Standard Operating Procedures

Transcription

1 Document number: HSWM-0002 Standard Operating Procedure Written by: Martin Long Reviewed by Date Reviewed Diane Aucott Change Control Version: Date Author(s): Summary of Changes: Martin Long 1 st Draft Diane Aucott 2 nd Draft rd Draft th Draft Contents Page: Contents: 2 Contents 3 Purpose, Principles, Assumptions and Scope 4 Review Date and Person/Group to Review Author: Ratified: Martin long John Sellars Date of Issue: Review Date: Page 1 of 5

2 Standard Operating Procedure Contents 1. Purpose of guidance Principles Assumptions Scope Procedure for: Page 2 of 5

3 Standard Operating Procedure: Introduction A Non Conformance Notice (NCN) can be issued by any of the Trusts waste collection, disposal or handling contractors, should it be found that the Trust has not fulfilled either its statutory requirements or contractual obligations. 1. Purpose of guidance 1.1 Consistency of response; To ensure consistency of response across the trust to the issue of a NCN To provide consistency in the methodology applied in response to the issue of a NCN. 1.2 To ensure that the Trust responds robustly and credibly to all non conformity issues. 1.3 To ensure that the Trust responds in a timely fashion to all non conformity issues. 1.3 To ensure that non conformity trends are logged and identified. 1.4 To provide core data to facilitate; The designing out of practises that are generating non conformities The development of training packages and plans to minimise potential reoccurrences of non compliances To provide a benchmarking database to measure each sites performance To provide the Trust with Key Performance Indicator (KPIs) statistics The development of competency checks for front line staff involved in waste handling. 1.5 To ensure legislative compliance. 1.6 To provide a model for the development of a Critical Path Analysis (CPA) should a NCN be issued. 1.7 To provide a model for the development of a Critical Action Plan (CAP), in response to a CPA should a NCN be issued. Page 3 of 5

4 2. Principles 2.1 The design of all new, and the reviewing of existing controls of each waste stream, is the responsibility of the Trusts Waste manager. 2.2 Individual responsibility and accountability cannot be devolved to the centre and remains with everyone involved with waste generation, identification, security, segregation, movement, collection and ultimately disposal. 2.3 Waste management systems must reflect the individual needs of each site, with the centrally maintained controls reflecting these needs. 2.4 The process and outcome will meet the needs of all relevant legislation and published Environmental Agency guidelines. 2.5 The risk of reoccurrence of any instance that generate a NCNs will be reduced as a consequence of CPAs being instigated and CAPs being introduced. 3. Assumptions 3.1 All Hotel Services managers, designated waste leads and front line staff involved in waste handling are fully trained and familiar with the Trust waste handling processes. 3.2 That all clinical staff involved in the generation, temporary storage and handling of waste are fully aware of the Trusts requirements in relation to the correct identification, segregation and security of each waste stream. 3.2 The Trust Health & Safety advisors will provide support for the process. 4. Scope 4.1 The principles included in this Standard Operating Procedure will be applied fully and consistently on all of the Trusts Sites, on all units/departments within each of the Trusts sites, and in all instances when a NCN is issued against the Trusts regardless of the waste stream or contractor the NCN relates to. Page 4 of 5

5 Procedure for: Title: Responding to Waste Non Conformance Notices Non Conformance Notice is issued by one of the Trusts waste contractors; Primary copy goes to Trust Waste manager Secondary copies to designated waste lead on site that has generated the waste and copy to Head of Hotel Services. The Trusts Waste Manager will establish communication links and protocols with each waste contractor for receipt of NCNs, with electronic copies being provided by being the primary delivery methodology. On receipt the Trusts Waste manager will formally investigate the allegations made on the NCN and record finding using the Trusts Report of Accident, Clinical Incident or Near Miss (R1) form. Investigations will be undertaken with the site designated waste lead and clinical team are appropriate. Food related NCN will be investigated with the Trust Catering Manager. A Critical Path Analysis (CPA) must be conducted to identify the source of the waste involved, once completed and a Corrective Action Plan must be agreed by all parties and implemented. The Trust Waste Manager will report all NCN to the Patient Environment Operational Group (PEOG) who will formally minute all NCN and the consequent CAPs. All CAPs will be followed up by the Trusts Waste Manager, being monitored and corrected as required. The success or otherwise of such CAPs will be reported to PEOG with Key Performance Indicators relating to NCNs being agreed with the directorates senior management team. The Trust Waste Manager will analyse all NCN, identifying any underlying trends, and amending staff training, competency checks and operational systems accordingly. Page 5 of 5