches great importance to the health and safety of its employees, members of the public and others who use its premises, or may be affected by its activities. The Trust recognises its responsibilities to meet the Care Quality Commissions Essential Standards of Quality and Safety (Outcome 10: Safety and Suitability of Premises), namely that there are arrangements and licences in place for the safe collection, classification, segregation, storage, handling, transport, treatment and disposal of clinical waste in line with current waste legislation. This policy has been compiled to provide clear guidance on how to dispose of the various types of waste produced as a result of the services provided by the Trust and the other agencies covered by agreements with the Trust. This policy and subsequent Contracts the Trust holds for disposal of Trust waste is purely for Trust waste and not for personal use. Flytipping and personal use of Trust skips/bins on site is prohibited. Waste Management Policy Page 5 of 46

6 5. Duties 5.1 The following table gives an overview of the roles and responsibilities of staff for the on-site management and disposal of waste. Management of waste produced by day-to-day activities Arrangement for waste disposal Chief Executive (Overall responsibility) Executive Directors Other Divisions & Directors Deputy Chief Executive / Social Care Leadership Director of Corporate Services (Delegated responsibility) Director of Facilities Management Head of Estates (Day-to-day responsibility) All Staff (Day-to-day handling of waste produced in their service area prior to final disposal) Estates and Facilities Support Officer (Day-to-day management of waste disposal) 5.2 All staff have a duty to comply with the procedures set out in this document and should report to their line manager any observed failure, or potential weakness. 5.3 The Service Managers, Heads of Departments, Building Managers and all Operational Managers are responsible for ensuring that waste within the areas of their responsibility is managed in accordance with this policy and procedure, ensuring that all staff involved in the handling and storage of waste are adequately trained and competent to operate these procedures. 5.4 Estates Services are responsible for ensuring arrangements are in place to provide for the collection and disposal of waste by an approved and licensed waste contractor, and for ensuring all premises, where hazardous waste is produced, have the appropriate registration with the Environment Agency to meet current legislation. Waste Management Policy Page 6 of 46

7 6. Specific details 6.1 Waste Types All waste is classified using the European Waste Catalogue Classification and Disposal processes, and should be segregated from the point of origin to final disposal. This forms part of our compliance needs, helps control costs, and reduces risk. The following categories of waste should be segregated: Domestic waste Recyclable waste Offensive waste Offensive hygienic waste Potentially infectious and known infectious waste clinical waste Sharps waste contaminated with medicinal waste other than cytotoxic and cytostatic medicines Sharps waste contaminated with cytotoxic and cytostatic medicines Pharmaceutical (Pharmacy Department) waste (excluding cytotoxic and cytostatic) Pharmaceutical (Pharmacy Department) waste (including cytotoxic and cytostatic) Sharps and discarded/refused medicines in ward/bedded areas Sharps waste contaminated with blood. Hazardous waste Confidential waste Waste Electrical and Electronic Equipment (WEEE) Furniture and equipment Medical Devices Mattresses Asbestos Mercury Fluorescent tubes Batteries 6.2 Waste Description Waste Type Definition Colour Code / storage prior to disposal Disposal Stream Domestic waste Waste which may be found in a domestic type setting, including food waste that cannot be disposed of by waste disposal unit. black bag Waste contractor for municipal incinerator producing district heating for the city of Sheffield. Waste Management Policy Page 7 of 46

8 Recyclable material Non-contaminated material which can be recycled (such as card, paper, tins, plastics etc.). clear plastic bag Local waste contractor for recycling. Offensive waste and offensive hygiene waste Offensive waste is not considered to be infectious waste and includes continence and other waste produced from human hygiene, sanitary waste, nappies, disposable aprons and gowns. yellow bag with black stripe Offensive waste contractor for deep landfill. Offensive hygiene waste is treated prior to being disposed for deep landfill. Potentially infectious and known infectious waste - known as clinical waste Any waste which consists wholly, or partly, of human tissue, blood or other bodily fluids, excretion, swabs or dressings. orange bag Waste contractor for treatment. Sharps waste contaminated with medical waste (but not including cytotoxic and cytostatic medicines) Syringes containing even small quantities of drugs or medicine. yellow bin with yellow top Waste contractor for incineration. Sharps waste contaminated with cytotoxic and cytostatic medicines Syringes containing drugs or medicines that has one or more of the following hazardous properties: toxic, carcinogenic, mutagenic or toxic for reproduction. yellow bin with purple top Waste contractor for incineration. Pharmaceutical waste (Pharmacy department only) Expired, unused or split medicines and drugs (non-sharps) blue bin with blue lid All unused medication must be returned to the Pharmacy for review and/or collection by the waste contractor for incineration. Waste Management Policy Page 8 of 46

9 Expired, unused or split medicines and drugs (sharps) yellow bin with yellow top If cytotoxic or cytostatic waste yellow bin with purple top Sharps and discarded/refused medicines in ward/bedded areas only Sharps and syringes containing even small quantities of drugs or medicine and discarded/refused medicines. yellow bin with purple top Waste contractor for incineration. If known cytotoxic or cytostatic waste Waste contractor for incineration. yellow bin with purple top Sharps waste contaminated with blood. Syringes and sharps contaminated with blood waste (phlebotomists) Shredded and sterilized by an approved waste disposal contractor. yellow bin with orange lid Hazardous waste Examples of hazardous waste: aerosols, gas, paint or varnish remover, batteries, fluorescent light tubes, petrol, diesel and oils, waste containing mercury, tyres. Varies dependent upon the item for disposal (see sections 6.17 to 6.21 for further information) Waste contractor for disposal to licensed facility in a designated container, disposed in accordance with the HTM Waste Management Policy Page 9 of 46

10 Confidential waste Examples of confidential waste: patient records, sensitive information relating to work carried out by the Trust, financial information, or information relating to staff. clear plastic bag Waste contractor for disposal by secure system. On site shredding, baled and recycled. Waste Electrical and Electronic Equipment The WEEE Directive covers a wide range of products, e.g. fridges, televisions, computers and monitors, vacuum cleaners. It covers any electrical or electronic item that has a plug attached. metal cage Waste contractor for disposal to licensed facility by designated container. The contractor recycles WEEE waste wherever possible. Furniture and equipment General ward and office furniture and equipment excluding electrical goods and mattresses. Every effort should be made to recycle furniture and equipment wherever possible N/A 1. Reuse. 2. Specified charity. 3. Waste contractor for disposal to landfill/recycling by designated skip. Medical devices Any device for diagnostic, treatment of therapy - examples include a bed, blood pressure machine. N/A Medical equipment must be decontaminated and disposed of via a licenced waste contractor. Mattresses All mattresses that require disposal. N/A, unless hazardous and then need to be placed in an approved mattress bag. Offensive mattress will be disposed of via a licensed waste contractor for disposal at deep landfill. Infectious mattresses will be incinerated. Waste Management Policy Page 10 of 46

11 Mercury Previously found within thermometers and sphygmomanometers no longer permitted to use within the Trust. yellow bin with yellow lid Licenced waste contractor for recycling. Batteries All types of battery waste of all chemistry compounds. Sealed container Waste contractor for disposal to licensed facility by designated container. Final disposal point of residue Ash is produced from incineration and disposed via deep landfill. Another residue from incineration is spent lime. Lime is used for the cleaning of flue gases produced by the incineration process. These spent lime residues are a hazardous waste for specialised landfill or can be used as part of another process in the neutralising of chemical wastes. Flock (shredded sterilised waste) is the only waste produced from Autoclaves and is disposed of via deep landfill. 6.3 Handling and Disposal Procedures Any queries and problems regarding the disposal of waste should be directed to Estates Services, telephone or All waste containers and bags must be UN tested and approved and obtained from NHS Supply Chain, via the Procurement Department. Containers should be positioned appropriately and discreetly. Where a waste compound or lockable area is available for the storage of bins, these must be used with the bin compound remaining locked at all times. Clinical bins containing infectious waste (orange bags or sharps bins), must remain locked at all times and stored in a locked compound/room. All staff have a responsibility to ensure that waste generated is deposited and contained within the appropriate container. If trolleys are used to transfer bags they must be dedicated solely for waste disposal, of impervious material, and cleaned regularly. Clinical and domestic waste must be segregated and not transported together on the same trolley. Staff required to handle waste must wear gloves and protective clothing, (see section 6.22). Bags must be handled by the neck only and checked for punctures prior to transfer. Waste Management Policy Page 11 of 46

12 6.4 Domestic Waste Any items of a general household nature which cannot be recycled or do not contain any hazardous substances. All domestic waste, other than glass or sharp objects, is to be placed in black waste bags. Glass or other sharp objects should be wrapped in newspaper and put in black bags or brown paper sacks (code WYF1943, NHS Supply Chain). When the bags are two thirds full they are to be tied and placed in the allocated wheelie bin for collection. Bags should not be overfilled and should be removed to storage areas as soon as possible. Storage areas should be kept clean and tidy, and in the event of spillage the waste should be re-bagged, the area swept, sluiced and mopped with a solution of hot water and sanitizer, rinsed and allowed to dry. All domestic waste and mixed skip waste is disposed of locally at Sheffield s Energy Recovery Facility, providing electricity and heat to Sheffield s District Energy Network (of which St Georges benefits from). To maximise the energy this facility can produce it is important that all recyclable material is segregated at source. 6.5 Recyclable Waste The NHS has a target set by the Sustainable Development Unit to reduce our carbon emissions by 34% by 2020, following the introduction of the Climate Change Act One way we can do this is to increase the amount of waste we recycle The Trust currently recycles cardboard, paper, plastics, tins, glass, metal, garden waste, fluorescent tubes, batteries, furniture and electrical equipment, and will continue to work with waste contractors to ensure recycling is carried out when the opportunity to do so arises. Cardboard packaging has been identified as a major waste product suitable for recycling. A cardboard bailer is situated at Transport Services, Shepcote Lane and requests for the collection of cardboard can be made to Transport Services on The cardboard must be flat packed prior to collection and stored in compounds, where available, or in appropriate areas as identified with the Trust s Fire Officer. The Trust provides internal recycling bins for the disposal of paper waste, (excluding confidential) including shredded paper, magazines, leaflets, tins, plastics, non-contaminated tissue paper and should be deposited in clear plastic bags. The clear bags are emptied into a designated Eurobin (external recycling bin) for collection and the bag returned to the internal recycling bins for re-use. Clear bags (code MVF039) can be obtained from the NHS Supply Chain, via the Procurement Department, and the internal recycling bins can be obtained by contacting Estates Services on For the disposal and recycling of electrical equipment please see Section Waste Management Policy Page 12 of 46

13 See also the Sustainable Development Policy. 6.6 Offensive/Hygiene Waste The term offensive/hygiene waste describes waste which is non-infectious and which does not require specialist treatment or disposal, but which may cause offence to those coming into contact with it. Example of offensive/hygiene waste include: - incontinence and other waste produced from human hygiene - sanitary waste - nappies - disposable aprons, gowns Offensive hygiene waste should be placed in yellow bags with black stripes, (Tiger bags). Requests for the disposal of offensive hygiene waste only should be via a non-stock requisition to the Procurement Department who will arrange for a licensed contractor to supply the required receptacles and dispose of the waste in line with legislation. 6.7 Clinical Waste Clinical waste should be placed in orange bags and should include the disposal of gloves and aprons used in the handling of such waste. Clinical waste bags should not be allowed to accumulate outside the containers and the wheelie bins and carts are to be kept locked and, if stored in a compound, the compound is also to be kept locked. Clinical waste bags must be secured and labelled and not overfilled, allowing the bag to be tied or knotted before being placed in the allocated container. Bags must not be moved unless they have been securely tied and a label completed so that waste can be traced to the place of origin. 6.8 Sharps All sharps must be disposed of in an approved Sharps box and the label on each box completed (dated and signed) when first commencing use and prior to disposal by the healthcare professional so the waste can be traced to its place of origin. Sharp bins should be: Available in all areas where sharps are to be disposed of Kept in a safe place to prevent misuse Not over-filled Sealed when full, correctly labelled and disposed of in a designated wheelie bin for sharps only, separate from clinical waste bags Waste Management Policy Page 13 of 46

14 NB. Sharp bins must not be placed in any bag; they must be able to be observed so any spillages can be seen. Sharps incidents are the most important factor in the transmission of blood borne viruses such as Hepatitis B and HIV. Sharps discovered in unexpected locations must be taken seriously. In line with the Trust s Incident Reporting Procedure as detailed within the Incident Reporting and Investigations Policy, a Trust Incident Form must be completed and the incident fully investigated by the supervisor and/or manager so that any follow-up action can be taken. In the event of a sharps injury the wounds should be washed with copious running water and hospital treatment sought immediately. A Trust Incident Form must be completed and staff referred to the Infection Prevention and Control Standard Precautions, Prevention of Sharps Injuries and prevention of Exposure to Blood and Body Fluids Policy and COSHH Policy. 6.9 Pharmaceutical Waste (Pharmacy Department only) All unused medication/pharmaceutical products should be returned to the Pharmacy from where it was supplied for review and/or collection by the waste contractor for incineration. Solids and liquids should be segregated and placed in the appropriate bin. For any queries or problems regarding the disposal of pharmaceutical waste please contact the Pharmacy Department on Alternatively, please see the Management of Medicines Local Guidance Sharps and discarded/refused medicines in ward/bedded areas only Within the wards and bedded areas only, sharps, syringes containing medicines and discarded/refused medicines must be disposed of in a purple lidded sharps bin for disposal by incineration. This is a higher classification of disposal and ensures that should any unknown cytotoxic/cytostatic waste medicines require disposal, then they are treated in accordance with the HTM 07-01: Safe Management of Healthcare Waste. The mixing of waste types in England and Wales is prohibited by law and therefore, for known cytotoxic/cytostatic medicines, these must be stored in an additional purple lidded sharps bin for disposal. For further information on the disposal of sharps and discarded medicines in ward and bedded areas, please refer to the Management of Medicines Local Guidance, specifically, Appendix 7 and 8: Standard Operational Procedure Controlled Drugs Supported Living / Residential. Further guidance can also be sought from the Pharmacy Department on Confidential Waste Requests to set up a contracted confidential waste disposal arrangement should be via a nonstock requisition to the Procurement Department who will arrange for a licensed contractor to dispose by a secure on-site shredding system. Waste Management Policy Page 14 of 46

15 One-off arrangements can be scheduled via Estates Services. Please contact who will obtain a quote for the collection and disposal via a licensed contractor to dispose by a secure shredding system. Please note an Inter-department Transfer of the cost of disposal will be made Waste Electronic and Electrical Equipment (WEEE) Electrical equipment should not be disposed of in the normal waste stream. If you are disposing of a PC then follow these steps: a) Contact the I.T. Department on to have the hard disk removed and destroyed b) Contact the Finance Department on and inform them of disposal c) Continue with the WEEE disposal procedure below: Requests for the disposal of any electrical or electronic equipment should be made to Transport Services on who will arrange for the equipment to be collected and taken to the designated containers within the car park compound at the Michael Carlisle Centre for disposal by a licensed contractor. Access to the compound is via Estates Services. A charge will be made by Transport Services for the collection Furniture and Equipment Where possible, undamaged furniture or equipment in good working order should be made available for re-use and can be advertised on the Public Folder Noticeboard. Please ensure all furniture and equipment for re-use is decontaminated prior to leaving its current location (please see the Decontamination and Disinfection Policy). If the items are not required for re-use within the Trust, but of good quality, the furniture can be offered to an approved Charity. The details to arrange for this can be obtained via Estates Services on If there are large amounts of furniture or equipment to be disposed of, then a skip can be arranged for the specific site by contacting Estates Services on A signed non-stock requisition, with a cost-code, would be required and a simple site plan showing where the required skip is be placed. If there are only small amounts to be disposed of, then requests should be made to Transport Services on , who will arrange for the items to be collected and taken to the designated skip within the car park compound at the Michael Carlisle Centre or Shepcote Lane for disposal. A charge will be made by Transport Services for the collection. Waste Management Policy Page 15 of 46

16 6.14 Medical Devices Any device used for diagnostic, treatment or therapy for disposal must be decontaminated in accordance with the Decontamination and Disinfection Policy. Examples of such devices can be obtained from the Medical and Therapeutic Devices Policy. Following the decontamination process, decommission and remove the item from the Department Inventory. The item can then be disposed of through the most appropriate route; general waste; WEEE; recycled (metal). Arrange collection of the item via Transport Services on , who will arrange for the items to be collected and taken to the designated skip within the car park compound at the Michael Carlisle Centre or Shepcote Lane for disposal. A charge will be made by Transport Services for the collection. Further details and advice can be sought from the Senior Nurse and Clinical Training Lead, please see Section 12 of this policy Mattresses The majority of mattresses will be disposed of as offensive waste and sent by licensed contractor for deep landfill under EWC code On no account must mattresses be disposed of in any on-site skips. To ensure mattresses are stored safely and securely they should be held in a cool, dry location on wooden pallets to ensure they are not laid directly on the ground. Mattresses deemed to be contaminated with anything that constitutes an infection risk to humans should be handled accordingly with the use of personal protective equipment. Such mattresses must be placed within a mattress bag which can be purchased via the Procurement Department or via NHS Supply Chain. Infectious mattresses will be consigned as EWC and disposed of via incineration. If there are large amounts of mattresses to be disposed of, these must be stored in a safe and secure location as noted above. To arrange disposal, contact Estates Services, , who will arrange for an on-site collection via licenced contractor. If there are only small amounts to be disposed of then a request should be made to Transport Services on , who will arrange for the mattresses to be collected and taken to their secure storage area at Shepcote Lane for disposal. A charge will be made by Transport Services for the collection Asbestos The removal and disposal of waste known or suspected to contain asbestos material is covered by specific regulations. If there is any suspicion that material to be discarded contains asbestos, advice should be sought from Estates Services on Waste Management Policy Page 16 of 46

17 6.17 Mercury The Trust no longer uses equipment containing mercury (previously used in thermometers and sphygmomanometers), however, should these be located, please deliver or arrange delivery via Transport Services ( ) to Estates Services, Michael Carlisle Centre ( ) A charge will be made by Transport Services for the collection. Mercury containing items will be stored by Estates Services in a 30ltr yellow lidded sharps unit and disposed of by way of incineration. For mercury spillages, please see Section 6.23 below Fluorescent Lights/Tubes Fluorescent lights/tubes must be disposed of by an approved contractor in accordance with HSE and EA waste permitting requirements. Fluorescent lights/tubes are stored in the large red metal coffin container within the waste compounds at Michael Carlisle Centre. Estates Services will arrange for the collection and onsite disposal once the container is near full. Often these tubes will be brought back to Michael Carlisle Centre by the Estates Maintenance Team after lights/lamps have been replaced. Any queries, please contact Estates Services on Batteries The Trust operates a battery recycling scheme for household (AA, AAA, D, C, 9-volt PP3, SR41/AG3 and SR44) batteries. Battery collection envelopes are supplied on request from Transport Services by ing recycling@shsc.nhs.uk. The used batteries are returned in the envelope via the internal post services to Shepcote Lane for collection by an authorised waste battery collection contractor. Batteries which fall out of the battery recycling scheme as noted above should be brought to Estates Services, Michael Carlisle Centre for storage prior to disposal within the WEEE compound. Please note that to comply with disposal legislation all battery chemistry types must be segregated. The most common types the Trust may produce are; portable lead acid batteries (e.g. small brick type with two terminals on top); industrial lead acid batteries (e.g. vehicle batteries); standard NiCad batteries (e.g. hoist batteries); industrial NiCad batteries (e.g. ALCAD); lithium batteries (e.g. hearing aid batteries). There must be no trailing wires and all terminals covered with insulation tape (available from Estates Services). Any leaking or heavily corroded or damaged batteries must be reported to Estates Services. For further advice/information, please contact Estates Services, Waste Management Policy Page 17 of 46

18 6.20 Paints Paints are a hazardous substance and hence must not be disposed of via the general waste route. All paints for disposal must be stored in the general waste skip compound at Michael Carlisle Centre. Further advice and access to the compound can be sought through Estates Services, Bottled gases The Trust does not use bottled gas (Co2, butane, propane); however, there may be the occasions when these have been located within the Trust. Please report any old, abandoned or unrequired gas bottles to Estates Services, , who will arrange the collection and disposal of the bottle(s) Protection of Staff Personal Hygiene Whenever waste has been handled, hands must be thoroughly washed before commencing other duties. No eating or drinking is to take place when handling waste in the collection areas or compounds. Personal Protective Equipment (PPE) and Clothing Protective clothing should be worn when dealing with all types of waste, and should be laundered regularly and changed following any contamination. Sturdy shoes or boots, preferably safety footwear, should be worn. Staff should wear heavyduty rubber gloves when handling waste bags or containers. Whenever there is a risk of flying fragments, eye protection goggles conforming to BS2092 impact grade, should be worn. Staff must bring any loss, defect, or other problem, regarding PPE to the attention of their linemanager without delay. Vaccination Immunisation of the appropriate kind will be offered to those deemed at risk in waste handling. Ill Health Should any ill health be associated to the handling of waste it is to be reported as an incident in line with the Trust s Incident Reporting Procedure as detailed within the Incident Reporting and Investigations Policy. Further information and advice is available from the Risk Management Department and the Infection Prevention and Control Policy. Waste Management Policy Page 18 of 46

19 6.23 Spillages In the event of a spillage, immediate action must be taken if no spillage kit is available. The waste should be re-bagged (offensive waste in to a tiger bag, infectious waste in to an orange bag), together with any paper towels used to absorb liquids, the area swept, sluiced or mopped with a solution of hot water and sanitizer, rinsed and allowed to dry. A Trust Serious Incident Form must be completed in line with the Trust s Incident Reporting Procedure as detailed within the Incident Reporting and Investigations Policy. Please see the Infection Prevention and Control Policy and Infection Prevention and Control Standard Precautions, Prevention of Sharps Injuries and prevention of Exposure to Blood and Body Fluids Policy for further information. Mercury Spillage In the event of a mercury spillage, a mercury spillage kit can be obtained from Estates Services, Mercury is a highly dangerous substance; under no circumstances should you clear up the spillage without following the correct procedure. Please refer to the COSHH policy (Control of Substances Hazardous to Health) for the safe procedure in cleaning up mercury spillages Reporting of Incidents Involving Loss or Misuse of Confidential or Hazardous Waste Any spillage, sharps injury, or loss of confidential or hazardous waste, should be reported to Estates Services, telephone , and a Serious Incident Report Form completed in line with the Trust s Incident Reporting Procedure as detailed within the Incident Reporting and Investigations Policy and forwarded to the Risk Department as soon as possible following the incident Documentation Consignment notes A consignment note will be issued by the waste contractor for each collection of hazardous/infectious waste detailing the date and time of collection, the type of waste, the weight and the address of the disposal facility. All consignment notes must be retained on site where the waste was disposed from for a minimum of three years. Waste Transfer notes A waste transfer note will be issued by the waste contractor for each collection of nonhazardous/offensive waste detailing the date and time of collection, the type of waste, the weight and the address of the disposal facility. All waste transfer notes must be retained on site where the waste was disposed from for a minimum of two years. The documentation of both Consignment notes and Waste Transfer notes will be checked annually by the Estates Compliance Officer and every 6 months by the Trust Waste Lead (Estates and Facilities Support Officer) via the site/ward audits. Licences Copies of the waste contractors licence s and documentation will be held on file in Estates Services and/or the Procurement Department as appropriate. Waste Management Policy Page 19 of 46

20 7. Dissemination, storage and archiving (Control) This policy will be posted on the Sheffield Health and Social Care NHS Foundation Trust intranet website and available to all staff within seven days of its ratification. Links to the new electronic copy of the policy shall be circulated via a Trust-wide . Previous copies should be replaced. The previous waste policy /2010 will be removed from the Trust intranet. An archive copy of the previous policy and the new updated policy shall be stored with the Estates Services department for reference. 8. Training and other resource implications All staff produce waste material and hence are involved in the waste disposal chain, therefore suitable training must be provided to ensure they are fully aware of the duties required of them and the extent of their responsibilities. This policy provides easy to read and digest information in relation to the types of waste produced and how they should be stored prior to disposal. Clarity on any specific element can be sought from Estates Services ( or ). The immediate line-manager of the ward or department must, within Local Induction training, make staff aware of waste hazards, risks, and the correct disposal procedures before they commence work, ensuring all staff have seen and read this Waste Management Policy. Posters and other training information will be made available for staff as necessary and can be obtained/requested via Estates Services in the first instance, In addition to the Local Induction Programme, all staff will need basic training which is provided as part of the Trust Welcome/Induction programme for new starters. Refresh of processes should be undertaken every two years or at the point in time when new guidance/regulations are issued. This policy should provide the necessary advice and training, however, support and further guidance can be obtained via Estates Services ( ) if it felt this is not covered as part of the Waste Management Policy or referenced policies. Job-specific training should be provided in line with the Trusts Training Needs Analysis, for staff with higher levels of responsibility for waste management (identified staff: transport, porters, housekeepers, caretakers, gardeners and others handling and transporting waste). The Audit Tool at Section F of this policy can also be used as a form of local training. The Management of Medicines Local Guidance covers training for staff who handle medication and medicines. A training record should be kept by line-managers to identify members of staff who are due for training, or who have not received the appropriate level of training. The Trust does not have a dedicated Waste Manager; therefore external resources may be required to co-ordinate the training of staff. Waste Management Policy Page 20 of 46

21 9. Audit, monitoring and review NHSLA Risk Management Standards - Monitoring Compliance Template Standard x Criterion x Minimum Requirement A) Duty of Care. Process for Monitoring Review, audit. Responsible Individual/ group/ committee Estates and Facilities Support Officer. Frequency of Monitoring Annual. Review of Results process (e.g. who does this?) Waste Contractor. Technical Support Officer. Responsible Individual/group/ committee for action plan development Waste Contractor. Estates and Facilities Support Officer. Responsible Individual/group/ committee for action plan monitoring and implementation Technical Support Officer. B) Pre- Acceptance. Audit. Estates and Facilities Support Officer. Annual. Waste Contractor. Technical Support Officer. Waste Contractor. Estates and Facilities Support Officer. Technical Support Officer. C) Trust site compound / storage area reviews. Review, audit. Estates and Facilities Support Officer. 6 monthly. Estates and Facilities Support Officer. Estates and Facilities Support Officer and Building/Ward Manager. Technical Support Officer. D) Ward/site audits Review, audit Building Manager/Ward Manager 6 monthly. Estates and Facilities Support Officer and Building/Ward Manager Estates and Facilities Support Officer and Building/Ward Manager Estates and Facilities Support Officer Every member of staff has a duty to ensure waste is effectively segregated to guarantee it is treated and disposed of appropriately. Waste Audits are a legal requirement to demonstrate compliance with Regulatory Standards. Ward/Building Managers must carry out regular audits of their area of responsibility, (every 6 months). The generic audit tool is available at Section D of this policy to record the results of the audit. These records should be retained on site, copies of which are to be ed to Christina.woolston@shsc.nhs.uk. A list of ward areas/premises which must undertake these audits can be found at Section E of this policy. Trust site compound/storage area reviews will be undertaken six monthly by the Estates and Facilities Support Officer from Estates Services in conjunction with site representatives, e.g. Nominated Building Contact, Ward Manager, Housekeepers, Caretakers. Staff will be informed of the audit dates so that a member of staff will be available to accompany the audit. The purpose of these audits is to ensure the waste is segregated in accordance with the HTM Safe Management of Healthcare Waste Guidance. The waste audits also allow for a review of the waste streams on site, promote recycling and ensure the contracted waste Waste Management Policy Page 21 of 46

22 disposal service undertaken for the site is value for money. Records of these audits will be retained within Estates Services, copies of which are shared with each Building Manager and action plans developed as required. Infection Control undertake an annual Environmental Audit, copies of which are shared with Estates Services, Ward/Building Managers and other pertinent staff to remedy any actions raised. Estates Services are responsible for an annual Duty of Care visit to the contractors sites to ensure waste is going to where it should. Records of the audit are retained within Estates Services. Annual Pre-Acceptance audits are also required, of which the 6 monthly ward/site audits feed in to. Copies of these are retained by Estates Services and shared with the Clinical waste contractor for information. Quarterly meetings are held with Estates staff and the Clinical waste contractor to monitor and review procedures, ensuring waste is disposed of according to legislative requirements. This policy will be reviewed every two years, or as and when there are changes in waste management legislation. Waste Management Policy Page 22 of 46

23 10. Implementation plan Action / Task Responsible Person Deadline Progress update Arrange for revised policy to be launched on to the Trust intranet and remove the old policy. Estates and Facilities Support Officer October 2015 Inform all Trust staff of the revised policy via a Trust-wide , asking Team Managers to ensure all staff have access to the latest version of this policy and the previous policy to be removed and destroyed Estates and Facilities Support Officer October 2015 Inclusion into the Risk Manual via the Trust intranet. Estates and Facilities Support Officer October Links to other policies, standards and legislation (associated documents) SHSC Policies/Documents CoSHH (Control of Substances Hazardous to Health). Decontamination and Disinfection Policy. Incident Management Policy and Procedure (including Serious Incidents). Infection Prevention and Control Policy. Infection Prevention and Control Standard Precautions, Prevention of Sharps Injuries and prevention of Exposure to Blood and Body Fluids Policy. Management of Medicines Local Guidance. Appendix 7 and 8: Standard Operational Procedure Controlled Drugs Supported Living / Residential Medical and Therapeutic Devices Policy. Sustainable Development Policy. Training Needs Analysis. Waste Management Policy Page 23 of 46

24 12. Contact details Title Name Phone Deputy Chief Executive/Social Care Leadership Director of Corporate Services Clive Clarke Director of Facilities Management Helen Payne Estates Services - Technical Support Officer Steve Dunkerley steve.dunkerley@shsc.nhs.uk Estates Services - Estates and Facilities Support Officer Christina Woolston christina.woolston@shsc.nhs.uk Estates Services - Admin Support Jill Leggott jill.leggott@shsc.nhs.uk Senior Nurse for Infection Prevention and Control Rosie Dixon Rosie.dixon@shsc.nhs.uk Deputy Chief Pharmacist Chris Hall Chris.hall@shsc.nhs.uk Senior Nurse and Clinical Training Lead Charlie Turner charlie.turner@shsc.nhs.uk Waste Management Policy Page 24 of 46

25 13. References Care Quality Commissions Essential Standards of Quality and Safety (Outcome 10: Safety and Suitability of Premises). Control of Substances Hazardous to Health (CoSHH) Department of Health HTM Safe Management of Healthcare Waste. Environment Agency. European Waste Catalogue (EWC) codes. Health and Safety at Work Act NHS Sustainable Development Unit Sustainable, Resilient, Healthy People & Places Strategy (2014). The Environmental Protection (Duty of Care) Regulation The Hazardous Waste (England and Wales) Regulation The List of Wastes (England) Regulations The Management of Health and Safety at Work Regulation Waste Management Policy Page 25 of 46

26 Appendix A Version Control and Amendment Log Version No. Type of Change Date Description of change(s) 1 Review of V2 Apr Consultation period V3 May Ratification V3 Nov Review of V3 Nov 2010 No changes made; awaiting 2013 HTM. 2.1 Review of V3 June 2014 Review of current policy in line with up to practices and current legislation (HTM). 2.2 Consultation period V4 Sept Review following consultation period V4 Sept Ratification V4 Oct Review of V4 June 2017 expected 3.1 Review on expiry of V4 policy Sept 2017 expected. Waste Management Policy Page 26 of 46

27 Appendix B European Waste Catalogue Codes (EWC) The table below denotes the EWC codes most commonly used in healthcare. Waste Type Domestic waste Offensive/hygiene waste Clinical waste, (hazardous by infection) Sharps contaminated with medical waste other than cytotoxic or cytostatic Sharps contaminated with cytotoxic or cytostatic medicines Pharmaceutical waste in original packaging Non-cyto Cyto Sharps (non-cyto) Pharmaceutical waste not in original packaging Non-cyto Cyto Sharps (non-cyto) EWC Code or or Waste Management Policy Page 27 of 46

28 Supplementary Section A - Stage One Equality Impact Assessment Form Please refer back to section 6.5 for additional information 1. Have you identified any areas where implementation of this policy would impact upon any of the categories below? If so, please give details of the evidence you have for this? Grounds / Area of impact People / Issues to consider Type of impact Description of impact and reason / Negative (it could disadvantage) Positive (it could advantage evidence Race People from various racial groups (e.g. contained within the census) NO Gender Male, Female or transsexual/transgender. Also consider caring, NO parenting responsibilities, flexible working and equal pay concerns Disability The Disability Discrimination Act 1995 defines disability as a physical or mental impairment which has a substantial and longterm effect on a persons ability to carry out normal day-to-day activities. This includes sensory impairment. Disabilities may be visible or non visible NO Sexual Orientation Lesbians, gay men, people who are bisexual NO Age Children, young, old and middle aged people NO Religion or belief People who have religious belief, are atheist or agnostic or have a philosophical belief that affects their view of the world. Consider NO faith categories individually and collectively when considering possible positive and negative impacts. 2. If you have identified that there may be a negative impact for any of the groups above please complete questions 2a-2e below. 2a. The negative impact identified is intended OR 2b. The negative impact identified not intended 2c. The negative impact identified is legal OR 2d. The negative impact identified is illegal OR (see 2e) (i.e. does it breach antidiscrimination legislation either directly or indirectly?) 2e. I don t know whether the negative impact identified is legal or not (If unsure you must take legal advice to ascertain the legality of the policy) Waste Management Policy Page 28 of 46

29 3. What is the level of impact? HIGH - Complete a FULL Impact Assessment (see end of this form for details of how to do this) MEDIUM - Complete a FULL Impact Assessment (see end of this form for details of how to do this) X LOW - Consider questions 4-6 below 4. Can any low level negative impacts be removed (if so, give details of which ones and how) N/A 5. If you have not identified any negative impacts, can any of the positive impacts be improved? (if so, give details of which ones and how) No 6. If there is no evidence that the policy promotes equality and equal opportunity or improves relations with any of the above groups, could the policy be developed or changed so that it does? No 7. Having considered the assessment, is any specific action required - Please outline this using the pro forma action plan below (The lead for the policy is responsible for putting mechanisms in place to ensure that the proposed action is undertaken) Issue Action proposed Lead Deadline Waste Management Policy Page 29 of 46

30 8. Lead person Declaration: 8a. Stage One assessment completed by : Christina Woolston. (name). (signature) 16/07/2014 (date) 8b. Stage One assessment form received by Patient experience and Equality Team..(date) 8c. Stage One assessment outcome agreed. (sign here).... (Head of Patient Experience and Equality) OR (date agreed) 8d. Stage One assessment outcome need review.. (sign here).... (Head of Patient Experience and Equality).. (date returned to policy lead for amendment) (if review required please give details in text box below) If a full EQIA is required the stage 1 assessment form should be retained and a completed EQIA report submitted to the relevant governance group for agreement by the chair. The chair will forward the completed reports to the Patient Experience and Equality team for publication. Any questions relating to the completion of this form should be directed to the Head of Patient Experience and Equality. Waste Management Policy Page 30 of 46

31 Supplementary Section B - Human Rights Act Assessment Form and Flowchart You need to be confident that no aspect of this policy breaches a persons Human Rights. You can assume that if a policy is directly based on a law or national policy it will not therefore breach Human Rights. If the policy or any procedures in the policy, are based on a local decision which impact on individuals, then you will need to make sure their human rights are not breached. To do this, you will need to refer to the more detailed guidance that is available on the SHSC web site (relevant sections numbers are referenced in grey boxes on diagram) and work through the flow chart on the next page. 1. Is your policy based on and in line with the current law (including caselaw) or policy? X Yes. No further action needed. No. Work through the flow diagram over the page and then answer questions 2 and 3 below. 2. On completion of flow diagram is further action needed? No, no further action needed. Yes, go to question 3 3. Complete the table below to provide details of the actions required Action required By what date Responsible Person Waste Management Policy Page 31 of 46