Waste Management Policy

Waste Management Policy Document Author Job Title: Environmental, Sustainability and Waste Manager Authorised Authorised By: Chief Executive Date: 18 th March 2014 Lead Director: Associate Director of Estates Date: 18 th March 2014 Effective Date: 18 th March 2014 Review Date: 17 th March 2017 Approval at: Policy Management Group Date Approved: 18 th March 2014 Waste Management Policy Page 1 of 59

DOCUMENT HISTOR (Procedural document version numbering convention will follow the following format. Whole numbers for approved versions, e.g. 1.0, 2.0, 3.0 etc. With decimals being used to represent the current working draft version, e.g. 1.1, 1.2, 1.3, 1.4 etc. For example, when writing a procedural document for the first time the initial draft will be version 0.1) Date of Issue January 2005 February 2014 March 2014 Versio n No. Date Approved 1.0 December 2006 1.1 February 2014 Director Responsi ble for Change Associate Director of Estates Associate Director of Estates 2.0 March 2014 Associate Director of Estates Nature of Change Consolidation of Household Waste Policy / Clinical Waste Policy with Waste Management Policy Update Ratification / Approval Approved at Waste Management Group and Risk Management Committee Policy Management Group NB This policy relates to the Isle of Wight NHS Trust hereafter referred to as the Trust. Waste Management Policy Page 2 of 59

Contents 1. EXECUTIVE SUMMAR... 7 2. INTRODUCTION... 7 3. SCOPE... 7 4. AIMS AND OBJECTIVES... 7 5. IMPACTS AND RISKS ASSOCIATED WITH WASTE MANAGEMENT... 7 5.1 Health & Safety and Fire Safety... 7 Manual handling... 7 Falls and trips... 8 Fire safety... 8 5.2 Infection Control... 8 5.3 Environmental impacts... 8 Environmental Policy statement... 8 Waste Hierarchy... 8 Zero-landfill... 9 5.4 Financial impact... 9 6. KE RESPONSIBILITIES... 10 6.1 The Chief Executive... 10 6.2 All Staff... 10 6.3 The Executive Director responsible for Estates... 10 6.4 The Associate Director of Estates... 10 6.5 The Waste Manager... 10 6.6 The Waste & Recycling Assistant... 11 6.7 The Clinical Waste Operative... 11 6.8 Associate Director... 11 6.9 The Estates Maintenance Foremen... 11 6.10 The Capital Planning and Development Manager... 11 6.11 The Infection Control Team... 11 6.12 The Health & Safety and Security team... 12 6.13 General Managers / Departmental Managers (non-clinical)... 12 6.14 Clinical managers / Ward managers / Modern matrons... 12 6.15 Community teams treating patients in their homes... 12 6.16 The Chief Pharmacist... 12 6.17 The Hotel Services Manager... 12 6.18 Portering staff... 13 6.19 Domestics staff... 13 6.20 Caretakers... 13 Waste Management Policy Page 3 of 59

6.21 Trust contractors... 13 7. WASTE MANAGEMENT GROUP... 14 8. DEFINITION OF WASTE... 14 8.1 European Waste Catalogue (EWC)... 14 8.2 Controlled Waste... 14 8.3 Hazardous Waste... 14 8.4 Radioactive Waste... 14 8.5 Confidential Waste... 14 8.6 Clinical wastes... 15 9. DUT OF CARE... 15 9.1 Waste Transfer Notes (Controlled waste)... 16 9.2 Hazardous Waste Consignment Notes (Hazardous waste)... 16 9.3 Duty of Care Audits... 16 9.4 Clinical Waste Pre-Acceptance Audits... 16 10. OTHER LEGISLATIVE AND REGULATOR REQUIREMENTS... 16 10.1 Landfill Tax... 16 10.2 Waste Management Licensing Regulations 1994... 16 10.3 The Waste (England and Wales) Regulations 2011... 17 10.4 Hazardous Waste Regulations 2005... 17 10.5 Waste Electrical and Electronic Equipment Directive... 17 10.6 Landfill directive... 17 10.7 Batteries directive... 17 10.8 Carriage of Dangerous Goods (CDG) Regulations... 17 11. WASTE GENERATED B THE TRUST... 17 11.1 Healthcare Wastes (Appendix A PART A)... 17 11.2 Non-Healthcare Wastes (Domestic waste) (Appendix A PART B)... 18 11.3 Non-Healthcare Hazardous Wastes (Appendix A PART C)... 18 12. WASTE GENERATED IN THE COMMUNIT... 18 12.1 Trust Community premises... 18 12.2 Waste generated by community teams in patients homes... 18 13. WASTE GENERATED B OTHER ORGANISATIONS... 18 13.1 Contractors working for the Trust... 18 13.2 Organisations for which the Trust arranges waste disposal... 18 14. SEGREGATION OF WASTE... 18 14.1 Waste segregation policy... 18 14.2 Domestic waste segregation Recycling scheme... 19 14.3 Organisations for which the Trust arranges waste disposal... 19 15. TRANSPORT OF WASTE... 19 Waste Management Policy Page 4 of 59

15.1... 19 15.2 External transport... 19 16. HANDLING OF WASTE... 19 16.1 Healthcare Wastes... 19 16.2 Other wastes... 20 17. STORAGE OF WASTE... 20 17.1 Waste bins... 20 17.2 Choosing waste containers and bags... 20 17.3 Purchasing of waste containers and bags... 20 17.4... 20 17.5 External storage... 21 17.6 Spills... 21 18. FL TIPPING... 21 19. DISPOSAL TO DRAINS AND SEWERS... 21 20. CLINICAL WASTE TRANSFER STATION... 21 20.1 Waste Management Licence Environmental Permit... 21 20.2 Technically Competent Manager (TCM) cover... 22 20.3 Quarterly Returns to the Environment Agency... 22 20.4 Access and ingress, building alterations... 22 21. AUDITING... 22 22. TRAINING AND AWARENESS-RAISING... 22 23. GOVERNANCE AND IMPLEMENTATION... 23 24. DISSEMINATION... 23 25. EQUALIT ANALSIS... 23 26. REVIEW AND REVISION ARRANGEMENTS... 23 27. MONITORING / KE PERFORMANCE INDICATORS... 23 28. LINKS TO OTHER ORGANISATION POLICIES/DOCUMENTS... 23 29. REFERENCES... 24 30. DISCLAIMER... 24 Waste Management Policy Page 5 of 59

Appendices 1. Checklist for the development and approval of controlled Documentation..25 2. Impact assessment forms on policy implementation (including checklist)....26 3. Equality analysis and action plan... 27 A. Waste Data Sheets (WDSs)..33 B. Standard Operating Procedures (SOPs)...57 C. Waste Management Group Terms of Reference.... 58 Waste Management Policy Page 6 of 59

1. EXECUTIVE SUMMAR This policy is a necessary requirement to ensure the Trust fulfils its moral and legal duties for safe, compliant, environmentally and financially sustainable Waste Management. This policy provides guidance to all staff, and defines responsibilities in all aspects of Waste Management with clear standards for appropriate waste segregation, storage, handling, transport and disposal. 2. INTRODUCTION Waste Management is the generic term given to the whole spectrum of activities associated with waste, namely, its generation, segregation, storage, handling and transportation from point of source (ward/department) to final place of disposal (recycling/landfill/incinerator). This policy details the Trust s arrangements, including responsibilities, for the classification, segregation, collection, storage, handling, transportation and disposal of all waste produced as a consequence of the Trust s activities. 3. SCOPE This policy applies to all services directly provided by the Trust and all staff should familiarise themselves with the policy. This policy encompasses the activities and responsibilities of all Trust staff, including in patients homes, Dental Surgeries and Community clinics when applicable. This policy applies also to all contractors and temporary workers who are engaged to work on the Trust premises. 4. AIMS AND OBJECTIVES This policy has been prepared with the objectives of: Ensuring full legislative compliance for Waste Management activities at the Trust at all time, and when possible lead on best practice; Reducing and mitigating the Health & Safety, Fire Safety and Infection Control risks associated with Waste Management activities at the Trust; Reducing and mitigating the environmental impacts associated with Waste Management activities at the Trust; Ensuring robust controls and assurances are in place for all Waste Management activities at the Trust. 5. IMPACTS AND RISKS ASSOCIATED WITH WASTE MANAGEMENT 5.1 Health & Safety and Fire Safety The Trust recognises the Health & Safety and Fire Safety risks associated with Waste Management. Manual handling The improper manual handling of waste presents a risk to Trust staff and contractors. The Trust is committed to minimise and mitigate these risks as far as practically reasonable. Waste Management Policy Page 7 of 59

This includes the conduct of risk assessments when new waste management equipments or practices are introduced. Falls and trips The inappropriate storage of waste can create falls and trips hazards. Refer to the STORAGE OF WASTE section for appropriate waste storage protocols. Fire safety The inappropriate storage of waste can create fire hazards or impact fire evacuation procedures. Refer to the STORAGE OF WASTE section for appropriate waste storage protocols. 5.2 Infection Control It is important to adopt appropriate handling and storage protocols which minimise the Infection Control risks associated with infectious waste. Refer to the STORAGE OF WASTE section for appropriate waste storage protocols. 5.3 Environmental impacts Disposing of waste has very significant environmental impacts. Throwing away things is a waste of resources. It wastes the raw materials and energy used in making the items and contributes to global resources depletion. Landfilling waste generates methane gas, which is explosive and contributes significantly to Climate Change. Leachate produced as waste decomposes in landfill causes land or water pollution. Incinerating waste produces toxic substances, such as dioxins which have an effect on local air quality. Gases from incineration cause air pollution and contribute to acid rain, while the ash from incinerators may contain heavy metals and other toxins. Transporting waste is very carbon intensive, contributes to Climate Change and has an effect on air quality. Environmental Policy statement As stated in the Trust Environmental Management Policy, it is the policy of the Isle of Wight NHS Trust to: Use the waste hierarchy at all time. Aim for zero landfill. Use local waste management treatment and disposal solutions when possible. Monitor, report and set targets on our management of domestic and clinical waste. Minimise the creation of waste particularly in medicines, food and ICT. Ensuring we have robust systems for recycling wherever possible. Waste Hierarchy The waste hierarchy is a classification of preferred waste management options in order of their environmental impact. Waste Management Policy Page 8 of 59

Zero-landfill Practice wherein wastes are re-used, recycled or undergo alternative treatment processes with the aim of avoiding the use of landfills for disposal. This is particularly relevant for the residual fraction of domestic waste (later referred as Non-Healthcare General waste, i.e. black bags). 5.4 Financial impact Waste Management Policy Page 9 of 59

Different types of waste attract different disposal price rates and as a result good waste segregation generates substantial costs-savings. 6. KE RESPONSIBILITIES 6.1 The Chief Executive The Chief Executive ultimately has overall responsibility for safe, effective and compliant Waste Management throughout the Trust. 6.2 All Staff All Staff have a responsibility and legal duty of care to comply with this policy and associated procedures. All staff are responsible for: Observing the waste policy and waste management procedures. Most particularly in regard to correct waste segregation. Reporting accidents and any incidence of non compliance with this policy. Considering any untapped opportunities for waste reduction, minimisation in recycling in their area/department. Actively participating and supporting waste reduction, minimisation and recycling initiatives undertaken in their area/department. Minimising waste production including: Ensuring double sided printing (duplex) printing is enabled as the default setting for all printing (where local printers allow); Reusing office stationary or waste paper that has been printed on one side only as scrap paper when appropriate; Reviewing the need to purchase items so that future waste is avoided (i.e. not over-ordering items with a shelf life or where there is limited storage capacity); Advertising fit for purpose redundant items in the e-bulletin prior to disposal; Considering purchasing options that minimise waste including leasing; Requesting that suppliers take unwanted items or packaging back where possible (e.g. pallets). 6.3 The Executive Director responsible for Estates The Executive Director responsible for Estates has delegated responsibility for safe, effective and compliant Waste Management throughout the Trust and is responsible to the Chief Executive for ensuring systems are in place to this effect. 6.4 The Associate Director of Estates The Associate Director of Estates has delegated responsibility for safe, effective and compliant Waste Management throughout the Trust. The Associate Director of Estates is responsible: To the Executive Director responsible for Estates for establishing systems to this effect and ensuring sufficient resources are allocated. For delegating some of these responsibilities and duties to a nominated Estates officer with a Waste Manager responsibility. 6.5 The Waste Manager The Waste Manager has a delegated responsibility for managing and monitoring systems for safe, effective and compliant Waste Management at the Trust. The Waste Manager is responsible: For providing advice and guidance on all matters related to Waste Management at the Trust. For the development, up-keeping and implementation of the Waste Management Policy and associated Procedures throughout the Trust. Waste Management Policy Page 10 of 59

For ensuring waste legislative requirements are satisfied at all Trust sites including applications for environmental permits or exemptions and registration with the Environment Agency as a Hazardous Waste Producer For ensuring that all relevant new and upcoming waste legislative requirements are identified and when appropriate communicated to managers and staff, in a timely manner to ensure the Trust remains compliant at all times. For reporting breaches of regulatory compliance, the reason for non-compliance, and the measures taken to regain compliance and prevent further incidents. For acting as the principal point of contact with regulatory bodies and ensuring that all communications are maintained on file. For managing St Mary s clinical waste transfer station in line with its permit licence. For procuring waste management services contracts in a sustainable and legally compliant manner. For managing the Trust waste budget in a sustainable and cost-effective manner. For producing pre-acceptance reports for clinical waste contractors and undertaking Duty of Care audits of the Trust waste contractors. For managing all waste contractors employed by the Trust. 6.6 The Waste & Recycling Assistant The Waste & Recycling Assistant has a delegated responsibility for all day to day administrative and operational aspects of waste management at the Trust. The Waste & Recycling Assistant is responsible: For conducting a rolling schedule of waste audits throughout the Trust. For staff training and raising awareness on this policy and associated procedures. 6.7 The Clinical Waste Operative The Clinical Waste Operative is responsible for all clinical waste transport operations at St Mary s Hospital, the up-keeping of the Waste Transfer Station and waste yard and the day to day operational management of the clinical waste transfer station. 6.8 Associate Director Associate Directors have overall responsibility for the implementation of this policy within their Directorate. 6.9 The Estates Maintenance Foremen The Estates Maintenance Foremen are responsible for ensuring that all the Estates Maintenance Teams are aware of the right procedures and protocols for disposing of waste arising from maintenance and refurbishment works. The Estates Maintenance Foremen are responsible for ensuring all contractors working on projects managed by the maintenance team are made aware and adhere to SOP 404 Contractors waste procedure. 6.10 The Capital Planning and Development Manager The Capital Planning and Development Manager is responsible for ensuring all contractors working on projects managed by the capital team are made aware and adhere to SOP 404 Contractors waste procedure. 6.11 The Infection Control Team The Infection Control Team is responsible for ensuring Infection Control policies/procedures are aligned with this Waste Policy and associated procedures. The Infection Control Team is responsible for providing advice and support to the Waste Manager to minimise the risks from exposure to infections caused by waste. Waste Management Policy Page 11 of 59

6.12 The Health & Safety and Security team The Health & Safety and Security team is responsible for providing pro-active advice and support to the Waste Manager to minimise the H&S (manual handling, falls and trips), and fire safety risks caused by waste. 6.13 General Managers / Departmental Managers (non-clinical) General Managers / Departmental Managers in non-clinical areas are responsible for: Ensuring that this policy and the procedures it contains, particularly regarding waste segregation are brought to the attention of and observed by all staff in the area under their responsibility. For non-clinical areas this includes segregating wastes for recycling and ensuring that correct Trust procedures are followed for any hazardous domestic waste (E.g. batteries, toners), electrical waste, bulky waste etc. Ensuring that there is a proactive approach to adhering to this policy and for staff under their management to be encouraged to participate in implementing this Waste Policy and associated procedures. Actively cooperating with the Waste Manager to ensure the effective and compliant management of waste arising in their area of responsibility. 6.14 Clinical managers / Ward managers / Modern matrons Ward/Department managers are responsible for: Ensuring that this policy and the procedures it contains, particularly regarding waste segregation are brought to the attention of and observed by all staff in the area under their responsibility. For clinical areas this relates particularly to clinical waste (infectious waste, sharps, medicines wastes, offensive wastes) and domestic waste. Responsible for ensuring that Waste Segregation posters are displayed in appropriate places to inform staff on adequate waste segregation (available from the Waste team). Ensuring that waste bins in their area are kept clean. Lockable metal yellow clinical waste cabinets and external clinical bins can be cleaned by Estates on demand. Ensuring that their designated waste storage areas (internal or external) are kept clean and tidy and free from loose waste, bulky items and items for storage. Ensuring any lockable waste bins/ are kept locked shut at all times except when being filled. 6.15 Community teams treating patients in their homes Community teams treating patients in their homes have a responsibility to comply with this policy and most importantly SOP 201- Clinical waste Community teams. 6.16 The Chief Pharmacist The Chief Pharmacist is responsible for Providing guidance on pharmaceutical matters relevant to waste management. Maintaining a list of cytostatic and cytotoxic pharmaceuticals dispensed at the Trust. Supporting departments/wards in identifying cytostatic and cytotoxic medicines when required. Facilitating the return of unused, faulty, expired or surplus pharmaceuticals to the pharmacy department. Ensuring Pharmacy s waste is segregated in accordance with this policy. 6.17 The Hotel Services Manager The Hotel Services Manager is responsible for ensuring effective systems are in place for the general portering staff, domestics staff and caretakers to fulfil their responsibilities and that they have received adequate training in order to comply with this policy. Waste Management Policy Page 12 of 59

6.18 Portering staff General portering staff are responsible for: Collecting and the basic segregation of domestic waste (black bags, clear recycling bags, cardboard, WEEE etc.) in all internal areas with waste cupboards at St Mary s Hospital phase III (and some external areas where applicable). Operating the Trust s waste compactor after receiving the necessary training. Operating the Trust s cardboard balers after receiving the necessary training. Departmental portering staff are responsible for: Collecting and the basic segregation of domestic waste (black bags, clear recycling bags, cardboard, WEEE etc.) in their areas. Operating the Trust s waste compactor after receiving the necessary training. Operating the Trust s cardboard balers after receiving the necessary training. Departmental portering staff managers are responsible for ensuring effective systems are in place for their portering staff to fulfil their responsibilities and that they have received adequate training in order to comply with this policy. 6.19 Domestics staff Domestics staff are responsible for: Emptying domestic/recycling office bins across the Trust sites at a frequency set by Hotel Services. Ensuring the correct bin bags are placed in the relevant bins (clear for recycling waste, black for domestic waste). Ensuring waste is placed in the correct external waste bins. Reporting any areas showing poor segregation practice (food waste in recycling bins, recycling waste in domestic waste bins) to the Waste team so that the area involved can be advised and training provided. Domestics staff in clinical areas are responsible for: Supporting clinical staff in emptying domestic and clinical waste bins, and transporting the waste to the correct internal cupboard or external bin. 6.20 Caretakers Caretakers are responsible for: Collecting redundant equipment and other bulky items (WDS208, 209, 210, 211, 213, 214) which have been identified and reported for disposal. Transferring waste (Redundant equipment and other bulky items as defined above) from its collection point to the Trust main waste compound (at Estates) and placing the waste items in the correct bay or container. 6.21 Trust contractors Trust contractors are responsible for ensuring all wastes they produce whilst on site are managed and disposed of in accordance with the Trust s policy and SOP 404. Contractors who transport Trust waste must be suitably licensed waste carriers or where required, waste brokers, with evidence provided (waste carriers licences). Paperwork for any waste streams leaving the Trust s control must be obtained in the form of consignment notes (for hazardous waste) and waste transfer notes (non-hazardous wastes). Contractors affected would include those undertaking refurbishment projects, routine or non-routine maintenance activities. Generally contractors are NOT permitted to use Trust facilities and these can only be used with prior consent of the Trust s contract manager and then in full accordance with this Policy. Waste Management Policy Page 13 of 59

7. WASTE MANAGEMENT GROUP The Trust Waste Management Group is tasked with producing recommendations and policies to ensure all waste streams arising from the Trust activities are managed in an environmentally sustainable and cost-effective manner, in line with applicable legislation, and current best practice when appropriate. The Group is formed of a cross-section of relevant Trust departments, including the Waste Manager, Infection Control, Health & Safety, a modern Matron, and representation from Community nursing and clinics. The Group currently meets every 2 months and reports to the Risk Management Committee. Please refer to the Group Terms of Reference available in Appendix C for more details. 8. DEFINITION OF WASTE Under the Waste Framework Directive (European Directive (WFD) 2006/12/EC), waste is Any substance or object the holder discards, intends to discard or is required to discard". 8.1 European Waste Catalogue (EWC) The European Waste Catalogue (EWC) classifies waste materials and categorises them according to what they are and how they were produced. The EWC uses a 6 digits code (EWC code) to reference waste streams. The EWC is used on Waste Transfer Notes and Hazardous Waste Transfer Notes in all waste transfer operations. 8.2 Controlled Waste Controlled Waste is waste that is subject to legislative control in either its handling or its disposal under the Controlled Waste Regulations 1992. The types of wastes covered include all domestic, commercial and industrial waste. All waste produced by the Trust is classed as controlled commercial waste. 8.3 Hazardous Waste Hazardous waste is waste that poses substantial or potential threats to public health or the environment. Waste is legally classified as hazardous if it is covered under the Hazardous Waste Regulations 2005 and it will be listed with a star (*) in the European Waste Catalogue (EWC). 8.4 Radioactive Waste Radioactive wastes are wastes that contain radioactive material. Radioactive waste typically comprises a number of radioisotopes: unstable configurations of elements that decay, emitting ionizing radiation which can be harmful to humans and the environment. See radionuclide contaminated waste (lymph biopsy WDS 114). 8.5 Confidential Waste Confidential waste are wastes that contain confidential information. Confidential information can be defined as; Any material that contains information of a personal nature - that can identify a living individual or relates to an individual under the 1998 Data Protection Act e.g. patient names, details of medical condition & treatment, staff personal details. Any information classed as Business Sensitive e.g. financial data. If there is any doubt regarding whether the information contained is confidential, disposal as confidential waste is advisable therefore reducing any potential risk. All information has a life cycle and the Trust has adopted the NHS Code of Practice: Records Management (available on the intranet) which gives guidance on how long the different types of information should be kept for. Waste Management Policy Page 14 of 59

8.6 Clinical wastes The following healthcare wastes have specific disposal requirements which are detailed in Appendix A Healthcare Wastes: Anatomical wastes (WDS104), Sharps wastes (WDS 105, 106 and 107), Medicines wastes (WDS 108, 109, 110), Medicinally contaminated wastes (WDS 109 and 110), Controlled drugs (WDS 111), Plaster/gypsum (WDS 112), Dental wastes (WDS 115), Radionuclide contaminated waste (Lymph biopsy WDS 114). General definition of clinical waste Wastes not listed above and known or believed to be contaminated with body fluids (blood, urine, sputum, vomit, faeces) are classed as either infectious clinical or offensive (non-infectious clinical) waste. Wastes that have not come into contact with blood or body fluid are neither infectious nor offensive, and are thus classed as domestic waste. As a result packaging (including sterile items packaging), paper towels from hand washing, bed rolls not contaminated with body fluids, and other domestic type wastes must not be disposed of in the infectious (orange bags) or offensive (tiger bags) clinical waste streams. These wastes must be disposed of in domestic waste bins (black bags) or if suitable and facilities exist recycling waste bins (clear bags). of Known or suspected infectious patient For the purpose of this policy a patient is known or suspected to be infectious if the answer is ES for AN of the following questions: Is the patient being isolated for any infection? Is the patient being treated for any infection, e.g. on antibiotics? Is the patient having diarrhoea or vomiting, where the cause is not certain and infection has not been excluded? Is the patient suspected to have an infection? Infectious clinical waste Wastes contaminated with body fluids from a patient known or suspected to be infectious is classed as infectious waste (orange bags). Some areas may be using yellow bags which are another classification of infectious clinical waste. See WDS 101 and 102. Offensive waste (i.e. Non-infectious clinical waste) Wastes contaminated with body fluids but from a non-infectious patient is classed as offensive waste (waste causing offence but not infectious). Such wastes are not hazardous and can be disposed of in tiger bags. The use of tiger bags will be introduced in targeted areas after an assessment has been undertaken jointly by the Waste and Infection Control teams. In areas where tiger bags are not available, offensive wastes (non-infectious clinical waste) must be disposed in orange bags. See WDS 103. 9. DUT OF CARE As a producer of waste the Trust has a legal Duty of Care to make sure its waste is handled safely and only passed to people authorised to receive it. For any waste removed from Trust premises, the designated waste contractor will have to supply a Waste Transfer Note (WTN) for controlled waste, and a Hazardous Waste Consignment Note (HWCN) for hazardous waste. Waste Management Policy Page 15 of 59

No waste may leave the Trust without a Waste Transfer Note or Hazardous Waste Consignment Note. 9.1 Waste Transfer Notes (Controlled waste) Before any Controlled waste leaves the Trust a Waste Transfer Note (WTN) must be produced ensuring all the required information is put onto the form. The form must be signed by an authorised Trust officer and be given to the waste carrier when they come to collect the waste. For regular collections an annual waste transfer note can be set up in advance of the first collection. Waste transfer notes must be retained for two years following the disposal of the waste. 9.2 Hazardous Waste Consignment Notes (Hazardous waste) Before any hazardous waste is removed from the Trust a Hazardous Waste Consignment Note (HWCN) must be completed ensuring all relevant information is put onto the form. This form cannot be completed annually but must be completed for each load. Waste consignment notes must be retained for three years following the disposal of the waste. 9.3 Duty of Care Audits It is the Trust responsibility to make sure its waste contractors are registered waste carriers and are taking the waste to legitimate sites. As a result the Trust has a legal responsibility to conduct Duty of Care audits to ensure the facilities receiving the waste handle and treat our waste in a safe, compliant and sustainable manner. 9.4 Clinical Waste Pre-Acceptance Audits Facilities authorised to incinerate or treat clinical wastes are required to assess and have access to detailed information on the composition of the waste from the producer before they receive it. As a result the Trust has a legal obligation to produce and provide its clinical waste contractor detailed and thorough clinical waste annual pre-acceptance audits for both St Mary s Hospital and its community premises producing clinical waste, in line with the requirements of the Environment Agency Additional guidance for clinical waste - EPR 5.07 (2011). 10. OTHER LEGISLATIVE AND REGULATOR REQUIREMENTS The Trust is committed to following all applicable waste legislation, statutory guidance, and other environmental requirements to which it subscribes, as well as to adhere to industry best practice when possible. The Associate Director of Estates is responsible for ensuring that the Trust adheres to all such legislation through the active support and guidance of the Waste Manager. The Trust is fully committed to cooperating with regulators, such as the Environmental Agency, the Water Authority, the Health & Safety Executive and DEFRA. 10.1 Landfill Tax This is a tax on the disposal of waste. It aims to encourage waste producers to produce less waste, recover more value from waste and to use more environmentally friendly methods of waste disposal. 10.2 Waste Management Licensing Regulations 1994 Waste Management Policy Page 16 of 59

10.3 The Waste (England and Wales) Regulations 2011 This regulation provides the requirements for using the waste hierarchy. The waste hierarchy is a classification of waste management options in order of their environmental impact, such as: reduction, reuse, recycling and recovery. 10.4 Hazardous Waste Regulations 2005 Hazardous waste is essentially waste that contains hazardous properties which if mismanaged has the potential to cause greater harm to the environment and human health than non-hazardous. As a result, strict controls apply from the point of its production, to its movement, management, and recovery or disposal. 10.5 Waste Electrical and Electronic Equipment Directive Waste Electrical and Electronic Equipment (WEEE) directive aim to reduce the quantity of waste from electrical and electronic and increase its re-use, recovery and recycling. 10.6 Landfill directive This directive aims to prevent or reduce as far as possible negative effects on the environment from the landfilling of waste, by introducing stringent technical requirements for waste and landfills and setting targets for the reduction of biodegradable municipal waste going to landfill. 10.7 Batteries directive This directive aims to improve the environmental performance of batteries and minimise the impact waste batteries have on the environment by banning the disposal batteries in landfill or by incineration. 10.8 Carriage of Dangerous Goods (CDG) Regulations The CDG Regulations are the UK s transposition of the EU ADR 2009 Regulations. Correctly classify the waste Package the waste according to specific standards Label the waste correctly Provide the collector with a consignors declaration Under the CDG and as a consignor of hazardous waste, the Trust may require an annual Dangerous Goods Safety report. 11. WASTE GENERATED B THE TRUST The Trust produces a very wide variety of waste streams. These can be broadly classed as Healthcare and Non-healthcare wastes. Please refer to Appendix A Waste Data Sheets for a detailed break-down of all waste streams and associated transport/disposal procedures. 11.1 Healthcare Wastes (Appendix A PART A) This category covers all the wastes specifically produced in a healthcare environment, such as clinical waste, offensive waste, anatomical waste, sharps wastes, etc Healthcare waste can be defined as: 1.... any waste which consists wholly or partly of human or animal tissue, blood or other body fluids, excretions, drugs or other pharmaceutical products, swabs or dressings, syringes, needles or other sharp instruments, being waste which unless rendered safe may prove hazardous to any person coming into contact with it; and 2. any other waste arising from medical, nursing, dental, veterinary, pharmaceutical or similar practice, investigation, treatment, care, teaching or research, or the collection of Waste Management Policy Page 17 of 59

blood for transfusion, being waste which may cause infection to any person coming into contact with it. 11.2 Non-Healthcare Wastes (Domestic waste) (Appendix A PART B) This category covers all the wastes which could typically be produced in a domestic / household setting such as general (black bag) waste, dry mixed recycling, bulky items, etc 11.3 Non-Healthcare Hazardous Wastes (Appendix A PART C) This category covers wastes not specific to a healthcare setting but which have a particular property making them hazardous such as asbestos, Waste Electrical and Electronic Equipments, chemicals, etc 12. WASTE GENERATED IN THE COMMUNIT 12.1 Trust Community premises This Policy and associated procedures fully apply to Trust community premises such as Health Centres and Community Clinics. 12.2 Waste generated by community teams in patients homes Trust staff generating patients homes should be familiar and adhere to SOP 201 Clinical Waste - Community teams. 13. WASTE GENERATED B OTHER ORGANISATIONS 13.1 Contractors working for the Trust All contractors employed or working on behalf of the Trust on the Trust s premises will make the necessary arrangements to comply with this policy, but most especially SOP 404 Contractors waste procedure. Waste carriers / contractors are required to follow on site rules for vehicle parking, loading/unloading, security and speed limit whilst on the Trust premise. 13.2 Organisations for which the Trust arranges waste disposal If the Trust arranges any waste disposal services through its waste contractor(s) for other organisations, those organisations have to adhere to this Waste Policy and are responsible for ensuring their staff are aware and apply the policy and associated procedure. Compliance might be audited by the Waste Manager or any other authorised officer. 14. SEGREGATION OF WASTE 14.1 Waste segregation policy All wastes produced at the Trust are segregated in accordance with the Waste Data Sheets supplied in Appendix A of this policy. There may be specific local circumstances which require to adopt adapted or different segregation procedures, but only if agreed in advance with the Waste team. Waste segregation in line with this policy is not optional but MANDATOR. Waste Management Policy Page 18 of 59

14.2 Domestic waste segregation Recycling scheme Estates is gradually phasing in the provision of recycling facilities (i.e. bins) throughout the Trust. Departments which have not been supplied with recycling facilities do not need to separate dry mixed recyclables (in clear bags) until supplied with the facilities to do so. When recycling facilities are deployed to an area, different communication channels will be used to make staff aware of the new segregation procedure. Every effort will be made to adapt to local circumstances but there is no requirements for Estates to formerly consult with the area staff prior to roll-out. Once supplied by Estates with facilities for recycling (recycling bins), then full segregation of dry mixed recyclables is required by all staff at all time. In office areas supplied with both recycling bins and general waste bins in shared locations (on same principle as confidential waste consoles), Hotel Services has full authority to instruct Domestics to only empty the provided shared bins. Staff can keep under desk bins but their emptying becomes the full responsibility of the bin owner. 14.3 Organisations for which the Trust arranges waste disposal If the Trust arranges any waste disposal services through its waste contractor(s) for other organisations, those organisations have to adhere to this Waste Policy and are responsible for ensuring their staff are aware and apply the policy and associated procedure. Compliance might be audited by the Waste Manager or any other authorised officer. 15. TRANSPORT OF WASTE 15.1 Healthcare (Clinical) and Non-healthcare (Domestic) wastes may under no circumstances be mixed for transport. Waste bins / trolleys used for the movement of clinical waste within premises shall be designed and constructed so they are easy to manually handle. Waste bins/trolleys must be regularly cleaned and drained to prevent infestation. Trolleys and carts must be disinfected when spillages occur before reuse. 15.2 External transport The only scenarios when waste may be carried in vehicles or out-of-site by Trust staff are: Estates, Transport or Portering staff transporting waste from one area to another within St Mary s site; or Estates, Transport or Portering staff transporting non-hazardous waste between Trust premises (subject to review); or Trust staff generating waste at patients homes and carrying the waste back to base in line with SOP 201. 16. HANDLING OF WASTE 16.1 Healthcare Wastes Refer to SOP 102 Handling of clinical waste and the Appendix A of this policy for each specific clinical waste stream (Part A Healthcare Wastes). Waste Management Policy Page 19 of 59

16.2 Other wastes Refer to Appendix A of this policy for each specific waste stream. 17. STORAGE OF WASTE 17.1 Waste bins Waste bins purchased by wards/ clinical departments must be as specified in the latest version of SOP 103 - Waste bins for clinical areas in line with the recommendations of the Waste Management Group. Clinical waste bins must be pedal operated, fire proof, easy to clean and disinfect to prevent risk of infection, odour and offence. They must be in a good state of repair (pedal and lid working properly etc) and carry the right colour-coding. The Waste Manager has final authority on the chosen type and model of recycling waste bin supplied when recycling is introduced to any area. The type and model of recycling waste bins supplied by Estates are the default option throughout the Trust for both clinical and non-clinical areas. Should departments purchase waste bins for domestic waste, these must be compatible with the Trust Recycling scheme and meet the approval of the Waste Manager. 17.2 Choosing waste containers and bags Subject to securing the relevant and appropriate assurances, the Waste Manager has final authority on the type of waste containers (e.g. sharps bins) and bags used by department/wards, so to ensure containers and bags are compatible with the Trust policy and procedures, internal transport arrangements, our waste contractors requirements, and the Carriage of Dangerous Goods. 17.3 Purchasing of waste containers and bags All waste containers and bags in clinical areas are purchased by the ward/department (through Supplies). Broken glass/crockery buckets in all areas are purchased by the ward/department. Bags for domestic (black) and recycling (clear) waste in all non-clinical areas (including public areas, such as corridors) are purchased and supplied by Hotel Services. Confidential waste bags (for clear-outs/office moves) are supplied by the Waste team at Estates 17.4 Healthcare (Clinical) and Non-healthcare (Domestic) wastes may under no circumstances be mixed in storage areas. Waste must not accumulate in corridors, lobbies, wards or other unsuitable places. Waste must not under any circumstances obstruct access routes, fire escape routes or fire doors. Waste items must not be placed in areas that are likely to cause a tripping hazard. Waste containers, waste cupboards and waste bins must be kept shut and locked when not in use to prevent unauthorised access or access to waste by vermin. Clinical waste bins shall be sited away from food preparation, general storage and route used by the public. Waste Management Policy Page 20 of 59

Access to clinical waste storage shall be for authorised personnel only. 17.5 External storage Waste must not be stored loose in any external areas See fly-tipping section below. Waste wheelie bins or any other containers must be kept shut and locked when not in use to prevent unauthorised access or access to waste by vermin. Access to clinical waste storage shall be for authorised personnel only. 17.6 Spills It is the responsibility of all staff within a work area, to be aware of any procedure regarding any Spillage of substance in their area of work, if applicable. To know where the spill kit is located and what course of action is required to clean up the spillage. Further guidance on blood or other body fluids spills can be found in the Infection Prevention & Control Clean Patient Environment Policy available on the intranet. Further guidance on chemicals can be found in the COSHH Policy available on the intranet. Any materials used in the containment and absorption of spills should be treated for disposal as the material spilled. For instance contaminated materials used to clean cytotoxic/cytostatic medicines spills should be disposed as cytotoxic/cytostatic waste. Same applies to chemicals. 18. FL TIPPING It is the responsibility of the person or department producing the waste to ensure a suitable waste disposal route is identified in line with this policy and associated procedures. Any waste left unattended in internal areas or on grounds with no arrangements for disposal will be considered fly-tipping. Fly-tipping of waste, including by Trust staff, be it internal to the Trust premises, or on Trust grounds will not be tolerated, and all occurrences will be fully investigated. 19. DISPOSAL TO DRAINS AND SEWERS Under no circumstances can any discharges to sewer other than domestic sewage be made. The following are also suitable for disposal to drains: body fluids, glucose / saline, sterile water and nutritional supplements. Currently the Trust it is not permitted to discharge anything to sewer other than the above. Any uncontrolled releases to sewers put us in breach of the Trade Effluent Regulations (Water Industry Act 2003) and expose us to prosecution from the regulatory body (Southern Water). Should a spill occurs which results in chemicals, oils and other toxic materials to be released to drains or sewers, contact the Waste Manager immediately. 20. CLINICAL WASTE TRANSFER STATION The Trust operates a Clinical Waste Transfer Station under licence from the Environment Agency at St Mary s Hospital in Newport. 20.1 Waste Management Licence Environmental Permit Environmental permit for the site is JP3494HJ/A001 (replacing Waste management Licence 19784). The current permit is bespoke, but is equivalent to Standard rules Waste Management Policy Page 21 of 59

SR2008No24_75kte clinical waste & healthcare waste transfer station. An annual licence fee has to be paid to the Environment Agency and Estates meets this cost. 20.2 Technically Competent Manager (TCM) cover As part of its licence condition, the Trust is required to ensure a Technically Competent Manager cover as specified by the Environment Agency. This is currently set at 15% of the station operating time (or 1 working day per calendar week). The required qualification is Certificate of Technical Competence Level 4 in the Transfer of Hazardous Waste (as awarded by WAMITAB). It is the responsibility of the Associate Director of Estates to ensure there is appropriate TCM cover at any time. In general the member of staff with designated Waste Manager responsibility will be the TCM. The TCM is responsible for all communications with the Environment Agency, including hosting audits, quarterly returns and consignee returns (see below). 20.3 Quarterly Returns to the Environment Agency As part of its licence condition, the Trust is required to submit Quarterly data returns to the Environment Agency. SOP 404 Returning EA returns lay out the standard protocol at Estates for this. The TCM is responsible for quarterly returns. Quarterly Waste Return This is a record of waste tonnages handled at the Transfer Station, being waste received and waste removed over the period of time reported for. Quarterly Consignee Return This is a record of all Hazardous Waste consignments accepted at the Transfer station over the period of time reported for. 20.4 Access and ingress, building alterations Access to the Clinical Waste Transfer Station is strictly limited to authorised personnel and at the discretion of the Waste Manager. No waste whatsoever can be deposited in the Clinical Waste Transfer Station without prior authorisation from the Waste manager. Any alterations or building works undertaken inside or within immediate vicinity of the Clinical Waste Transfer Station and which could affect its use or access cannot be undertaken without prior written authorisation of the Waste manager. 21. AUDITING It is the responsibility of the Waste & Recycling Assistant under the leadership of the Waste Manager to conduct a monitoring and auditing programme for all clinical areas for waste management to ensure the correct implementation of this policy. The monitoring and auditing programme will follow a pro-format audit schedule with a wide scope ranging from adequate waste segregation at ward level, staff awareness of operational procedures for waste management, to opportunities for waste minimisation. Departments/Wards managers will have full responsibility for addressing any negative audit findings and taking adequate corrective actions. Audit findings will be reported and discussed at the Waste Management Group, and a summary of findings to the Risk Management Committee. 22. TRAINING AND AWARENESS-RAISING This Waste Management Policy does not have a mandatory training requirement but the following non mandatory training will be available: Waste Management Policy Page 22 of 59

Waste management e-learning training will be available. Undertaking the e-learning module will be risk driven. Should an area display poor practice or understanding of waste segregation, the Waste Manager may require the Department/Ward manager to train their staff using the module. Waste management awareness will be actively promoted through a number of communication channels. 23. GOVERNANCE AND IMPLEMENTATION The Waste Management Group is responsible for monitoring implementation of this policy. Some of the actions which will be undertaken to implement this policy are: Rolling schedule of audits (See section 21 Auditing above). Production of a non-mandatory e-learning module. Communications through e-bulletin and other channels. 24. DISSEMINATION When approved this document will be available on the Intranet and will be subject to document control procedures. Staff using the Trust s intranet can access all procedural documents. It is the responsibility of managers to ensure that all staff are aware of where, and how, documents can be accessed within their areas of work. It is the responsibility of each individual who prints a hard copy of any document to ensure that the printed hardcopy is the current version. Current versions are maintained on the Intranet. 25. EQUALIT ANALSIS This procedure has undergone an equality analysis please refer to Appendix 3. 26. REVIEW AND REVISION ARRANGEMENTS The Waste Manager will be responsible for reviewing and revise as appropriate this Policy no later than 3 years after its publication. Should legislation or any other changes of circumstances arise; this Policy will be updated accordingly prior to the 3 years timeframe. 27. MONITORING / KE PERFORMANCE INDICATORS For the successful implementation of this policy, the following key performance indicators will be measured: ERIC (Estates Return Information Collection) data Waste risk register for compliance to the relevant legislation 28. LINKS TO OTHER ORGANISATION POLICIES/DOCUMENTS The following policies and procedures should be consulted alongside this Policy document: Health & Safety Policy Environmental Management Policy Safe Handling and Disposal of Sharps Policy Decontamination of Reusable Medical Devices Policy Clean Patient Environment Policy Waste Management Policy Page 23 of 59

COSHH Policy 29. REFERENCES (HTM 07/01) Safe Management of Healthcare Waste Version 3 Department of Health, 2013. Hazardous Waste Regulations 2005 Health & Safety at Work Act 1974 The Environmental Protection Act 1990 Waste Management Licensing Regulations 1994 ( amended 1995, 1996, 1997 and 1998) The Waste Management (Miscellaneous Provisions) Regulations 1997. Environmental Protection (Duty of Care) Regulations 1991. Environmental Protection (Prescribed Processes and Substances) Regulations 1991 Controlled Waste Regulations 1992 as amended 1993. Environmental Act 1995 Control of Pollution (Amendment) Act 1989 Controlled Waste (Registration of carriers and seizure of vehicles) Regulations 1991 Transport of Infectious Substances Revision 2 March 2006 Landfill Tax Regulations 1996 as amended 1996 & 1998. Waste Minimisation Act 1998 Carriage of Dangerous Goods Regulations Waste of Electrical & Electronic Equipment (WEEE) Regulations. HTM 07/05 - The Treatment, recovery, recycling and safe disposal of WEEE 30. DISCLAIMER It is the responsibility of all staff to check the organisation intranet to ensure that the most recent version/issue of this document is being referenced. Waste Management Policy Page 24 of 59

Appendix 1 CHECKLIST FOR THE DEVELOPMENT AND APPROVAL OF CONTROLLED DOCUMENTATION To be completed and attached to any document when submitted to the appropriate committee for consideration and approval. Title of document being reviewed: 1. Title/Cover Is the title clear and unambiguous? Does the title make it clear whether the controlled document is a guideline, policy, protocol or standard? 2. Document Details and History Have all sections of the document detail/history been completed? 3. Development Process 4. /N/ Unsure Comments Is the development method described in brief? NA Waste Mngt Group Are people involved in the development identified? See below Health & Safety and Security team Connie Wendes - Martin Keightley Infection Control Derek Bampton Michelle Ould Dr Emily McNaughton Estates Kevin Bolan Rob Graham Brian Meszynski Hotel Services - Michael Head Gayle Perryman Simon Laughton Modern matrons Tracy Cloke Louise Webb - MAG Information Governance Tony Martin SRCL (Trust clinical waste contractor) Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? Review and Revision Arrangements Including Version Control Is the review date identified? Is the frequency of review identified? If so, is it acceptable? Are details of how the review will take place identified? Does the document identify where it will be held and how version control will be addressed? 5. Approval Does the document identify which committee/group will approve it? If appropriate have the joint Human Resources/staff side committee (or equivalent) Waste Management Policy Page 25 of 59 NA Estates Delivery Group, Risk Committee Group, Policy Management Group, Executive Committee NA

Title of document being reviewed: approved the document? 6. Consultation Do you have evidence of who has been consulted? 7. Table of Contents Has the table of contents been completed and checked? 8. Summary Points Have the summary points of the document been included? 9. Is it clear whether the controlled document is a guideline, policy, protocol or standard? 10. Relevance Has the audience been identified and clearly stated? 11. Purpose Are the reasons for the development of the document stated? 12. Roles and Responsibilities Are the roles and responsibilities clearly identified? 13. Content Is the objective of the document clear? Is the target population clear and unambiguous? Are the intended outcomes described? Are the statements clear and unambiguous? 14. Training Have training needs been identified and documented? 15. Dissemination and Implementation 16. Is there an outline/plan to identify how this will be done? Does the plan include the necessary training/support to ensure compliance? Process to Monitor Compliance and Effectiveness Are there measurable standards or Key Performance Indicators (KPIs) to support the monitoring of compliance with and effectiveness of the document? Is there a plan to review or audit compliance within the document? /N/ Unsure Comments Waste Management Policy Page 26 of 59

Title of document being reviewed: Is it clear who will see the results of the audit and where the action plan will be monitored? 17. Associated Documents Have all associated documents to the document been listed? 18. References Have all references that support the document been listed in full? 19. Glossary Has the need for a glossary been identified and included within the document? 20. Equality Analysis Has an Equality Analysis been completed and included with the document? 21. Archiving Have archiving arrangements for superseded documents been addressed? Has the process for retrieving archived versions of the document been identified and included within? 22. Format and Style Does the document follow the correct style and format of the Document Control Procedure? 23. Overall Responsibility for the Document Is it clear who will be responsible for co-ordinating the dissemination, implementation and review of the documentation? Committee Approval /N/ Unsure N Comments If the committee is happy to approve this document, please sign and date it and forward copies for inclusion on the Intranet. Name of Committee Print Name Date Signature of Chair Waste Management Policy Page 27 of 59

Appendix 2 IMPACT ASSESSMENT ON DOCUMENT IMPLEMENTATION Summary of Impact Assessment (see next page for details) Document title Waste Management Policy Totals WTE Recurring Non Recurring Manpower Costs 0 0 0 Training Staff 0 0 0 Equipment & Provision of resources 0 0 0 Summary of Impact: NA Risk Management Issues: Benefits / Savings to the organisation: Equality Impact Assessment Has this been appropriately carried out? ES Are there any reported equality issues? NO If ES please specify: Use additional sheets if necessary. Waste Management Policy Page 28 of 59

IMPACT ASSESSMENT ON POLIC IMPLEMENTATION Please include all associated costs where an impact on implementing this policy has been considered. A checklist is included for guidance but is not comprehensive so please ensure you have thought through the impact on staffing, training and equipment carefully and that ALL aspects are covered. Manpower WTE Recurring Non-Recurring Operational running costs Additional staffing required - by affected areas / departments: 0 0 0 Totals: 0 0 0 Staff Training Impact Recurring Non-Recurring Affected areas / departments e.g. 10 staff for 2 days 0 0 Totals: Equipment and Provision of Resources Recurring * Non-Recurring * Accommodation / facilities needed Building alterations (extensions/new) IT Hardware / software / licences Medical equipment Stationery / publicity Travel costs Utilities e.g. telephones Process change Rolling replacement of equipment Equipment maintenance Marketing booklets/posters/handouts, etc Totals: 0 0 Capital implications 5,000 with life expectancy of more than one year. Funding /costs checked & agreed by finance: Signature & date of financial accountant: Funding / costs have been agreed and are in place: Signature of appropriate Executive or Associate Director: Waste Management Policy Page 29 of 59

Appendix 3 Equality Analysis and Action Plan Step 1. Identify who is responsible for the equality analysis. Name: Charles Joly Role: Environmental, Waste and Sustainability Manager Other people or agencies who will be involved in undertaking the equality analysis: Step 2. Establishing relevance to equality Show how this document or service change meets the aims of the Equality Act 2010? Protected Groups Age Gender Reassignment Race Sex and Sexual Orientation Religion or belief Disability Marriage and Civil Partnerships Human Rights Pregnancy and Maternity Staff Relevance Service Users Wider Community Equality Act General Duty Eliminates unlawful discrimination, harassment, victimization and any other conduct prohibited by the Act. Advance equality of opportunity between people who share a protected characteristic and people who do not share it Foster good relations between people who share a Relevance to Equality Act General Duties No Impact No Impact No Impact Waste Management Policy Page 30 of 59

protected characteristic and people who do not share it. Step 3. Scope your equality analysis What is the purpose of this document or service change? Who will benefits? What are the expected outcomes? Why do we need this document or do we need to change the service? Scope To ensure that the Trust fulfils its legal duties for waste management. Staff, patients, and general public. Effective waste management. Essential to adhere to legislation and wider policy environment. It is important that appropriate and relevant information is used about the different protected groups that will be affected by this document or service change. Information from your service users is in the majority of cases, the most valuable. Information sources are likely to vary depending on the nature of the document or service change. Listed below are some suggested sources of information that could be helpful: Results from the most recent service user or staff surveys. Regional or national surveys Analysis of complaints or enquiries Recommendations from an audit or inspection Local census data Information from protected groups or agencies. Information from engagement events. Step 4. Analyse your information. As yourself two simple questions: What will happen, or not happen, if we do things this way? What would happen in relation to equality and good relations? In identifying whether a proposed document or service changes discriminates unlawfully, consider the scope of discrimination set out in the Equality Act 2010, as well as direct and indirect discrimination, harassment, victimization and failure to make a reasonable adjustment. Findings of your analysis No major change Description our analysis demonstrates that the proposal is robust and the evidence shows no Justification of your analysis No impact with regard to equality. Waste Management Policy Page 31 of 59

Adjust your document or service change proposals Continue to implement the document or service change Stop and review potential for discrimination. This involves taking steps to remove barriers or to better advance equality outcomes. This might include introducing measures to mitigate the potential effect. Despite any adverse effect or missed opportunity to advance equality, provided you can satisfy yourself it does not unlawfully discriminate. Adverse effects that cannot be justified or mitigated against, you should consider stopping the proposal. ou must stop and review if unlawful discrimination is identified 5. Next steps. 5.1 Monitoring and Review. Equality analysis is an ongoing process that does not end once the document has been published or the service change has been implemented. This does not mean repeating the equality analysis, but using the experience gained through implementation to check the findings and to make any necessary adjustments. Consider: How will you measure the effectiveness of this change When will the document or service change be reviewed? Who will be responsible for monitoring and review? What information will you need for monitoring? How will you engage with stakeholders, staff and service users 5.2 Approval and publication The Executive Board will be responsible for ensuring that all documents submitted for approval will have completed an equality analysis. Under the specific duties of the Act, equality information published by the organisation should include evidence that equality analyses are being undertaken. These will be published on the organisations Equality, Diversity and Inclusion website. Waste Management Policy Page 32 of 59

WASTE MANAGEMENT POLIC APPENDIX A - WASTE DATA SHEETS (WDS) For ease of use, the Waste Management Policy is divided into Waste Data Sheets (WDS) for all waste streams generated by the Trust. WDS are indexed below, headings give the following details: WDS Waste Stream Colour EWC Code Haz Description WDS reference number Heading description of the waste stream Colour-coding of containers European Waste Catalogue code (* if hazardous) : Hazardous N: Non-hazardous LB: Landfill ban More detailed description of waste stream Each WDS gives the following details for each waste stream when applicable: EWC code Examples Container(s) Handling Internal Storage Internal Transport Final Disposal European Waste Catalogue code of the waste materials Relevant examples Details of waste container(s) / packaging to be used including colour coding. (If required) Requirements for handling the waste stream. Details of correct storage for the waste Details of transport arrangements for the waste to storage before disposal. Details of disposal route / treatment process for waste stream. INDEX PART A HEALTHCARE WASTES WDS Waste Stream 101 Clinical waste - ellow stream 102 Clinical waste - Orange stream 103 Offensive waste - Tiger stream 104 Anatomical waste 105 Sharps - Orange lidded 106 Sharps - ellow lidded 107 Sharps - Purple lidded 108 Medicines waste - Pharmacy returns 109 Medicines waste - Blue stream 110 Medicines waste - Purple stream 111 Controlled Drugs 112 Plaster / Gypsum 113 Infectious mattresses 114 Lymph biopsy waste 115 Dental Wastes WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 33 of 59

PART B NON-HEALTHCARE NON-HAZARDOUS WASTES WDS Waste Stream 201 General Waste 202 Dry Mixed Recycling 203 Cardboard 204 Confidential paper 205 Crockery / Broken glass 206 Sanitary / Fem hygiene 207 Green/Garden waste 208 Non-infectious mattresses 209 Metals 210 Furniture - Bulky items 211 Pallets 212 Rubble / Inert 213 Wood 214 Textiles 215 Catering oil PART C NON-HEALTHCARE HAZARDOUS WASTES WDS 301 Asbestos Waste Stream 302 Plasterboard - plaster 303 Drain sludges 304 Oils / oil contaminated waste 305 Paints 306 Chemicals / gas cylinders 307 Printer toners and inkjet cartridges WEEE (Waste Electrical & Electronic Equipment) 308 WEEE - Domestic type 309 WEEE - IT Equipment 310 WEEE - Medical Equipment 311 Batteries 312 Lamps & Bulbs WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 34 of 59

PART A - Healthcare Wastes PART A - HEALTHCARE WASTES WDS Waste Stream Colour EWC Code Haz Description 101 Clinical waste - ellow stream 18 01 03* 102 Clinical waste - Orange stream 18 01 03* 103 Offensive waste - Tiger stream 18 01 04 N Infectious clinical waste for incineration only Infectious clinical waste suitable for alternative treatment Clinical waste not identified as infectious 104 Anatomical waste 18 01 03* Anatomical waste 105 Sharps - Orange lidded Sharps 18 01 03 Non-Medicinally Contaminated Sharps 106 Sharps - ellow lidded Sharps 18 01 03* / 18 01 09 Medicinally Contaminated Sharps 107 Sharps - Purple lidded Sharps 18 01 03* / 18 01 08* Cytotoxic and cytostatic contaminated Sharps 108 Medicines waste - Pharmacy returns Medicines waste suitable for transport to Pharmacy 109 Medicines waste - Blue stream 18 01 09 N Medicines / Medicines contaminated waste (Non-cyto) 110 Medicines waste - Purple stream 18 01 08* Cytotoxic and cytostatic medicines / contaminated waste 111 Controlled Drugs Controlled Drugs denaturing kits 112 Plaster / Gypsum 18 01 04 N 113 Infectious mattresses 18 01 03* 114 Lymph biopsy waste 18 01 03* 115 Dental Wastes Misc Non-infectious gypsum (plaster) wastes Mattresses classed as infectious clinical waste Very low level radioactive waste for incineration only Amalgams, teeth, fixers/developers, lead foils etc WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 35 of 59

WDS 101 Infectious clinical waste ellow stream EWC 18 01 03* Waste known or believed to be contaminated with body fluids (blood, urine, sputum, vomit, faeces) from a patient known or suspected to be infectious with category A pathogens (as defined in section 8.6 of this Policy). A list of Category A pathogens can be found as an Appendix to SOP 101. Any category A pathogen outbreak must immediately be reported to the Infection Control Doctor/ Consultant microbiologist and the relevant Infection Control policies and procedures followed. The Infection Control team will liaise with the Waste Manager to deploy appropriate waste disposal procedures. OR Infectious clinical waste (category A or B pathogens) with any of the following additional property: Containing anatomical waste (recognisable body parts and placenta); or Chemically contaminated samples and diagnostic kits; or Medicinally-contaminated infectious waste. OR Large volumes of liquid infectious clinical waste (category A or B pathogens) (E.g. suction bags). Examples Due to the very high costs associated with the disposal of the yellow stream, it is Trust policy to use the orange stream (WDS102) whenever possible with the exception of local procedures developed in consultation and approved by the Waste Manager. Diagnostic specimens, reagents or test vials and kits containing chemicals. Suction bags. Handling Refer to SOP102 ellow bags / ellow containers Disposal cupboards place loose (inside the dedicated lockable clinical waste cabinet or bin when available). External bins place in the bin dedicated for clinical waste bags Estates Clinical Waste operative Incineration only WDS 102 Infectious clinical waste Orange stream EWC 18 01 03* Examples Waste known or believed to be contaminated with body fluids (blood, urine, sputum, vomit, faeces) from a patient known or suspected to be infectious with category B pathogens (as defined in section 8.6 of this Policy). See WDS 101 for category A pathogens. Incontinence/sanitary/nappy waste, Couch roll, catheter bags, Protective clothing (gloves, aprons, gowns), dressings, swabs, Non-medicated IV bags/giving sets WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 36 of 59

Handling Refer to SOP102 Orange bags Disposal cupboards place loose (inside the dedicated lockable clinical waste cabinet or bin when available). External bins place in the bin dedicated for clinical waste bags Estates Clinical Waste operative Suitable for Alternative Treatment (Autoclave) / Incineration WDS 103 Offensive (non-infectious clinical) waste Tiger stream EWC code 18 01 04 Examples Wastes contaminated with body fluids but not from a known or suspected infectious patient. Also defined as waste items and materials which have not been identified as infectious but are recognisable as healthcare waste or may cause offensive due to their nature. Incontinence/sanitary/nappy waste, Couch roll, catheter bags, Protective clothing (gloves, aprons, gowns), dressings, swabs, Non-medicated IV bags/giving sets Any material listed above and soiled with body fluids should not be contaminated with Infectious waste or with medicines. Tiger bags Disposal cupboards place loose (inside the dedicated lockable clinical waste cabinet or bin when available). External bins place in the bin dedicated for clinical waste bags Estates Clinical Waste operative Suitable for deep landfill WDS 104 Anatomical waste EWC 18 01 03* Body parts or other recognisable anatomical items Examples Placenta. Recognisable human tissues. Limbs. Bones. Red-lidded containers / ellow-lidded with an Anatomical waste label (supplied by the Waste team). Important: Ensure anatomical waste containers are very clearly recognisable. If the use of red-lidded containers is not possible (e.g. items too large), then the containers should be very clearly labelled Anatomical waste with printed tape (supplied by the Waste team). WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 37 of 59

Red-lidded containers should never be placed in clinical waste bags Disposal cupboards place loose (inside the dedicated lockable clinical waste cabinet or bin when available). External bins place in the bin dedicated for sharps/rigid containers Estates Clinical Waste operative Incineration WDS 105 SHARPS Orange-lidded EWC 18 01 03* Non-Medicinally Contaminated Sharps Sharps are items that could cause cuts or punctures. Examples Due to the difficulty to segregate non-medicinally sharps, it is Trust policy to use yellow-lidded sharps bins as standard. Subject to review and with the exception of local procedures developed in consultation and approved by the Waste Team. Plastic single use instruments and phlebotomy sharps. Handling Orange-lidded sharps bins All sharps bins should be disposed of when the fill line is reached. Seal and label with your name, ward/department name and date. DO NOT OVERFILL. If any sharps are protruding through the container or opening, do not attempt to push the items inside, but call the Waste team on x4524 for safe removal. At no time should sharps wastes be contaminated with domestic, medicinal waste, tubes, swabs, anatomical or electronic waste. Sharps containers should never be placed in clinical waste bags Disposal cupboards place loose (inside the dedicated lockable clinical waste cabinet or bin when available). External bins place in the bin dedicated for sharps/rigid containers Estates Clinical Waste operative Incineration WDS 106 SHARPS ellow-lidded EWC 18 01 03* / 18 01 09 Medicinally Contaminated Sharps Examples Sharps are items that could cause cuts or punctures. Needles, syringes with needles, scalpels, infusion sharps, glass ampoules, guide wires, blades, air inlets, intravenous cannulae, single use instruments (scissors, clip removers...)... WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 38 of 59

Handling ellow-lidded sharps bins All sharps bins should be disposed of when the fill line is reached. Seal and label with your name, ward/department name and date. DO NOT OVERFILL. If any sharps are protruding through the container or opening, do not attempt to push the items inside, but call the Waste team on x4524 for safe removal. At no time should sharps wastes be contaminated with domestic waste, tubes, swabs, anatomical or electronic waste. Sharps containers should never be placed in clinical waste bags Disposal cupboards place loose (inside the dedicated lockable clinical waste cabinet or bin when available). External bins place in the bin dedicated for sharps/rigid containers Estates Clinical Waste operative Incineration WDS 107 SHARPS Purple-lidded EWC 18 01 03* / 18 01 08* Sharps waste contaminated with cytotoxic and/or cytostatic medicines Sharps are items that could cause cuts or puncture. Cytotoxic and/or cytostatic medicines: products displaying toxic, carcinogenic, toxic for reproduction or mutagenic properties (Eg. Cancer and hormone therapy drugs, live vaccines). Examples A list of cytotoxic / cytostatic medicines can be found as an Appendix to SOP101. Needles, syringes with needles, scalpels, infusion sharps, glass ampoules, guide wires, blades, air inlets, intravenous cannulae, single use instruments (scissors, clip removers, laryngoscopes)... Handling Purple-lidded sharps bins All sharps bins should be disposed of when the fill line is reached. Seal and label with your name, ward/department name and date. DO NOT OVERFILL. If any sharps are protruding through the container or opening, do not attempt to push the items inside, but call the Waste team on x4524 for safe removal. Internal Transport Disposal At no time should sharps wastes be contaminated with domestic, medicinal waste, tubes, anatomical or electronic waste. Sharps containers should never be placed in clinical waste bags Do not place in waste cupboards/external bins. Arrange collection with the Clinical Waste operative Estates Clinical Waste operative Incineration WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 39 of 59

WDS 108 Medicines waste Pharmacy returns EWC Medicines suitable for transport All medicines suitable for transport, e.g. blister packs. Leave medicines in their original packaging. Also includes medicinal aerosols (i.e. inhalers) metal part only (dispose of plastic part as black bag waste). Used Controlled Drugs denaturing kits. Excludes: loose tablets, patches, liquids. Green Pharmacy box / Green Pharmacy padded bag Sluice ready for collection by Pharmacy Pharmacy porters Re-use when appropriate, Incineration WDS 109 Medicines waste Blue stream (Non cyto) EWC 18 01 09 Medicines or medicines contaminated waste (non cyto) Examples Empty or part-full medicated IV's - with/without giving sets (but no glucose, saline) Medicated syringes (NO sharps) Medicines not suitable for return to Pharmacy (e.g. Loose tablets, capsule, medicated patches) Empty or part-full medicine bottles Other non-sharp items contaminated with medicine Not suitable for any cytotoxic or cytostatic waste (see WDS 110 below). Blue-lidded lidded rigid container / Blue cardboard container Blue containers should be placed in non-patient areas. 5 litres containers for treatment rooms. 50 litres rigid containers for sluices. Cardboard containers are only approved for use at Pharmacy at this stage. Blue-lidded lidded containers should never be placed in clinical waste bags Disposal cupboards place loose External bins place in the bin dedicated for sharps/rigid containers Estates Clinical Waste operative Incineration WDS 110 Medicines waste - Purple stream (Cyto) EWC 18 01 08* Cytotoxic and cytostatic medicines / medicines contaminated waste. Cytotoxic and/or cytostatic medicines: products displaying toxic, carcinogenic, toxic for reproduction or mutagenic properties (Eg. Cancer and hormone therapy drugs, WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 40 of 59

live vaccines). Examples An indicative list of cytotoxic and cytostatic medicines can be found as an Appendix to SOP101. Absorbing materials used to contain a cytotoxic medicines spill. Purple-lidded lidded container / Purple striped yellow bag Effectively sharps purple lidded container can be used for this waste stream Purple-lidded lidded containers should never be placed in clinical waste bags Disposal cupboards place loose External bins place in the bin dedicated for sharps/rigid containers Estates Clinical Waste operative Incineration WDS 111 Controlled Drugs EWC Controlled Drugs are any drug identified within the Misuse of drugs regulations 2012 and Misuse of drugs (safe custody) regulations 2007. Examples Denaturing kits are required for Controlled Drugs which are not suitable for return to Pharmacy for denaturing i.e. liquids Part-used CD vial Controlled Drugs denaturing kits Once full return to Pharmacy as per WDS 108 WDS 112 Plaster / Gypsum waste (Non-infectious) EWC 18 01 04 Gypsum and plaster wastes are not permitted in mixed landfill with general domestic waste as it generates hydrogen sulphide gas. The vast majority of plaster casts and models are not infectious and should not be placed in the clinical waste stream. Gypsum plaster casts should not be placed in the offensive waste stream either. These should be segregated and labelled as a gypsum waste stream and disposed of separately. Infectious plaster/gypsum is disposed of as Clinical - Orange stream. Examples Plaster casts, back slabs and related materials (chiropodists/podiatrists) and plaster study models in dental. WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 41 of 59

Gypsum cardboard container or yellow bags with a Gypsum waste label (supplied by the Waste team). Disposal cupboards place loose External bins arrange collection with the Clinical Waste operative Estates Clinical Waste operative Recycling or incineration WDS 113 Infectious mattresses EWC 18 01 03* In the event a mattress is contaminated with body fluids beyond that which can be removed by decontamination methods, then the mattress will need to be disposed of as clinical infectious waste. A yellow mattress disposal bag will need to be used (ordering code MVN003, supplied by Hotel Services). Mattresses not identified as infectious are disposed of as domestic waste please refer to WDS 208. Mattresses yellow bags ordering code MVN003 Not suitable for internal storage, Portering to bring direct to the Clinical waste transfer station. Hotel Services Incineration WDS 114 Lymph biopsy waste EWC 18 01 03* All theatre waste from patients undergoing sentinel node biopsy involving the use of Technetium-99 Please refer to the Protocol for Sentinel Node Studies ellow bags with a completed sentinel node label Not suitable for internal storage in an unlocked or any area accessible by the public. If needed pre-arrange collection by the Clinical Waste Operative. Estates Clinical Waste operative 7 days storage and Incineration WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 42 of 59

WDS 113 Dental wastes EWC Misc. - See below Wastes produced as a result of dentistry which require specialist disposal. Examples Amalgam 18 01 10* Teeth 18 01 10* Crowns/bridges 20 01 40 Sludge 18 01 10* Fixer 09 01 04* Developer 09 01 01* Lead Foils 15 01 04 Plaster models 18 01 04 Range of specific containers as provided by the Waste Contractor WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 43 of 59

PART B - Non-Healthcare Non-hazardous Wastes WDS Waste Stream Colour EWC Code Haz 201 General Waste 20 03 01 N 202 Dry Mixed Recycling 20 03 01 N 203 Cardboard 20 01 01 N 204 Confidential paper 20 01 01 N Other confidential media 205 Crockery / Broken glass 20 03 01 N 206 Sanitary / Fem hygiene 20 03 99 N 207 Green/Garden waste 20 02 01 N 208 Mattresses 20 03 01 N 209 Metals 20 01 40 N 210 Furniture - Bulky items 20 03 01 N 211 Pallets 20 01 38 N 212 Rubble / Inert 20 02 02 N 213 Wood 20 01 38 N 214 Textiles 20 03 01 N 215 Catering oil 20 01 25 N WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 44 of 59

WDS 201 General Waste EWC 20 03 01 Examples Non recyclable domestic wastes. Domestic waste is defined as waste items commonly produced in a private household. Hand towels, waste food, shrink wrap, polystyrene, foil, sterile items packaging, flowers, food contaminated items. Black bags General waste cannot be left loose in corridors, public areas or other unsuitable places & must not obstruct access routes or form a potential fire hazard. Disposal cupboards place loose External bins RED with BLACK LID General waste bins or Waste compactor Porters or Domestics OR Energy recovery (Gasification) WDS 202 Dry Mixed Recycling EWC 20 03 01 Fractions of domestic waste which can be recycled. Examples Alcohol hand gels empty bottles are suitable for recycling but need to be rinsed out with clear water first. For other chemical containers please check with the waste team. Tins / cans. Domestic glass. Plastic bottles / containers. Paper, card, magazines. Clear bags Disposal cupboards place loose External bins GREEN Dry Mixed Recycling bins Porters or Domestics Recycling (materials recovery) WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 45 of 59

WDS 203 Cardboard EWC 20 01 01 Corrugated cardboard Examples Cardboard boxes Flattened Always flatten cardboard prior to disposal Put any packaging foam, polystyrene, and plastic in black bags Disposal cupboards place loose External bins Cardboard baler or RED with BROWN LID Cardboard bins. If not available GREEN Dry Mixed Recycling bins Porters (disposal cupboard) collected and taken to the cardboard baler for recycling. Domestics collected and taken to the Recycling (materials recovery) OR WDS 204 Confidential paper / other confidential media EWC 20 01 01 Examples Documents containing Personal Confidential Data (PCD) or business sensitive information. No need to remove staples or small paper clips. Any other nonpaper items have to be removed prior to disposal (E.g. plastic binding). Patients case files, procurement documents, meeting minutes, empty medicines boxes with patient details etc. Confidential paper waste consoles or confidential waste paper heavy-duty bags Put any packaging foam, polystyrene, and plastic in black bags Day-to-day place in the provided confidential paper waste consoles Office clear-out / large quantities confidential waste paper heavy-duty bags can be obtained from the waste team (waste@iow.nhs.uk). Store those securely (under lock if required) until the contractor s next due collection. WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 46 of 59

Other confidential media (non-paper) Confidential waste contractor Shredding and recycling (materials recovery) Other confidential media : Either destroy before disposal in black bag (e.g. cut CD in 2). If not suitable, for small quantities send back to Estates in internal post, or if volume too high arrange collection waste@iow.nhs.uk Do not mix with confidential paper CDs / DVDs Video tapes, Dictaphone tapes X-rays Fax ribbons WDS 205 Crockery / Broken glass EWC 20 03 01 Crockery, broken glass and glass items not suitable for recycling. All disposed as black bag waste (WDS 201). Important: Any glass contaminated with medicines is disposed of as medicines contaminated waste (Blue stream WDS 109). Domestic glass (e.g. coffee jars, glass bottles etc) is suitable for recycling in clear bags (WDS 202). However, due to the weight, if you produce large quantities of glass please e consult with the waste team on a safe disposal process. Examples Some glass items are not suitable for recycling, such as PREX (hardened glass dishes), mirrors and glass panes. Please make sure to package/wrap those safely for transport by the porters or domestics, clearly indicating the nature of the waste (CAUTION- GLASS, with a permanent marker). Mugs and cups, any broken glass, glass panes, mirrors etc. Orange bucket (ordering code FSL413) or packaged/wrapped safely for disposal as black bag waste Disposal cupboards place loose External bins RED with BLACK LID General waste bins or waste compactor Porters or domestics Landfill WDS 206 Sanitary / Feminine hygiene EWC 20 01 99 Sanitary and feminine hygiene waste (Sanpro) Examples Feminine hygiene products, nappies. Sanibins tiger bags Sanibins available in female toilets. Nappy bins available in toilets with baby- WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 47 of 59

changing facilities Sanitary Waste Contractor Deep landfill or incineration WDS 207 Green / Garden waste EWC 20 02 01 Examples Biodegradable green waste (excluding rubble, soil and food) Gardening waste materials from the clearance and up keep of the hospital sites including leaves and twigs, tree trimmings and grass cuttings Loose As above Estates Grounds Maintenance staff to transport to the Garden waste skip at the Estates Recycling ard Composting WDS 208 Non-infectious mattresses EWC 20 03 99 Mattresses. Please note potentially infectious mattresses need to go through decontamination first. Loose Always make disposal arrangements in advance Caretakers (arranged through the Portering Coordinator on x 4603 or via email to PortersLodge@iow.nhs.uk) Landfill WDS 209 Metals EWC 20 01 40 Examples All scrap metals items Trolleys, chairs, bed frames etc Loose Always make disposal arrangements in advance Caretakers (arranged through the Portering Coordinator on x 4603 or via email to PortersLodge@iow.nhs.uk) Transported to the Scrap metal skip at the Estates Recycling ard Recycling (materials recovery) WDS 210 Furniture / Bulky items EWC 20 03 99 Examples All items too big for disposal in internal cupboards or external waste bins Desks, chairs, cupboards etc Loose Always make disposal arrangements in advance Caretakers (arranged through the Portering Coordinator on x 4603 or via email to PortersLodge@iow.nhs.uk) Transported to the Scrap metal skip at the Estates Recycling ard WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 48 of 59

Re-use though Charity when possible. Recycling (materials recovery). Landfill. WDS 211 Pallets EWC 20 01 38 Pallets wood pallets / plastic pallets Loose Always make disposal arrangements in advance Caretakers (arranged through the Portering Coordinator on x 4603 or via email to PortersLodge@iow.nhs.uk) Transported to the Pallets recycling bay at the Main waste yard (back catering) Recycling (materials recovery). WDS 212 Rubble / Inert EWC 20 02 02 Examples Inert materials such as arising from construction and demolition Brick, soil, cement, tiles etc Loose As above Estates Maintenance staff to transport to the Rubble waste skip at the Estates Recycling ard Inert landfill WDS 213 Wood EWC 20 01 38 Examples Wood Wood trimmings, furniture part Loose Always make disposal arrangements in advance Caretakers (arranged through the Portering Coordinator on x 4603 or via email to PortersLodge@iow.nhs.uk) Transported to the General waste skip at the Estates Recycling ard Landfill. Subject to review. WDS 214 Textiles EWC 20 03 01 Examples Textiles and fabrics Curtains, uniforms etc Very small quantities suitable for black bag waste (WDS 201). Larger quantities arrange collection as below. Always make disposal arrangements in advance Caretakers (arranged through the Portering Coordinator on x 4603 or via email to PortersLodge@iow.nhs.uk) Transported to the Sewing Room, storage in clear bags before collection. Recycling (materials recovery). WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 49 of 59

WDS 215 Catering oil EWC 20 01 25 Kitchen oil (Catering Department) Suitable leak-proof containers. All containers to be securely stored to prevent any risks of spills. Catering staff Recycling (materials recovery). WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 50 of 59

PART C - Non-Healthcare Hazardous Wastes WDS Waste Stream Colour EWC Code Haz 301 Asbestos 17 06 05* 302 Plasterboard - plaster 17 08 02 LB 303 Drain sludges 13 05 03* 304 Oils / oil contaminated waste Misc 305 Paints 08 01 11* - 08 01 12 306 Chemicals / gas cylinders Misc 307 Printer toners and inkjet cartridges 08 03 17* WEEE (Waste Electrical & Electronic Equipment) 308 WEEE - Domestic type Misc 309 WEEE - IT Equipment Misc 310 WEEE - Medical Equipment Misc 311 Batteries 20 01 33* 312 Lamps & Bulbs 20 01 21* WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 51 of 59

WDS 301 - Asbestos EWC 17 06 01* - 17 06 05* Responsibilities Storage Transport Asbestos is the term used for fibrous forms of several naturally occurring silicate minerals used in many construction materials for fireproofing, thermal insulation, electrical insulation, sound insulation, decorative plaster, gaskets and friction products. For all asbestos waste removed from Trust premises, Hazardous Waste Consignment Notes and consignee returns are kept at Estates for 3 years It is the responsibility of the relevant project manager at Estates to ensure the documentation above is obtained from contractors. Specialist containers will be used for the removal of asbestos in line with the latest environmental and Health & Safety guidance. Contact Estates if you come across any asbestos products. Do not handle asbestos or suspected asbestos, as this must be done by specially trained personnel under controlled conditions. Staff finding asbestos or suspected asbestos are to vacate the area and cordon off the area and immediately contact Estates Secure storage areas for asbestos will be arranged by the responsible project manager at Estates. Specialised contractors will be arranged for safe transport It is the responsibility of the project manager with support from the Waste Manager to ensure asbestos waste is collected and transported by a licensed and authorised contractor, and appropriately disposed at a permitted facility. WDS 302 Plasterboard plaster - gypsum EWC 17 08 02 Examples Any materials containing plaster/gypsum Materials from maintenance/refurbishments works, including plasterboard off-cuts and waste, plaster materials for demolition and construction. Heavy duty grab bag As above Estates Maintenance staff to transport to the Plaster container at the Estates Recycling ard Recycling or separate landfill cell WDS 303 Drains sludges EWC 13 05 03* Liquid materials from the clearing of drains, interceptors and fat traps. Examples Ambulance station wash bay interceptor Waste Contractor Tanker vehicle As above Estates Maintenance Foreman to liaise with waste contractor Treatment WDS 304 Oils / oils contaminated waste EWC Misc Any oils or items contaminated with oil Examples Waste engine oil, oily rags, etc WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 52 of 59

Original container or suitable leak proof container. Special care must take taken to ensure all risks of spills have been mitigated and adequate bunding has been put in place (i.e. use of a secondary container, bund or drip tray to catch any accidental leaks or spills). Estates Maintenance staff to transport to the Estates Recycling ard and store undercover. Treatment WDS 305 Paints EWC 08 01 11* - 08 01 12 08 01 11* waste paint and varnish containing organic solvents or other dangerous substances Select 08 01 12 waste paint and varnish other than those mentioned in 08 01 11 Examples Paint tins (solvent base or water based) with remaining contents. In original containers Chemicals container or storage area at the Estates Recycling Ward Estates Maintenance staff to transport to the dedicated storage area at the Estates Recycling ard Treatment. WDS 306 Chemicals / gas cylinders EWC Misc Chemicals, including amongst others Household chemicals Solvents Acids and alkalis Aerosol containers containing residues of hazardous substances Mercury thermometers Alcohol gels Pesticides Solvent paints Antifreeze If in doubt refer to your COSSH file. Aerosols with the following symbols are disposed of as chemicals (even if empty): Gas cylinders 16 05 04* gases in pressure containers (including halons) containing dangerous substances 16 05 05 gases in pressure containers other than those mentioned in 16 05 04 Examples Oil drum, part full chemical container, mercury thermometer Loose Must be stored in accordance with related COSHH requirements Estates. Contact the waste manager on waste@iow.nhs.uk with all details of the product, quantities/volumes and your location for advice on disposal Treatment/incineration WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 53 of 59

WDS 307 Toners and cartridges EWC 08 03 17* All printer toners and cartridges. Please note fax machine ribbons are classed as confidential waste and should be returned to Estates for destruction. Put in the outgoing mail in original packaging or in an envelope. Clearly indicate Post room recycling on the label. Fax machine ribbons send back to Estates Dedicated cage located by Post room for collection by Solent Supplies staff and bulking before dispatch for recycling. Postroom staff Recycling at a specialised facility Waste Electrical and Electronic Equipements (WEEE) WDS 308 WEEE Domestic type WDS 309 WEEE - IT and Telecommunications Equipment WDS 310 WEEE Medical Equipment WDS 311 - Batteries WDS 312 Lamps & Bulbs WDS 308 WEEE Domestic type EWC Misc All items with an electrical or electronic aspect (including if running on batteries). With the exception of IT & Telecommunications equipment (see WDS 309) and some medical equipment (see WDS 310). Mixed items 16 02 14 Fridges 16 02 11* TVs / Monitors 16 02 13* Examples Large items: Television sets, fridges/freezers, macerators, etc Small items: Microwave ovens, kettles, fans, mobile phones, cabling, smoke detectors, thermostat, etc WEEE bin at Estates Recycling Ward Contact Portering for disposal x4603 or email to PortersLodge@iow.nhs.uk Always make disposal arrangements in advance. Do not fly-tip items in corridors/disposal cupboards/external locations. Caretakers (arranged through the Portering Coordinator on x 4603 or via email to PortersLodge@iow.nhs.uk) Transported to the WEEE bin at the Estates Recycling ard Recycling (materials recovery). WDS 309 WEEE - IT and Telecommunications Equipment EWC Misc All IT equipment items with an electrical or electronic aspect (including if running on batteries). Mixed items 16 02 14 Printers / faxes 16 02 14 Comms items 16 02 14 Computers 16 02 14 WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 54 of 59

Monitors 16 02 13* Cables 17 04 11 Responsibilities Examples The IT department is responsible for all data erasing prior to disposal. Computers, monitors, hard drives, printers, fax machines, telephones, keyboards, cabling etc IT department WEEE containers Contact the IT helpdesk for disposal itservicedesk@iow.nhs.uk - x4401 Always make disposal arrangements in advance. Do not fly-tip items in corridors/disposal cupboards/external locations. IT staff Recycling (materials recovery). WDS 310 WEEE Medical Equipment EWC Misc All medical equipment items with an electrical or electronic aspect (including if running on batteries). Mixed items 16 02 14 Responsibilities Examples The Medical Devices department is responsible for ensuring equipments are fully decontaminated in line with the Decontamination of Reusable Medical Devices Policy prior to disposal or resale to/re-use by a third party (in accordance with the Redundant Equipment Procedure), and bear the appropriate decontamination tagging. If porters/caretakers transport medical devices to the Waste yard for disposal, it is their responsibility to ensure the Medical Devices department lead the condemning procedure. Any items left in the Waste yard without appropriate decontamination tagging will be fully investigated. Pacemakers and Implantable Cardioverter Defibrillators (ICDs) ALL pacemakers removed from patients are returned to the manufacturer by the department undertaking the procedure in accordance with the Management of Explanted Pacemakers and Implantable Cardioverter Defibrillators (ICDs) Standard Operating Procedure. Dialysis machine, Patient Monitors, Infusion Devices, Electric Profiling Beds, Patient Movement Alarms, Defibrillators, ECG Machines, Incubators, Pressure Relieving Mattresses, Dental Equipment, etc Contact the Medical Devices team for disposal x2161 Always make disposal arrangements in advance. Do not fly-tip items in corridors/disposal cupboards/external locations. Consult with the Medical Devices Co-ordinator prior to disposal. Refer to the Redundant Equipment procedure. Recycling (materials recovery). WDS 311 - Batteries EWC 20 01 33* All waste batteries, including alkali-manganese, zinc-carbon, nickel-metal hydride and nickel- cadmium batteries for batteries recycling are located in a large number of areas both at St Mary s and in the community. Only used issued containers for storing batteries. Do NOT use sharps bins. Batteries should be kept dry at all time. If storing specialised batteries, do not mix with domestic batteries Waste team email waste@iow.nhs.uk indicating your exact location WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 55 of 59

Recycling at a specialised facility. WDS 312 Lamps & Bulbs EWC 20 01 21* All lamps and bulbs Examples Incandescent bulbs, lamp tubes, low-energy bulbs, etc In packaging of new tube/bulb for internal transport. Estates recycling yard. Lamp tubes: green coffin. Bulbs: bulbs bins. Estates Maintenance staff to transport to the Estates Recycling ard. Recycling at a specialised facility. WASTE MANAGEMENT POLIC APPENDIX A WASTE DATA SHEETS Page 56 of 59

WASTE MANAGEMENT POLIC APPENDIX B Standard Operating Procedures All Standard Operating Procedures can be found on the Trust Intranet at: Homepage > Non-Clinical Zone > Estates > Environmental and Waste INDEX SOP Name Version Clinical Waste 101 Waste Segregation Procedure 1.1 Appendix A - List of Category A pathogens Appendix B - List of cytotoxic / cytostatic medicines 102 Clinical Waste Handling 1.3 103 Waste bins for clinical areas 1.0 104 Medicines contaminated waste Poster 1.2 105 Identification Tape Ordering Procedure 1.0 Local Procedures 201 Clinical Waste - Community Teams 1.0 > Trust Clinical waste collections - Referral form > IoW Council Clinical waste collections - Referral form 202 Management of Explanted Pacemakers and Implantable Cardioverter Defibrillators (ICDs) 1.0 Clinical Waste Transfer Station 301 Haz Waste Consignment Notes - Transfer Station 2.0 302 Consigning Clinical Waste - Transfer Station 1.1 303 Submitting EA returns 1.0 Domestic Waste 401 Cardboard Baler - Operating Procedure 1.0 402 Domestic Hazardous Waste Disposal 1.0 403 Redundant Equipment Procedure 1.1 WASTE MANAGEMENT POLIC APPENDIX B Standard Operating Procedures Page 57 of 59

WASTE MANAGEMENT POLIC APPENDIX C WASTE MANAGEMENT GROUP TERMS OF REFERENCE MAIN PURPOSE The Waste Management Group is tasked with producing recommendations and policies to ensure all waste streams arising from the Trust activities are managed in an environmentally sustainable and cost-effective manner, in line with applicable legislation, and current best practice when appropriate. MEMBERSHIP Environmental Waste & Sustainability Manager Charles Joly - Chair Assistant Director Health & Safety and Security Connie Wendes Chief Pharmacist Gillian Honeywell Community Clinics Manager Anthea Church Community Nursing Pat McCamley Infection Control Derek Bampton Hotel Services Manager Michael Head Modern Matron Tracy Cloke Waste & Recycling Assistant Brian Meszynski If they cannot attend meetings, members are kindly asked to arrange for deputies from their area to attend on their behalf. Quorum is reached when 5 members/deputies or more are present. The Group may invite other managers and staff of the Trust, and invite staff from partner organisations to attend meetings as necessary. DELEGATED AUTHORIT and REPORTING ARRANGEMENTS The Waste Management Working Group will operate as a sub-group of the Risk Management Committee. The Group Chair or a deputy will report on the Group s work at Risk Management Committee meetings. FREQUENC OF MEETINGS The Waste Management Group usually meets every two months. DUTIES For members of the Group to be trained and knowledgeable on waste management best practice in a healthcare environment (including legislative requirements and Department of Health Guidelines). To review current waste management practices and procedures for the Trust. To make recommendations to ensure compliance with waste legislation applicable to the Trust. To keep up-to-date on upcoming waste legislation and what actions are required to ensure compliance. To make recommendations for the implementation of Department of Health Guidelines for waste management when appropriate. To be responsible for the development of Waste Management policies for the Trust. To formulate proposals for the implementation of Waste Management policies, including staff training. To track and monitor Key Performance Indicators for waste management. To ensure that the broader financial and operational consequences of waste management decisions are taken into account. It is the duty of the group to uphold the Code of Conduct for NHS Managers, which includes the seven principles of public life (The Nolan Committee), namely: selflessness, integrity, objectivity, accountability, openness, honesty and leadership. Revised August 2013 - Approved by: Risk Management Committee WASTE MANAGEMENT POLIC APPENDIX C Waste Group Terms of Reference Page 58 of 59

Chief Executive Trust Board Overall responsibility for Waste Management Executive Committee Risk Management Committee Scrutiny and monitoring Health & Safety Committee Infection Prevention and Control Committee Consultation Waste Management Group Env Waste & Sustainability Manager Infection Control, Health & Safety Hotel Services Community nursing and clinics Pharmacy Matrons Develop and maintain Policy / procedures Guide and monitor implementation (Refer to Group Terms of Reference) Estates Department Environmental Waste & Sustainability Manager Legislative compliance Budget and Contracts control Quality control Environmental performance Waste & Recycling Assistant Operational control Training and awareness Auditing and Data collection Waste Contractors Hotel Services All staff Service delivery Follow policy and procedures WASTE MANAGEMENT POLIC APPENDIX C Waste Group Terms of Reference Page 59 of 59