Waste management policy

Waste management policy Document Reference No. IPC006 Status Approved Version Number 3.1 Replacing/Superseded policy or v3.0 documents Number of Pages 26 Target audience/applicable to All Staff Author Waste and Environment Manager, Kent and Medway NHS Facilities Acknowledgements Kent and Medway NHS Facilities Contact Point for Queries Waste and Environment Manager, Kent and Medway NHS Facilities Head of Hotel Services Date Ratified 4 June 2013 Date of Implementation/distribution 19 February 2014 Circulation Policy Dissemination / Intranet Review date March 2016 Copyright Kent Community Health NHS Foundation Trust 2013

Governance Arrangements Directorate or Function Governance Group responsible for developing document Circulation group Authorised/Ratified by Governance or Function Group Nursing and Quality Directorate Infection Prevention and Control Assurance Group, Staff Consultation on Intranet, Staff Partnership Forum and Quality Committee Quality Committee Authorised/Ratified On 4 June 2013 Review Date June 2015 Review criteria Key References This document will be reviewed prior to review date if a legislative change or other event dictates. HTM 07-01: Safe Management of Healthcare Waste, Department of Health 2013 The Environmental Protection (Duty of Care) Regulations, 1990 The Hazardous Waste (England and Wales) Regulations, 2005 The Hazardous Waste (England and Wales) (Amendment) Regulations, 2009 The List of Wastes (England) Regulations, 2005 Environment Agency, Hazardous Waste Technical Guidance WM2 Version 2.3, April 2011 The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment (Amendment) Regulations, 2011 The Management of Health & Safety at Work Regulations, 1999 Waste Framework Directive, 2008 The Waste (England and Wales) Regulations, 2011 Department of Health, Estates and Facilities Alert EFA/2012/001, January 2013 Related Policies/Procedures Title KCHFT Waste Management Procedures and Guidelines KCHFT Medicinal Waste Policy KCHFT SAFEMED (Medicine Risk Management) Policy KCHFT Infection Prevention and Control Policy KCHFT Infection Prevention and Control Protocol Needle stick, Sharps or Splash Injury KCHFT Outbreak Policy KCHFT Mattress and Pillow Policy KCHFT Health and Safety Policy KCHFT COSHH Policy KCHFT Data Protection and Confidentiality Policy Reference MM006 MM010 IPC0014P IPC0015P IPC0011P HS012 HS006 KIG002 V3.1 Page 2 of 26 February 2014

Document Tracking Sheet Policy and Procedure Drafting Arrangements Version Status Date Issued to/approved by Comments / summary of changes 0.1 Draft 16/06/09 Infection Prevention and Control Group 0.2 Final Draft 10/09/09 Risk and Governance Committee Comments received and included within document. Authorised 1.0 Authorised 14/09/09 Policy Manager Re-Formatting 2.0 Authorised 01/04/2010 Policy Manager Re-Formatted into ECK Community Services template. 2.1 Revision 19/10/12 KCHFT Waste Management Group 2.2 2 nd Draft 07/03/2012 KCHFT Waste Management Group 2.2 2 nd Draft 11/03/2012 KCHFT Infection Prevention and Control Group 2.3 3 rd Draft 15/04/13 KCHFT Infection Prevention and Control Group 3.0 Approved 4 June 2013 Quality Committee Published 3.1 Approved 19 February 2014 Summary of Changes (if applicable) KCHFT Waste Management Group Comments received and included within document. No further comments Comments received and included within document. Agreed with no further comments. Minor amendments. Comments received and included within document This document has been produced to replace the existing Waste Management Policies for NHS Eastern & Coastal Kent and NHS West Kent Community Services. The policy has been updated in line with both current legislation and best practice. The minor changes to the existing document are; Updated KMF contact details Updated legislation list Updated poster in Appendix C to reflect the new pharmaceutical waste bins Amended Head of Information Governance responsibilities 3.4.16 Updated version of HTM throughout the document. Removed reference to and Head of Procurement responsibilities for the Site Waste Management Plan Regulations as legislation has been repealed. V3.1 Page 3 of 26 February 2014

CONTENTS PAGE 1.0 EXECUTIVE SUMMARY 5 2.0 INTRODUCTION 5 3.0 ROLES AND RESPONSIBILITIES 6 4.0 REGULATORY FRAMEWORK 10 5.0 CLASSIFICATION OF WASTE 10 6.0 AUDITING 10 7.0 RECORD KEEPING 11 8.0 WASTE PREVENTION AND MINIMISATION 11 9.0 WASTE SEGREGATION 11 10.0 WASTE HANDLING 11 11.0 WASTE STORAGE 11 12.0 WASTE DISPOSAL 12 13.0 RECYCLING 12 14.0 TRANPORTATION 12 15.0 WASTE IN THE COMMUNITY 12 16.0 CARBON REDUCTION 13 17.0 MONITOIRNG AND REPORTING 13 18.0 ACCIDENTS AND INCIDENTS 13 19.0 CONTRACTORS 13 20.0 CONTINGENCY PLANNING 14 21.0 TRAINING AND AWARENESS 14 22.0 STAKEHOLDER, CARER AND USER INVOLVEMENT 14 23.0 MONITORING COMPLIANCE AND EFFECTIVENESS OF THIS POLICY 15 24.0 EQUALITY ANALYSIS 15 25.0 EXCEPTIONS 16 26.0 GLOSSARY AND ABBREVIATIONS 16 27.0 REFERENCES 16 Appendix 1 Persons/Groups Involved in Document Development 17 Appendix 2 Clinical Waste Segregation Poster 18 Appendix 3 List of Hazardous Medicines 20 Appendix 4 Regulatory Framework 22 Appendix 5 Waste Classification Using EWC Codes 23 Appendix 6 Waste Hierarchy 24 Appendix 7 Waste Audit Protocol 25 V3.1 Page 4 of 26 February 2014

1.0 EXECUTIVE SUMMARY Scope and Purpose of Policy 1.1 The Kent Community Health NHS Foundation Trust (KCHFT) acknowledges its legal responsibility to dispose of all waste so that no harm is caused to either human health or the environment. The responsibility for waste extends from cradle (production of the waste) to grave (final disposal of the waste) even where authorised agents are used. 1.2 To effectively manage waste generated on healthcare premises, those responsible for the management of waste should understand and must comply with the requirements of 4 regulatory regimes: Environment, Health and Safety, Transport and Data Protection. 1.3 To ensure that Waste Management practices comply with these requirements it is necessary for the Trust to procure appropriate waste management services and to have access to competent waste management advice. 1.4 As a member of the Kent and Medway NHS Total Waste Management (TWM) Consortium, KCHFT has contracted with Tradebe Healthcare Holdings Ltd to provide a total waste management service to the Trust and the other Kent based NHS Trusts who form the consortium. 1.5 Access to competent waste management advice is through the Kent and Medway NHS Facilities (KMF) Waste and Environment Manager based at Pembroke Court on 01634 335220. 1.6 This policy should be read in conjunction with the KCHFT Waste Management Procedures and Guidelines. Both documents address the risks regarding waste and form a basis for managing waste in a safe and compliant manner. The risks of not addressing these issues correctly are fines, prosecution, reputational damage and harm to people and the environment. 2.0 INTRODUCTION 2.1 This policy covers all of the Trust s staff and sites including areas for inpatients, outpatients, day care and community services. It describes the systems for waste handling, segregation, storage, disposal and monitoring. In addition it sets out key responsibilities for waste management within the Trust. 2.2 This policy draws together both best practice and legal requirements and should be used in conjunction with the Waste Management Procedures and Guidelines to ensure that waste produced by the Trust is managed responsibly and appropriately. 2.3 The implications of a breach of this policy and failing to provide a safe system of work are: the potential for injury; contamination of sites; risk of infection to staff, patients, visitors and contractors; the imposition of civil sanctions and prosecution. 2.4 The success of this policy is incumbent upon every staff member to analyse that part of the waste process to which they contribute and to ensure that they comply with the legislative and other requirements. 2.5 The purpose of this policy is to identify the procedures required for the management of all waste produced by the Trust in accordance with current legislation and best practice guidance as detailed in the Department of Health document HTM 07-01: Safe Management of Healthcare Waste, and other codes and regulations that are listed in Appendix 4. 2.1 Ethnicity and Diversity 2.1.1 Communication and the provision of information are essential tools of good quality care. All patients, carers and staff should be given full assistance to ensure understanding. This V3.1 Page 5 of 26 February 2014

assistance will take many forms and media. These principles should be enshrined in all formal documents. 2.1.2 Kent Community Health NHS Foundation Trust is committed to ensuring that patients whose first language is not English receive the information they need and are able to communicate appropriately with healthcare staff. It is not appropriate to use children under the age of 16 to interpret for family members who do not speak English. There is an interpreter service available and staff should be aware of how to access this service. 2.1.3 The privacy and dignity rights of patients must be observed whilst enforcing any care standards e.g. providing same sex carers for those who request it. (Refer to Privacy and Dignity Policy.) 2.1.4 All forms of communication (e.g. sign language, visual aids or other means) which ensures the patient understands should be considered. Different languages or format regarding publications can be produced through the Communications and Engagement Team and a translation service should be made available where required. 3.0 ROLES AND RESPONSIBILITIES 3.1 Trust Board / Heads of Service The Trust Board/Heads of Service are responsible to; 3.1.1 Ensure that all waste produced by KCHFT is disposed of in accordance with the relevant legislation. 3.1.2 Provide sufficient resources to ensure that all waste is handled and disposed of safely and in accordance with relevant legislation. 3.1.3 Ensure that this policy is implemented and adhered to across the Trust. 3.2 Staff and Managers Staff All Staff are responsible to; 3.2.1 Ensure compliance with all relevant legislation. 3.2.2 Comply fully with the Trust policy, procedures, guidelines and training on waste. 3.2.3 Comply with the Environmental Protection (Duty of Care) Regulations (1990) as defined in Regulatory Framework section. 3.2.4 Undertake waste training at least once every three years. 3.2.5 Pay particular attention to items of confidential waste and ensure that the rights of individuals are protected as specified under the Data Protection Act and the Trust s Data Protection and Confidentiality Policy. Assistance should be sought from the Head of Information Governance if the requirements for this are unclear. 3.2.6 Ensure that personal protection and basic hygiene precautions are adhered to when handling waste. 3.2.7 Work safely without creating a risk to themselves or others. 3.2.8 Report illegal/dangerous waste situations to their line manager as soon as they are identified and assist with the incident report form. V3.1 Page 6 of 26 February 2014

3.2.9 Not handle any waste considered to be too heavy, or for which the correct method of disposal is unknown to them. 3.2.10 Only move correctly sealed and labelled waste. 3.2.11 Apply the waste hierarchy prior to disposal of any waste. 3.2.12 Assist with the correct classification of waste by use of EWC codes. 3.2.13 Ensure that the nature and dangers of the waste to be carried are made known to the collectors, handlers and contractors etc through proper segregation and clear labelling. 3.2.14 Contact the KMF Waste and Environment Team for advice as required. Managers 3.2.15 Management responsibility extends to all Site or Service Managers, Team Managers and anyone with delegated management responsibility in their absence. Managers are responsible to; 3.2.16 Receive updates on legislation via the admin email route and ensure that this information is cascaded to all Staff. 3.2.17 Ensure that all staff are aware of segregation procedures and identify and seek funding for the correct equipment to be supplied, enabling waste streams to be segregated in accordance with this policy and the accompanying procedures and guidelines. 3.2.18 Ensure that safety requirements associated with waste are adhered to and that any risks regarding waste are properly documented on a risk assessment in accordance with the Trust s Health and Safety Policy. 3.2.19 Ensure that all Staff involved in the handling of healthcare waste will receive appropriate training and attend periodic refresher training. 3.2.20 Ensure that all staff are provided with PPE appropriate to the task. 3.2.21 Ensure that a moving and handling assessment is carried out before moving heavy items of waste. 3.2.22 Ensure that all elements of the Infection Control and Health and Safety and Data Protection policies with regard to waste are adhered to. 3.2.23 Ensure that the Site Waste Management File is kept up to date and accessible at all times. 3.2.24 Ensure that all waste collection paperwork is fully completed at the point of collection and filed in the Waste Management File on site. 3.3 Committees and Committee Heads KCHFT Waste Management Group The KCHFT Waste Management Group is responsible to; 3.3.1 To provide a monitoring forum for all waste management activity within the Trust. V3.1 Page 7 of 26 February 2014

3.3.2 To implement a waste strategy in accordance with legislation and best practice guidance as detailed in the Department of Health document HTM 07-01: Safe Management of Healthcare Waste. 3.3.3 To ensure that waste management systems are compliant with the relevant outcomes in the Care Quality Commission (CQC) Essential Standards of Quality and Safety. 3.3.4 To seek opportunities for reducing costs and adopting best practice wherever possible. 3.3.5 To report into the Trust wide Infection Prevention and Control Group. Head of Hotel Services / Chair of Waste Management Group The Head of Hotel Services is responsible to; 3.3.6 Chair the KCHFT Waste Management Group 3.3.7 Forward minutes and reports from the Waste Management Group into relevant Governance routes. 3.3.8 Liaise with the KMF Waste and Environment Manager 3.3.9 Represent KCHFT at contract review meetings. 3.3.10 Receive and disseminate monthly reports and waste information from the KMF Waste and Environment Manger 3.4 Specialist Roles KMF Waste and Environment Manager The Waste and Environment Manager is responsible to; 3.4.1 Manage all waste contracts including representing KCHFT as part of the Kent and Medway NHS Total Waste Management Consortium. 3.4.2 Ensure that a monitoring process is in place to certify that all waste management requirements are being complied with. 3.4.3 Inform the Authorised KMF lead for the Trust of any changes in legislation and guidance so that this can be sent through the appropriate communications email route in a timely fashion. 3.4.4 Liaise with relevant Service Leads where waste impacts on service activity. This includes Clinical Services, Infection Control, Health and Safety, Information Governance, Estates Management, Hotel Services and NHS Property Services. 3.4.5 Provide an annual training programme for all staff to ensure that they are aware of the legal and safety implications of managing healthcare waste including categorisation, segregation, handling, storage, transportation and collection. 3.4.6 Provide advice to all Staff regarding the safe management of healthcare waste including advice on legislation and appropriate equipment. 3.4.7 Ensure that all sites producing hazardous waste are registered with the Environment Agency on an annual basis. 3.4.8 Ensure that all Waste Contractors have Waste Carriers licences, Site Permits and exemptions in place and that these are in accordance with relevant regulations. V3.1 Page 8 of 26 February 2014

3.4.9 Ensure that all relevant information on waste is collated and submitted to support the Estates Returns Information Collection (ERIC) and Care Quality Commission (CQC) Essential Standards of Quality and Safety requirements. 3.4.10 Review and update this Waste Policy and associated Procedures and Guidelines in line with the agreed review date or when there is a significant change to legislation or guidance. KCHFT Head of Procurement The Head of Procurement is responsible to; 3.4.11 Ensure that all purchases are made bearing in mind the impact of packaging and specify packaging type on tender/purchasing criteria, where applicable. 3.4.12 Make suppliers responsible for the removal of their own packaging, where applicable, by inclusion in the tender/purchasing criteria. 3.4.13 Make suppliers responsible for the removal of items including Waste Electronic and Electrical Equipment (WEEE) when being replaced on a like for like basis, where applicable, by inclusion in the tender/purchasing criteria. 3.4.14 Make contractors responsible for removing their own waste by inclusion in the tender/purchasing criteria. KCHFT Head of Information Governance 3.4.15 The Head of Information Governance at KCHFT is responsible for ensuring that confidential waste (in particular documents relating to the care of individual patients and the employment of individual staff) is managed correctly with regard to retention dates and storage. The responsibility for ensuring appropriate storage at a local level is delegated to Site and Team Managers. KCHFT Link Workers The Infection Control Link Workers are responsible to; 3.4.16 Provide a point of contact for general queries on site. 3.4.17 Lead by example with regard to best practice and waste segregation. 3.4.18 Assist with implementation of audit action plans. Landlord / Tenant Responsibilities 3.4.19 Landlords are responsible for providing appropriate facilities for the segregation and storage of waste e.g. compounds/ designated storage areas. 3.4.20 Tenants are responsible for segregating, packaging, the safe storage of waste whilst awaiting collection and in many cases also for the collection service. 3.4.21 Some Landlords may provide waste collection services, but this does not indemnify the Tenant from their responsibility for the safe management of the healthcare waste that they have produced. 3.4.22 The Landlord and Tenant should work together to ensure the safe management of waste and report any breaches of policy or issues to either party. 3.4.23 Where there are shared facilities, the Tenant should cooperate with other tenants to ensure the safe management of waste. V3.1 Page 9 of 26 February 2014

3.4.24 In negotiating a lease for a rental property, clarification must be sought on who is responsible for waste and how it will be managed on site. 3.4.25 A representative from NHS Property Services Ltd will be invited to attend the KCHFT Waste Management Group. 4.0 REGULATORY FRAMEWORK 4.1 The Acts, Regulations and Guidance which are central to the Waste Policy and with which compliance is mandatory are detailed in Appendix 4. This list is not exhaustive and will be added to/updated as appropriate. The Acts and Regulations are available on the following website www.opsi.gov.uk 4.2 Also included within this framework are the local Policies, Procedures and Guidelines of KCHFT. This list is not exhaustive and is subject to change periodically. The local Policies, Procedures and Guidelines are available on the following website www.kentcht.nhs.uk/intranet/ 4.3 The Waste Management Procedures and Guidelines give further detail on the practical implementation of the legislative requirements. 5.0 CLASSIFICATION OF WASTE 5.1 Waste regulation requires the classification of waste on the basis of hazardous characteristics and point of production. All waste produced by the Trust will be classified in accordance with the Hazardous Waste Regulations, List of Waste Regulations and using the relevant European Waste Catalogue (EWC) Codes as defined in Appendix 5. 5.2 Clinical waste will also be segregated and classified in accordance with the NHS national colour coding for waste receptacles as identified in the HTM 07-01: Safe Management of Healthcare Waste. 6.0 AUDITING 6.1 To ensure that Trust sites are compliant with legal obligations, all sites producing clinical waste will be audited (see KMF Waste Audit Protocol, Appendix 7) as part of an annual programme. The audit will focus on the following areas; Classification, Segregation, Packaging, Waste Description, Paperwork Completion and Retention, Storage, Movement and Transport, Health and Safety, Final Disposal. 6.2 Following each audit a report will be sent out to the Site Manager and any other relevant staff detailing observations, areas of concern and recommendations for improvement. The report will be reviewed by the KMF Waste and Environment Manager and given a risk rating of Red, Amber or Green and a deadline for actions to be completed. 6.3 The Site or Service Manager is required to put any red risks onto the risk register. 6.4 The Site or Service Manager concerned will be required to ensure that all required actions are completed within the specified timescale and to ensure that the audit is signed and returned to KMF. 6.5 The relevant Service Director will be informed of serious breaches of policy and procedures and if the deadline for action is not met. V3.1 Page 10 of 26 February 2014

7.0 RECORD KEEPING 7.1 Each site that produces clinical waste will be provided with a site Waste Management File. Any updates to the file will be dated and given an issue number and will be issued through the admin email route. 7.2 The site Waste Management File must be kept up to date and used to store all Controlled Waste Transfer Notes, Hazardous Waste Consignment Notes, Hazardous Waste Producer Returns and Certificates of Destruction for a minimum of 3 years. 7.3 Hazardous Waste Producer Returns will be received by the KMF Waste and Environment Team and will be distributed to sites after being logged and copied. 7.4 If a site closes the waste management file must be returned to the KMF Waste and Environment Manager for retention by the Trust. 8.0 WASTE PREVENTION AND MINIMISATION 8.1 KCHFT is striving for operations close to the top of the Waste Hierarchy (See Appendix 6) where prevention is the preferred option and disposal is the least preferred option. A variety of waste management options are possible to prevent and minimise waste on all sites and it is the responsibility of all Staff to explore these wherever possible. 9.0 WASTE SEGREGATION 9.1 KCHFT will ensure that all waste is segregated at the point of production. Staff will be given guidance on appropriate segregation through the Waste Management Procedures and Guidelines, site audit visits and the waste training programme. 9.2 Posters and bin signs will be displayed in all relevant areas to provide an aid to correct segregation. See Appendices 2 and 3. 9.3 The Trust will ensure that all necessary equipment is made available as necessary to ensure appropriate segregation. 10.0 WASTE HANDLING 10.1 KCHFT will ensure that all waste is handled safely and appropriately. Staff will be given guidance on appropriate handling through the Waste Management Procedures and Guidelines and the Waste Training Programme. All Staff are required to complete object moving and handling training and to wash their hands after handling waste. 10.2 The Trust will ensure that appropriate Personal Protective Equipment (PPE) is available at all times when staff are handling waste. 11.0 WASTE STORAGE 11.1 KCHFT will ensure that all waste is stored safely and appropriately both at the point of production and whilst awaiting collection. Different types of waste must be stored separately taking into account any hazardous properties and specific storage requirements for those items. Staff will be given guidance on appropriate storage through the Waste Management Procedures and Guidelines and the Waste Training programme. 11.2 All confidential waste in any format must be stored securely whilst awaiting appropriate destruction. V3.1 Page 11 of 26 February 2014

11.3 The Trust will ensure that appropriate storage areas are identified for waste to await collection. Arrangements have been made to receive and store clinical waste generated in the community, and these sites around the Trust s area of operations will be advertised on Intranet and to relevant service departments. 12.0 WASTE DISPOSAL 12.1 KCHFT will ensure that all waste is disposed of appropriately and within the legal requirements for each category of waste. All contractors will be checked to ensure the appropriate licensing is held and that the correct paperwork is completed for all waste transactions. 12.2 All requests for waste disposal must be handled via the KMF Waste and Environment Team. Under no circumstances should sites be making their own arrangements for disposal. 12.3 The Waste Management Procedures and Guidelines give further detail on this topic. 13.0 RECYCLING 13.1 In order to be legally compliant the Trust will recycle any specified product. The Trust will also recycle if is economically prudent to do so, or where the Trust considers it desirable from an environmental perspective and the process offers value for money. 13.2 Confidential waste may be shredded on site and the resulting chaff placed within the normal paper recycling waste stream. This is the best method of disposal at most Trust sites, and shredders should be bought to allow it to take place. In a few larger sites specific collections will be arranged for destruction (see section 12 above). 13.3 The Waste Management Procedures and Guidelines give further detail on this topic. 14.0 TRANSPORTATION 14.1 The Trust requires all staff to comply with the requirements of The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations when moving any waste within their own or a Trust vehicle. 14.2 KCHFT has a Waste Carriers Licence which permits all directly employed staff to carry waste on the public highway and will ensure that this is renewed every three years upon expiry. 14.3 The Trust employs the services of a Dangerous Goods Safety Advisor (DGSA) via KMF to monitor the transportation of dangerous goods including but not limited to clinical waste, diagnostic specimens and used medical instruments. The DGSA can be accessed through the KMF Waste and Environment Manager. 15.0 WASTE IN THE COMMUNITY 15.1 Any waste produced by a Healthcare professional in a Patient s home is considered to be the responsibility of both the professional and the Trust. It is not acceptable to put infectious waste into a Patient s domestic waste stream. 15.2 The Trust will ensure that Staff are provided with appropriate receptacles and transport containers where necessary to ensure that it is returned to the Trust for disposal. 15.3 In circumstances where it is not practicable to return the waste to the Trust, arrangements will be made for safe and legally compliant disposal via a licensed contractor. 15.4 The Waste Management Procedures and Guidelines give further detail on this topic. V3.1 Page 12 of 26 February 2014

16.0 CARBON REDUCTION 16.1 KCHFT recognise that waste in all forms has a significant impact on the environment, not just in the end of life disposal but in the whole life cycle of the product. Carbon emissions are created in the manufacturing, packaging, marketing, use and end of life disposal of products. Waste is not just the environmental cost of disposal but also the value of the wasted products. 16.2 KCHFT will monitor carbon emissions through waste and put procedures in place to ensure that waste is managed appropriately from cradle to grave. KCHFT is committed to reducing unnecessary waste, reducing waste to landfill and increasing recycling wherever possible. Waste will be monitored and targeted as part of the Trust s carbon reduction strategy. 17.0 MONITORING AND REPORTING 17.1 All waste issues and incidents will be monitored by the KMF Waste and Environment Manager. Monthly monitoring reports will be provided by the Waste and Environment Manager and will include Serious Untoward Incidents (SUI s), Non-conformances, Audits completed, Training completed, Costs and Weights of waste disposal. 17.2 Monthly exception reports will be produced by the Waste and Environment Manager for the purpose of Board assurance under the CQC s Essential Standards of Quality and Safety. These reports will include; Contract Updates, Legislation and Compliance Issues. 18.0 ACCIDENTS AND INCIDENTS 18.1 All accidents and incidents with regard to waste will be reported via the completion of a Health and Safety incident form in accordance with the Trust s Health and Safety Policy. The Waste and Environment Manager will assist the investigating Manager in the implementation of any recommended actions as the result of an investigation. 18.2 Where an accident or incident is related to medicines a SAFEMED must be completed using the DATIX on-line reporting facility. 18.3 Incidents of non conforming waste are reported to the Waste and Environment Manager via the waste contractor and incur a minimum fine of 100.00 + VAT for the site concerned. All such incidents will be investigated by the Waste and Environment Team and a report will be provided to the Site/Service Manager. 19.0 CONTRACTORS 19.1 All contractors undertaking any form of work for KCHFT are required to comply with all relevant legal obligations and to adhere to best practice as described in Safe Management of Healthcare Waste wherever possible. 19.2 Contractors are also required to; Provide copies of all waste related licences and permits upon request. Provide collection paperwork including Controlled Waste Transfer Notes and Hazardous Waste Consignment Notes where applicable. Provide copies of risk assessments and method statements. Report any concerns or incidents to the Waste Manager. Provide the Trust with up to date emergency contact numbers and contingency plans where required. Adhere to basic hygiene and infection control principles. Behave in an appropriate manner whilst on Trust property. V3.1 Page 13 of 26 February 2014

20.0 CONTINGENCY PLANNING 20.1 KCHFT will work to ensure that there are appropriate contingency procedures in place to reduce both the likelihood and impact of waste being built up on site in the event of a system failure or serious incident affecting the ability of our contractor/s to fulfil their contractual obligations. 20.2 The Waste and Environment Manager will hold a file containing the following information for use in an emergency situation or serious system failure; Contact details for relevant persons in the Trust, including Senior Managers, Infection Control and Health and Safety representatives. Contact details for existing contractors, including emergency numbers and a copy of their contingency plan. Contact details for local Environment Agency offices including emergency numbers. Site lists including information on those identified as priority sites for collection purposes. Contact details for alternative waste contractors operating in the area in the event of the Trust contractors being unable to collect waste, or provide a service, for any reason. 21.0 TRAINING AND AWARENESS 21.1 Training 21.1.1 To ensure that Staff are aware of and compliant with legal obligations, all staff will be provided with the opportunity to attend Waste Management training as part of a training programme administered by the KCHFT Learning and Development Department. 21.1.2 A clinical and non clinical waste training package will be provided for all Staff. Further packages may be produced as necessary for identified staff groups. Training can be completed via e- learning or through face to face training. 21.1.3 The e-learning package can be accessed on Intranet. The face to face training can be accessed via the KCHFT Learning and Development Department. 21.1.4 The training packages for face to face delivery will be written and produced by the KMF Waste and Environment Manager and delivered by a member of the Waste and Environment Team. All training packages will include as a minimum the following information: legal requirements, best practice, classification, segregation, handling, storage and collection of waste. 21.1.5 Waste training is essential for all Clinical Staff, all Domestic and Portering Staff and all Site and Service Managers. 21.2 Awareness 21.2.1 This policy will be placed on the staff intranet under the policies section and an admin email will be sent to all staff to notify them of its existence. Any updates or amendments to the Waste Policy or the Procedures and Guidelines will be notified to staff via the admin email route. 22.0 STAKEHOLDER, CARER AND USER INVOLVEMENT 22.1 This policy was developed by the KMF Waste and Environment Manager to comply with the recommendations contained within the Safe Management of Healthcare Waste and after consultation with relevant agencies and groups. 22.2 This policy will be used by all employees of the Trust. 22.3 Employees will be informed of the policy and changes via the Policy Manager using the Trust website. This will be published on the internet for access by the public. V3.1 Page 14 of 26 February 2014

22.4 This policy was reviewed and commented on by various parties including Kent and Medway NHS Facilities (KMF) Waste and Environment Team, the KCHFT Waste Management Group and the Trust Wide Infection Prevention and Control Group. (See Appendix 1 for full list) 23.0 MONITORING COMPLIANCE AND EFFECTIVENESS OF THIS POLICY 23.1 The following table outlines the process by which adherence to the document requirements will be audited and monitored: 23.2 Monitoring Matrix: What will be monitored? How will it be monitored? Who will monitor? Frequency All sites producing clinical waste to be audited annually. By the completion of an annual audit programme. Waste Manager Ongoing Annually. All non-conforming waste incidents to be investigated. By the completion of nonconformance reports. Waste Manager Ongoing - Annually All actions identified through audit reports to be completed within specified timescale. All relevant staff to be offered waste training. 24.0 EQUALITY ANALYSIS All required actions to be overseen by Site Manager or identified lead on waste issues. By the completion of an annual training programme. Waste Manager Ongoing - Annually Learning and Development Department Ongoing - Annually 24.1 Kent Community Health NHS Foundation Trust is committed to promoting and championing a culture of diversity, fairness and equality for all our employees, potential employees, service users as well as members of the public. 24.2 Understanding of how policy decisions and services can impact on protected groups under the Equality Act 2010 is key to ensuring quality and productive environments for patient care and also the workforce. Protected groups' are: Race Disability Sex Religion or belief Sexual orientation (being lesbian, gay or bisexual) Age Gender Re-assignment Pregnancy and maternity Marriage and civil partnership 24.3 All forms of communication (e.g. sign language, visual aids, interpreting and translation or other means) which ensures the patient understands should be considered. (See the Big Word pages for help) http://www.kentcht.nhs.uk/intranet/resources/helping-you-to-doyour-job/interpreting-and-translation 24.4 The privacy and dignity (human rights) of patients must be considered alongside any care standards and identify the fundamental links between good health care and equality. 24.5 The Equality Analysis for this policy is located on the public website: http://www.kentcht.nhs.uk/about-us/equality-and-diversity/equality-analysis/ V3.1 Page 15 of 26 February 2014

25.0 EXCEPTIONS 25.1 There are no exceptions to this policy. A basic requirement is that all Trust staff must have read and understood this policy and the accompanying Waste Management Procedures and Guidelines. 26.0 GLOSSARY AND ABBREVIATIONS Abbreviation KCHFT KMF EA TWM CQC ERIC WEEE DGSA PPE SUI EWC SWMP EA Meaning Kent Community Health NHS Foundation Trust Kent and Medway NHS Facilities Environment Agency Total Waste Management Care Quality Commission Estates Returns Information Collection Waste Electrical and Electronic Equipment Dangerous Goods Safety Advisor Personal Protective Equipment Serious Untoward Incident European Waste Catalogue Site Waste Management Plan Equality Analysis 27.0 REFERENCES Disposal of Sharps and Clinical Waste Poster, Kent and Medway NHS Facilities, 2012 List of Hazardous Medicines, Kent and Medway NHS Facilities, 2012 WM2 Hazardous Waste: Interpretation of the Definition and Classification of Hazardous Waste, Environment Agency, 2011 V3.1 Page 16 of 26 February 2014

APPENDIX 1 PERSONS/GROUPS INVOLVED IN THE DEVELOPMENT AND APPROVAL OF THIS DOCUMENT Review and Comment KMF Waste and Environment Team KCHFT Waste Management Group Head of Health and Safety, NHS Kent and Medway Head of Information Governance, KCHFT KCHFT Trust wide Infection Prevention and Control Group Review and Approval/Ratification KCHFT Trust wide Infection Prevention and Control Group V3.1 Page 17 of 26 February 2014

APPENDIX 2 CLINICAL WASTE SEGREGATION POSTER The following poster (available from the KMF Waste and Environment Team) must be laminated and displayed in all clinical and treatment areas. The poster will be periodically updated and the existing versions must be replaced with the new one when made available by the Waste and Environment Team. DISPOSAL OF SHARPS and CLINICAL WASTE CONTAINER EWC CODE WASTE DESCRIPTION Infectious Waste 18 01 03* Infectious or potentially infectious healthcare waste Examples: Dressings, swabs, cotton wool, used protective clothing. Offensive Waste 18 01 04 Non-infectious healthcare waste Examples: Continence pads, sanitary towels, empty saline and blood bags. Sharps Uncontaminated by Medicines 18 01 03* Syringes and sharps objects NOT contaminated with medicinal residue. Examples: Phlebotomy sharps, lancets, acupuncture needles, scissors, razors and scalpels. Sharps Contaminated with Non-hazardous Medicines 18 01 03*/09 Syringes and sharps objects, contaminated with Non-cytotoxic / Non-cytostatic medicinal residue. Examples: Used syringes, broken ampoules. Sharps Contaminated with Hazardous Medicines 18 01 03*/08* Syringes and sharps objects, contaminated with Cytotoxic and Cytostatic medicinal residue. Examples: Used syringes, broken ampoules. Non-hazardous Medicinal Waste 18 01 09 Non-cytotoxic and Non-cytostatic tablets and liquid medicinal waste in original packaging. Examples: Tablets, liquids, refused medicines (liquids must be contained), empty medicine bottles, medicated IV bags. V3.1 Page 18 of 26 February 2014

Hazardous Medicinal Waste 18 01 08* Cytotoxic and Cytostatic tablets and liquid medicinal waste in original packaging. Examples: Tablets, liquids, refused medicines (liquids must be contained), empty medicine bottles, medicated IV bags. All bags and boxes must be labelled with the following; Site Name, Ward or Department, Date, Hazardous Waste Registration Number and EWC code. Your Site Hazardous Waste Registration No. Is: Please contact the KMF Waste and Environment Team on 01634 335220 with any queries. V3.1 Page 19 of 26 February 2014

APPENDIX 3 The following poster (available from the KMF Waste and Environment Team) must be laminated and displayed in all clinical and treatment areas. LIST OF HAZARDOUS MEDICINES The following is a list of medicines that due to their Cytotoxic or Cytostatic properties are deemed to be hazardous and must be disposed of via the purple route; A Actinomycin Aldesleukin Alemtuzumab Alitretinoin Altretamine Amsacrine Anastrozole Arsenic Trioxide Asparaginase Azacitidine Azathioprine B Bacillus Calmette-Geurin Vaccine (BCG) Bevacizumab Bexarotene Bicalutamide Bleomycin Bortezomib Botulinum Toxin (Botox) Busulfan C Capecitabine Carboplatin Carmustine Cetrorelix Acetate Cetuximab Clorambucil Chloramphenicol Chlormethine Hydrochloride Choriogonadotropin Alfa Ciclosporin Cidofovir Cisplatin Cladribine Clofarabine Clorambucil Coal Tar containing products Colchicine Crisantaspase Cyclophosphamide Cytarabine D Dacarbazine Dactinomycin Danazol Dasatinib Daunorubicin HCI Decitabine Denileukin Dienostrol Diethylstilbestrol Dinoprostone Dithranol containing products Docetaxel Doxorubicin Dutasteride E Epirubicin Ergometrine/Methylergometrine Estradiol Estramustine Phosphate Sodium Estrogen-Progestin Combinations Estrogens, Conjugated Estrogens, Esterified Estrone Estropipate Etoposide Exemestane F Finasteride Floxuridine Fludarabine Fluorouracil Fluoxymesterone Flutamide Fulvestrant G Ganciclovir Ganirelix Acetate Gemcitabine Gemtuzumab Ozogamicin Gondaotrophin, chorionic Goserelin (Zoladex) H Hydroxycarbamide I Ibritumomab Tiuxetan Idarubicin Ifosfamide Imatinib Mesilate Interferon Alfa-2b Interferon containing products Irinotecan HCI L Leflunomide Letrozole Leuprorelin Acetate Lomustine Lymphoglobuline M V3.1 Page 20 of 26 February 2014

Medroxyprogesterone Megestrol Melphalan Menotropins Mercaptopurine Mesena Methotrexate Methyltestosterone Mifepristone Mitomycin Mitotane Mitoxantrone HCI Mycophenolate Mofetil N Nafarelin Natalizumab Nilutamide O Oestrogen containing products (see also Estrogen) Oxaliplatin Oxytocin (including syntocinon and syntometrine) P Paclitaxel Paraldehyde Pegaspargase Pemetrexed Disodium Pentamidine Isethionate Pentostatin Perphosphamide Pipobroman Piritrexim Isethionate Plicamycin Podoflilox Podophyllin Podophyllum Resin Prednimustine Procarbazine Progesterone containing products Progestins R Raloxifene Raltitrexed Ribavirin Rituximab S Sirolimus Streptozocin T Tacrolimus Tamoxifen Temozolomide Teniposide Testolactone Testosterone Thalidomide Thioguanine Thiotepa Thymoglobulin Tioguanine Topotecan Toremifene Citrate Tositumomab Trastuzumab Treosulfan Tretinoin Trifluridine Trimetrexate Glucuronate Triptorelin U Uramustine V Vaccines (Live) Valganciclovir Valrubicin Vidarabine Vinblastine Sulfate Vincristine Vindesine Vinorelbine Tartrate Z Zidovudine This list is intended as a guide and is not an exhaustive list. Please check the data sheets for further guidance if you are unsure as to the Cytotoxic and Cytostatic properties of any medicines or consult with a Pharmacist. If you have any queries regarding the disposal of the medicines listed, please contact the Waste and Environment Team on 01634 335220. V3.1 Page 21 of 26 February 2014

APPENDIX 4 Regulations REGULATORY FRAMEWORK The Environmental Protection Act, 1990 The Environmental Protection (Duty of Care) Regulations, 1991 The Hazardous Waste (England and Wales) Regulations, 2005 The Hazardous Waste (England and Wales) (Amendment) Regulations, 2009 The List of Wastes (England) Regulations, 2005 The Landfill (England and Wales) Regulations, 2002 The Controlled Waste Regulations, 1992 The Controlled Waste (Registration of Carriers and Seizure of Vehicles) Regulations, 1991 The Pollution Prevention and Control (England and Wales) Regulations, 2000 The Waste Incineration (England and Wales) Regulations, 2002 The Waste Management Licensing Regulations, 1994 The Environmental Permitting (England and Wales) Regulations, 2007 The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations, 2009 Control of Substances Hazardous to Health Regulations (COSHH), 2002 The Health and Safety at Work etc. Act, 1974 The Management of Health and Safety at Work Regulations, 1999 The Personal Protective Equipment at Work Regulations, 1992 The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations, 1995 The Waste Electrical and Electronic Equipment (WEEE) Regulations, 2006 The Waste Batteries and Accumulators Regulations, 2009 The Waste (England and Wales) Regulations, 2011 The Waste (England and Wales) (Amendment) Regulations, 2012 Waste Framework Directive, 2008 Data Protection Act, 1998 Health and Safety (Sharp Instruments in Healthcare) Regulations, 2013 Guidance & Requirements HTM 07-01: Safe Management of Healthcare Waste, Department of Health 2013. HTM 07-05: The Treatment, Recovery, Recycling and Safe Disposal of Waste Electrical and Electronic Equipment. WM2 Hazardous Waste: Interpretation of the Definition and Classification of Hazardous Waste. Care Quality Commission, Essential Standards of Quality and Safety. Estates and Facilities Alert EFA/2013/001, Department of Health, January 2013. Trust Policies Waste Management Procedures and Guidelines Medicinal Waste Policy SAFEMED (Medicine Risk Management) Policy. Policy for the Management of Medicines Related Incidents Including Near Misses Infection Prevention and Control Policy Infection Prevention and Control Protocol Needle stick, Sharps or Splash Injury Outbreak Policy Outbreak Policy Mattress and Pillow Policy Heath and Safety Policy COSHH Policy KCHFT Data Protection and Confidentiality Policy V3.1 Page 22 of 26 February 2014

APPENDIX 5 WASTE CLASSIFICATION USING EWC CODES The Environment Agency document Hazardous Waste Technical Guidance WM2 provides guidance on the classification of wastes found in the European Waste Catalogue (EWC) in relation to the hazard groups identified in the Hazardous Waste Regulations. Because healthcare premises produce a wide variety of waste, reference should be made to the relevant EWC chapters in WM2 for all other wastes. Trust staff are advised to contact the KMF Waste and Environment Team for further advice. EWC coding for Healthcare (Clinical) Wastes EWC Code Description of waste 18 01 XX Waste from natal care, diagnosis, treatment or prevention of disease in humans 18 01 01 Sharps except 18 01 03* 18 01 02 Body parts and organs including blood bags and blood preserves (except 18 01 03*) 18 01 03* Waste whose collection and disposal is subject to special requirements in order to prevent infection 18 01 04 Waste whose collection and disposal is not subject to special requirements in order to prevent infection e.g. dressings, plaster casts, linen, disposable clothing 18 01 06* Chemicals consisting of dangerous substances 18 01 07 Chemicals other than those listed in 18 01 06* 18 01 08* Cytotoxic and Cytostatic medicines 18 01 09 Medicines other than those mentioned in 18 01 08* 18 01 10* Amalgam waste from dental care Environment Agency, 2011 * Hazardous Waste List Entries It is a legal requirement to use the asterisk on relevant EWC codes, not an indicator of further information. Hazardous wastes can be absolutes entries (in which case they are always hazardous highlighted red in the Table) or mirror entries (which can either be hazardous or non-hazardous depending on their properties highlighted blue in the Table). V3.1 Page 23 of 26 February 2014

APPENDIX 6 WASTE HIERACHY Under the Waste (England and Wales) Regulations 2011, it is legal requirement to apply the Waste Hierarchy to all waste prior to disposal, with prevention being the top priority. In order to reduce waste, the following considerations and actions should be followed by all staff in relation to purchasing and disposal. 1. Prevention Keep products for longer Manage ordering. Rotate supplies to ensure products with best before dates are used with the closest dates first. Store materials properly to avoid damage. Talk to suppliers about reducing packaging on delivered items. Use less hazardous materials. Consider if all stock items are necessary or can be replaced with alternative products. 2. Preparing for re-use Check, clean and repair items as many times as safely possible. Good condition items that are no longer required should be offered to other sites via the global admin emails. Liaise with relevant teams to arrange for unwanted items to be sold at auction or donated to charity. 3. Recycling Separate waste at the source of creation. Use on site recycling facilities. Do not contaminate segregated bins or skips with inappropriate items. Use recycled or secondary materials if they are fit for purpose. Take full advantage of any take-back services offered by suppliers of new goods. 4. Other Recovery Most of the Trust s domestic waste is sent for incineration with energy recovery. 5. Disposal (Landfill or Incineration without Energy Recovery) Sharps and Medicinal waste is sent for incineration without energy recovery and infectious waste sacks are sent to autoclave and then landfill. All remaining waste non contaminated general waste will be disposed of via landfill; therefore disposal should only take place as a last resort when all other options have been considered. The Waste and Environment Team should be contacted to discuss disposal options. V3.1 Page 24 of 26 February 2014

APPENDIX 7 KMF Waste and Environment Team Waste Audit Protocol 1. To ensure that Trust sites are compliant with legal obligations, all sites producing clinical waste will be audited as part of an annual programme. The audit will focus on the following areas as outlined in the Department of Health document HTM 07-01: Safe Management of Healthcare Waste ; Classification Segregation Packaging Waste Description Paperwork Completion and Retention Storage Movement/Transport Health and Safety Final Disposal 2. The audit will be carried out by a member of the Kent and Medway NHS Facilities (KMF) Waste and Environment Team. The auditor will be trained in waste auditing techniques and have a good knowledge of the requirements for the safe management of healthcare waste. 3. The audit process has been risk assessed and the auditor will be aware of safe practices in auditing and whilst on site. 4. The auditor will require access to all clinical areas, particularly wards, clinic rooms, treatment rooms and sluice rooms. A random sample of bathrooms, toilets and admin areas will be checked in addition to all internal and external waste storage areas. 5. A member of site staff will be required to accompany the auditor around the site and must be in a position to answer questions regarding operational and management issues on behalf of the site users. 6. On the day of the audit, the auditor will; Inspect the contents of waste bins, sharps boxes and medicinal waste bins. The contents of these will be noted on the Waste Room Data Sheet. Question staff regarding procedures for the segregation and handling waste. Examine the contents of the Waste Management File, checking all waste collection paperwork e.g. Hazardous Waste Consignment Notes and Controlled Waste Transfer Notes are present and correct. Inspect all internal and external waste storage areas to ensure safe and appropriate storage. Check posters, information and bin labels are in place and up to date. Give advice on the safe management of healthcare waste, legal obligations, waste minimisation and recycling. 7. The auditor will complete a report detailing observations, areas of concern, recommendations for improvement and actions required. 8. The report will be reviewed by the KMF Waste and Environment Manager and given a risk rating of Red, Amber or Green and a deadline for actions to be completed. 9. Following each audit a report will be sent out to the Site Manager and any other relevant staff within 6 weeks. A copy will also be issued to the appointed Organisation lead for waste and other nominated persons e.g. infection control, health and safety as necessary. V3.1 Page 25 of 26 February 2014

10. Any action marked recommendation is a recommendation only and cannot be enforced. All other actions must be completed to ensure compliance. 11. The Site or Service Manager concerned will be required to ensure that all required actions are complete and that details of action taken are added to the Action Taken and Comments Box at the end of the report. 12. The Site or Service Manager concerned will be required to sign to confirm all actions have been completed and return the audit to the following address; Waste and Environment Team Kent and Medway NHS Facilities 50 Pembroke Court Chatham Maritime Chatham Kent ME4 4EL PLEASE NOTE: The KMF Waste and Environment Team are required to pass on copies of the completed audit to the Clinical Waste Contractor at set intervals to comply with the legal requirements for clinical waste pre-acceptance. Failure to supply this information will result in collections being suspended from the site concerned. The Contractors will share this information with the Environment Agency, who may also request copies direct from KMF or the site at any time. If you have any queries prior to your inspection, please contact the KMF Waste and Environment Team on 01634 335220. V3.1 Page 26 of 26 February 2014