Waste Management Policy

Transcription

1 Waste Management Policy

2 Policy Title: Executive Summary: Waste Management Policy This policy provides guidance to all staff, contractors and subcontractors regarding the arrangements for the management of healthcare waste, including the generation, segregation, handling and disposal of all waste on Trust premises. This guidance, when followed, will: ensure Trust compliance with all relevant legislation provide all staff with explicit guidance in the safe handling and disposal of all waste in line with health and safety and infection control requirements enable all staff to recognise and comply with legal requirements identify specific responsibilities identify and promote safe methods of segregation and disposal reduce the impact that the Trust s business has on the environment Supersedes: Version 4.0 Description of Complete re-write Amendment(s): This policy will impact on: This policy will be applicable to all Business Units, Directorates and Departments in the Trust. Financial Implications: There will be small financial investment required for the provision of appropriate training. Potential to reduce spend if instructions on waste segregation are followed. Policy Area: Health and Safety Document ECT/H&S Infection Control Reference: Version Number: 0.5 Effective Date: March 2016 Issued By: Director of Finance Review Date: March 2019 Author: Contract & Performance Manager APPROVAL RECORD Impact Assessment Date: Consultation: Associate Director of Performance Head of Assurance, Risk and Legal Services Committees / Group Date Infection Control Committee March 16 Approved by Director: Director of Finance March 16 Received for information: Health & Safety March

3 Contents: 1.0 Introduction Page Purpose of the Policy Page Responsibilities Page Legalisation and Statutory Responsibilities Page Environmental Protection Act 1990 Page Definition of Waste Page Waste Management Page Segregation and Containment of Waste Page Waste Generated in the Community Page Waste Transfer and Waste Consignment Notes Page Selection of Waste Contractors Page Site Registration Page Recycling and Waste Minimisation Page Waste Audits Page References Page Review Page 15 Appendix 1 Mercury Spillage Procedure Appendix 2 Waste Disposal Flow Chart Appendix 3 Specification and Traceability of Waste Containers Appendix 4 Procedure for the use of waste bags, One-way Containers & Bio-Systems Appendix 5 Colour Coding Key to Segregation System Equality Analysis Impact Assessment - 3 -

4 1.0 INTRODUCTION 1.1 Effective management of waste is essential to any organisation if they are to avoid prosecution, avoid cross-contamination of waste streams and prevent unnecessary financial burden upon the organisation. This policy gives detailed guidance on the measures to take in order to manage waste successfully and specifies everyone s responsibilities for the safe disposal of waste. Waste disposal is a burden on the earth s natural resources. When discarded all the materials, time, energy and money put into producing it in the first place are lost. 1.2 Disposing of waste requires energy and material resources as well as generating emissions. Consequently, as with any other activity, society and industry both need to behave in a sustainable manner so as to safeguard the availability of resources for future generations. In this context waste needs to be considered as a potential resource wherever possible and organisations have an important role to play in making this happen, and ensuring that where waste cannot be reduced, reused or recycled it is disposed of in the most sustainable manner. 2.0 PURPOSE OF THE POLICY The purpose of this policy is to describe in detail the arrangements for the correct segregation, storage, collection and disposal of all types of waste in order to assist managers to establish and maintain safe and effective waste management systems and procedures based on Safe Management of Healthcare Waste best practice. To inform and assist staff to apply correct and safe procedures at all times and comply with the law. 3.0 RESPONSIBILITIES 3.1 Chief Executive The Chief Executive has overall responsibility for the implementation of this policy within the Trust however Heads of Service/Departmental Managers have been delegated the responsibility for implementing the policy within their areas of control. 3.2 Head of Facilities (Soft FM) The Head of Facilities (Soft FM) will ensure that processes are in place to monitor compliance with this policy and that any non-conformance is acted upon. 3.3 Service Managers/Heads of Service Service Manager and Heads of Service have been delegated the responsibility for implementing this policy within their areas of control by ensuring that: Processes are in place to minimise risks from waste All staff have been trained in how to correctly and safely dispose of waste - 4 -

5 Risk assessments are carried out for waste management within their areas of control, as appropriate Setting clear objectives for Ward/Department Managers concerning waste management Ensuring that Ward/Department Managers receive appropriate training in the safe management of waste in the workplace 3.4 Managers Managers will be responsible for the operational implementation of safe management of healthcare waste all supporting legislation within their area(s) of responsibility and in particular will ensure that: The waste hierarchy is applied to all materials before they are considered as waste Ensure risk assessments are carried out for the safe disposal of waste Waste is segregated into the appropriate containers and that staff are made aware of the correct container to use Will respond to any concern raised by staff through liaison with the Contract & Performance Manager responsible for Waste Will act upon the findings of waste audits and take any necessary corrective action Ensure staff receive adequate training to allow them to safely dispose of all healthcare waste 3.5 Employees Employees have a responsibility to ensure that: They dispose of waste safely and only in the correct container The waste hierarchy is applied to all materials before they are considered as waste Receive waste training which is normally carried out at ward level by the service provider Keep all waste streams separate and correctly segregated Report all incidents involving waste to their Line Manager or Supervisor Ensuring that waste bags and sharp boxes are not overfilled Keep waste disposal rooms locked at all times to prevent the unauthorised removal or accidental loss of any waste bags or boxes All waste must be suitably labelled and dated 3.6 Waste Porters Waste Porters in addition to the duties of employees will ensure that: Waste is kept segregated throughout transport and disposal Waste is correctly consigned for disposal and that the waste is only given to a waste contractor approved by the Trust to carry that type of waste Complete and sign any necessary waste transfer notes or waste consignment notes and return any customer copy to the correct location for retention Keep waste disposal rooms locked at all times to prevent the unauthorised removal or accidental loss of any waste bags or boxes Keep the waste compound tidy at all times. Waste should be put into the correct container for disposal in order to mitigate a potential fire hazard within the compound and the hospital building - 5 -

6 3.7 Contract & Performance Manager (Waste) Responsible for providing advice, support, instruction and training for the safe management of healthcare waste Undertaking waste audits and report back findings Complete pre-acceptance audits at the required frequency 3.8 Infection, Prevention and Control Provides advice and guidance on the Infection, Prevention and Control issues concerned with the safe management of healthcare waste within the Trust 3.9 Contractors Employed by the Trust The person introducing the contractor on site will ensure that before a contractor is employed on site they are aware that they must not use any of our facilities to dispose of their waste All waste is to be removed from site by the contractor which must be overseen by the relevant Estates Department 4.0 LEGISLATION AND STATUTORY RESPONSIBILITIES 4.1 Criminal Liability The management and disposal of waste is governed by both Health & Safety and environmental legislation. Both sets of legislation assign strict duties to employers and to individuals who create or handle waste. A breach of the legislation is increasingly likely to result in a criminal prosecution of both the employer and of any identifiable individual who committed the offence 4.2 Health & Safety Legislation the employer, through individual managers is responsible for providing: The necessary resources for correct and effective waste management Written assessments of any significant risk to health or safety associated with waste generation, management and disposal Safe systems of work for staff generating, handling, storing or transporting waste Appropriate information and training for all relevant staff Regular monitoring and periodic review of the system so that deficiencies are corrected within a reasonable timescale and the system continuously refined and improved in the light of experience 4.3 Individual Employees are required to: Take reasonable care of themselves and others who may be affected by their acts or omissions Co-operate in matters of health and safety Correctly use any Personal Protective Equipment (PPE) and any other work equipment designated for the task Correctly apply the information and training, previously received Report any perceived hazards in their working environment, or deficiencies in the safe system or work, to their Line Manager - 6 -

7 5.0 ENVIRONMENTAL PROTECTION ACT 1990 Everyone concerned with waste has a Duty of Care to: Only receive waste if properly authorised to do so, and only from an authorised person Keep waste securely contained and prevent its escape or unauthorised removal Ensure it is adequately contained and packaged for safe transport Label the waste clearly to identify its contents and point of origin Transfer the waste only to a licensed contractor authorised to transport that type of waste Describe the waste (on the appropriate forms) in sufficient detail that subsequent carriers and disposers can deal with it safely Take reasonable steps to check that those providing or removing waste are acting properly and within the law The employer must also comply with a range of waste management regulations and guidance which govern the correct method of disposal of waste and the keeping of adequate written records regarding the disposal of the waste 6.0 DEFINITION OF WASTE Any substance or object the holder discards, intends to discard or is required to discard is WASTE under the Waste Framework Directive (European Directive (WFD) 2006/12/EC) Classes of Waste 6.1 Controlled Waste General waste comes under the category of Controlled Waste in the Controlled Waste Regulations 1992 SI 558. Waste from this would be classed as commercial waste under the regulation. This waste stream consists of non-hazardous wastes including paper, some packaging materials, some metals and some food waste. Typically it goes to landfill and in many companies the waste is compacted to reduce the volume and increase the amount that can be contained in a skip. The waste is carried by a licenced waste carrier who will take it to either a transfer station or directly to a landfill site 6.2 Hazardous Waste Waste is classed as hazardous if it is dangerous to people, the environment or animals. Waste is also classified as hazardous if it is covered under the Hazardous Waste Regulation 2005 SI 894 (Hazardous Waste Regs) and will be listed in the European Waste Catalogue (EWC). Typical examples of hazardous waste include things such as lead acid batteries, fluorescent tubes or clinical waste which has been designated as infectious waste. Non-infectious clinical waste can be disposed of as controlled waste. The hazardous nature of the waste will determine where its final destination will be. Some hazardous waste can go to landfill following treatment. Others may have to be incinerated within the level of incineration being determined by the hazardous properties of the waste - 7 -

8 6.3 Radioactive Waste under s.13 of the Radioactive Substances Act 1993 an authorisation is required for the disposal of radioactive waste on or from any premises or arising from any mobile radioactive apparatus All radioactive waste arising from all sources (including Pathology) shall be the responsibility of the appropriate Radiation Supervisor. The responsibility for ensuring compliance with the legal requirements shall be led by the following designated officers: (a) Radiation Protection Supervisor, Pathology Services (b) Radiation Protection Supervisor, X-Ray Services The above designated officers shall ensure that the terms of the authorisation issued by the HM Inspector of Pollution are complied with. The designated offers shall also ensure that the advice and guidance issued by the Integrated Radiological Services Limited (IRS) are both adhered to and implemented 7.0 WASTE MANAGEMENT Waste is segregated into the classes as specified above. Each category will then be disposed of via identified separate waste streams. The Waste (England and Wales) Regulations 2011 place a specific requirement on all organisations to utilise the waste hierarchy when dealing with waste. The following steps should always be considered in descending order: 7.1 Reduce the amount of waste produced by using less material in design and manufacture. Keeping products for longer or using less hazardous materials 7.2 Re-use waste items as and when appropriate, by checking, cleaning, repairing, refurbishing, whole items or spare parts. THIS DOES NOT APPLY TO SINGLE USE OR SINGLE PATIENT USE PRODUCTS 7.3 Recycle, turning waste into a new substance or product. Includes composting if it meets quality protocols 7.4 Recovery which includes anaerobic digestion, incineration with energy recovery, gasification and pyrolysis which produce energy (fuels, heat and power) and materials from waste 7.5 Disposal includes landfill and incineration without energy recovery 8.0 SEGREGATION AND CONTAINMENT OF WASTE Each waste stream requires a different method of disposal. Therefore it is of paramount importance that each waste stream is segregated from the other at source, and remains separate throughout the process of containment, collection and disposal. Mixing wastes, even in small quantities is not acceptable as this will mean the waste transfer or consignment note will have the wrong information on it and will result in a range of non-compliances with legislation. This section describes each type, and each - 8 -

9 sub-category of waste and the means by which it is contained and kept separate from the rest 8.1 Controlled Waste or Municipal Waste is designed in 6.1. This type of waste is disposed of in black bags and typically goes to landfill. The parts of this waste that cannot be recycled at present are segregated from the dry mixed recycling. Typically this waste is food, dead flowers and anything else which is bio-degradable 8.2 Dry Mixed Recycling is factions of municipal waste which can be recycled. This includes paper, cardboard, plastic and metal cans. This waste is all collected in one clear bag which is taken away by the waste contractor and recycled on our behalf. A compactor can be used to compact the waste and maximise the space available in the skip. A paragraph 27 exemption from the Environmental Agency needs to be in place to allow a compactor to be used 8.3 Offensive Waste, this describes healthcare and similar municipal waste, apart from clinical and hazardous waste, which may cause offence to people. Examples include nappies, feminine hygiene products, used but uncontaminated PPE (has not been in contact with an infected patient), resin cast and incontinence waste. This type of waste can be put through a landfill site for deep landfill. Offensive waste goes into a yellow bag which has black stripes on it (tiger stripe bags). Waste which has been autoclaved is now classed as offensive waste. Blood bags are now classed as offensive waste once any remaining blood has been discharged to drain. There is no need to wash out blood bags. Please note on sites that do not have the offensive waste stream nappies will have to be disposed of in the municipal waste which is a black bag 8.4 Offensive or Infectious? When disposing of nappies, feminine hygiene products, used but uncontaminated PPE and incontinence waste a decision has to be made by healthcare workers whether this waste is offensive or infectious. If it is known that the waste comes from a person who has a known infection which would affect the waste then the waste is clearly infectious. Infectious waste is classed as clinical waste and should be disposed of in an orange bag. Conversely the absence of known infections should ensure that the waste is disposed of as offensive waste and disposed of in a tiger stripe bag. This decision should be considered every time this type of waste is disposed of in case the results of tests indicate that the patient s condition has changed 8.5 Clinical Waste is defined as: 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, or syringes, needles or other sharp instruments, being waste which unless rendered safe may provide hazardous to any person coming into contact with it: and - 9 -

10 Any other waste arising from medical, nursing, dental, veterinary, pharmaceutical or similar practice, investigation, treatment, care teaching or research, or the collection of blood for transfusion, being waste which may cause infection to any person coming into contact with it Clinical waste is a major component of wastes from many NHS Trusts. Clinical waste bags are coloured orange which denotes that they are to be sent for treatment via alternative technology. Rather than burn the waste it is pasteurised using hot oil and then when the biological hazard has been reduced it is sent for landfill Yellow clinical waste bags are for waste which has a chemical or medicinal contamination which requires disposal by incineration Clinical waste carts are all coloured red and are clearly labelled and marked with a bio-hazard sign. Standard soft waste is placed in orange clinical waste bags, whilst rigid yellow plastic boxes are used for sharps and for large pieces of human tissue Any substantial pieces of metal which are contaminated with blood or bodily fluid are also classed as clinical waste. These must be labelled for incineration only due to the risk of damage to the shredder at the waste disposal plant where most of the clinical waste is heat-treated prior to landfill. Contaminated metal objects are placed into a red lidded containers 8.6 Human Tissue in any form must only be sent for incineration in red lidded containers (with appropriately labelled body of the box) 8.7 Laboratory Waste laboratory and post mortem waste should be handled as per the Code of Practice for the Prevention of Infection in Clinical Laboratories and Post Mortem Rooms 8.8 Pacemakers pacemaker generators removed from patients are decontaminated in Theatres. The Cardiac Physiologist then completes relevant paperwork and arranges return of the device to the company for disposal 8.9 Sharps sharps boxes used within the Trust will have the following colour coded lids:- Orange lidded sharps bin (with appropriately labelled body of the box) are for sharps which are not contaminated with medicinal products for example phlebotomy sharps and blood sample vials Yellow lidded sharps bin (with appropriately labelled body of the box) are for sharps such as needles, glass phials and small amounts of broken glass not contaminated with Cytotoxic or Cytostatic medicines Purple lidded sharps bin (with appropriately labelled body of the box) are for cytotoxic or cytostatic drugs and equipment contaminated with these drugs (A list of drugs is available from Pharmacy)

11 8.10 Pharmaceutical Waste within wards and department is divided into two separate waste streams: Those medicines containers which contain more than a dose should be returned to Pharmacy in the box provided for returns Medicine containers which contain less than a dose (residue) should be disposed of at ward level into a blue lidded pharmacy box which has a blue labelled body of the box Fluid bags and giving sets which have contained POMs must also be disposed of in the blue lidded box Syringes which have not been fully discharged and contain POMs should be put straight into a yellow lidded sharps box without discharging the contents of the syringe Any establishment which carries our sorting or denaturing of controlled drugs will need to register the site with the Environment Agency for a T28 exemption. The only exception to this is where a Pharmacy is operating within a building which already has an exemption such as a hospital site 8.11 Controlled Drugs the disposal of these drugs are covered under the Controlled Drugs Policy - Safe and Secure Handling which is available on the Trust Infonet 8.12 Mattresses mattresses that are identified as being infected or damaged should be: Infected mattresses should be placed in a large plastic bag which is available from the Waste Services. Before removal, the bag should be sealed and a yellow plastic bag firmly taped to the outer cover, for identification as clinical waste. The Mattress will be collected by Waste Services and stored safely and securely in the Waste Compound before it is collected by the waste collection contractor Non-infected mattresses that are either damaged, worn or below the acceptable standard, should be placed in a large plastic bag and then sealed with a black plastic bag firmly taped to the outer cover to identify it is as non-clinical waste. Arrangements should be made with Waste Services to collect the mattress Further advice can be sought from Tissue Viability/Infection Prevention & Control 8.13 Chemical Waste is waste which is not infectious and contains chemicals or chemical residue Examples within a clinical environment include alcohol gel containers and aerosols Everywhere chemical waste includes reagent containers, alcohols, xylene, formaldehyde, formalin and waste containers chemicals If there are any chemical containers for disposal, establish does the product go down the toilet, sluice or drain. If it does then wash out the container with soap and waste and put the container into municipal waste (black bag). If it does not then it will need to dealt with differently so contact the Contract & Performance Manager (waste) for advice

12 Another type of container which will probably have at least one hazard symbol is an aerosol. A fully discharged aerosol can be placed in municipal waste but do not put accumulations of these containers in the same bag Any aerosol which have contained prescription only medicines should be placed in a blue lidded pharmaceutical box 8.18 Plaster of Paris (gypsum) has to be collected separately and cannot go to landfill. This is because it degrades in landfill sites to produce hydrogen sulphide gas which goes up into the atmosphere and mixes with water and comes back down as acid rain (sulphuric acid). Plaster of Paris should be disposed of in an yellow clinical waste bag 8.19 Broken Glass is collected as controlled waste but for health and safety reasons has to be collected separately from the rest of the controlled waste. The broken glass should be put into a bag and a broken glass label should be completed indicating the hospital and ward/department and then affixed to the box Glass which has contained pharmaceutical products cannot be recycled and must be disposed of as pharmaceutical waste 8.20 Batteries batteries should be put into the plastic bin situated next to the WRVS shop and they will be collected and sent to a suitable recycling facility 8.21 Waste Electrical and Electronic Equipment (WEEE) is collected and sent away for recycling 8.22 Other Waste any waste that is disposed of must not leave site without the appropriate waste documentation being completed. In addition the waste must only be handed to a registered waste contractor that has been approved by the Trust 8.23 Confidential Waste this is waste containing staff or patient details or potentially sensitive information about the Trust e.g. patient records/information, financial records, non-paper items such as x-rays. Confidential waste is shredded on site by a contractor who is also responsible for the removal of this waste from site to send it for recycling 8.24 Protocol for Disposal of Products of Conception products of conception must be disposed of in the most sensitive way possible and working with the Crematorium, the following should be followed: Records should be kept by both the Mortuary and the Crematorium of the name of the client, date of occurrence and the burial place The Mortuary will use a bio-degradable box for the products of conception and it should be secure at all time with a list of number under cover attached to the outside of box Mortuary will arrange a convenient date and time with the Crematorium (telephone no ) for the box to be collected by them

13 Facilities (Soft FM) will arrange with the Hospital Chaplain to perform a blessing at Mortuary/Chapel of Rest prior to the collection 9.0 WASTE GENERATED IN THE COMMUNITY Any waste produced by a healthcare professional in a patient s home is considered to be the responsibility of both the professional and the Trust It is not acceptable to put infectious waste into a patient s domestic waste stream Infectious waste produced in the home should be placed into an orange bag and transported back to the Trust for disposal Non-infectious waste can be disposed of in a black bag or a carrier bag if a black bag is not available and disposed of within the household waste Sharps used by healthcare professionals must never be left in a patient s home and should be disposed of in a secured sharps bin after use and returned to the Trust for disposal. Self-medicating patients should dispose of sharps through their GPs Home births placenta must be placed in a yellow bag within a red-lidded sealed unit and is transported back to the Trust by the Midwife for disposal The Trust will ensure that staff are provided with the appropriate receptacles and transport containers where necessary to ensure that sharps and offensive waste can be returned safely to the Trust for disposal In circumstances where it is not practical to return the waste to the Trust, arrangements will be made for safe and legally compliant disposal via a licenced contractor Healthcare professionals should ensure that when transporting waste containers in a vehicle that they are rigid, leak proof, sealed and secured at all times 10.0 WASTE TRANSFER AND WASTE CONSIGNMENT NOTES 10.1 Waste Transfer Note (Controlled Waste) before any controlled waste leaves the Trust, a waste transfer note must be produced ensuring all that required information is put into the form. The form must be signed by an Authorised Trust Signatory 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 No waste must leave the Trust without a waste transfer note or waste consignment note 10.2 Waste Consignment Note (Hazardous Waste) before any controlled waste leaves the Trust a waste consignment note must be produced ensuring all that required information is put into the form. This form cannot be completed annually but must be completed for each load. Waste transfer notes must be retained for three years following the disposal of the waste

14 No waste must leave the Trust without a waste consignment note or waste transfer note 10.3 Producer Returns is information that waste contractors send to the Trust advising how much waste has been taken from site over a given period (normally quarterly). It is important to maintain a database of these returns for three years from the time the information is received so that waste production levels can be monitored and there is an audit trail of where the waste has been disposed of 10.4 Waste Transfer transferring waste between sites within the Trust is not permitted as the Trust does not have waste transfer licence. Waste should only be consigned to a licenced waste contractor from the site it was produced on. The Trust is not registered as a waste transfer station and cannot accept waste brought onto any of the sites 11.0 SELECTION OF WASTE CONTRACTORS All persons who remove waste from any Trust site must comply with the following minimum requirements: Registered with the Environment Agency as a waste carrier Use the correct waste transfer or waste consignment notes for the type of waste Give the Trust producer returns at agreed intervals to enable monitoring of how much waste is being produced and how much is being taken away for disposal In addition to the minimum requirements above there will be other contractual obligations to be met which are arranged through the Facilities Department 12.0 SITE REGISTRATION The Hazardous Waste Regulations 2005 require that most sites which produce hazardous waste are registered by the Facilities Department with the Environment Agency on an annual basis. The exceptions are those sites which produce less than 500kg per year. Each site is given a unique registration number which must be quoted on every waste consignment note 13.0 RECYCLING AND WASTE MINIMISATION It is essential that the Trust seeks to minimise waste production as a means of reducing costs. Each piece of waste costs the Trust to buy it in its original form and if benefit is not derived from it then financial losses occur. Even when benefit has occurred there are still opportunities for an organisation to gain further income by separating out waste streams and sending waste for recycling rather than final disposal. The Trust currently undertakes recycling of cardboard, magazines, nonconfidential waste paper, plastic bottles and tin cans and continues to look at further

15 recycling of waste streams. Clear bags can be ordered through the Waste Operatives by contacting the Helpdesk on WASTE AUDITS Waste audits are undertaken by the Contract & Performance Manager (Waste) in order to establish as to how wards/departments are managing their waste streams. The audits will be undertaken as follows: The waste audits are carried out randomly and without prior notification to establish a true picture of how well waste is being managed 14.2 Wards and departments will be audited at least once annually but follow up visits could be planned depending on the findings of the original waste audit. Included in the audit will be waste collection services and record keeping 14.3 Following the audit visit a report will be compiled outlining the areas of noncompliance and the remedial action required. The report will be sent to the ward/departmental manager 14.4 Periodically the carriers of our waste will request an audit of waste to be carried out on site so that we can satisfy them that what we are stipulating on our waste documentation is in fact what we put into out waste bags The Environment Agency views healthcare waste as a high risk because if it poorly managed it could have serious consequences for the health of people or for the environment. The Environment Agency carries out waste audits within NHS Trusts and can recommend that changes be made to the manner in which waste is being managed and if necessary take enforcement action 15.0 REFERENCES Environmental Protection Act 1990 Controlled Waste Regulations 1992 Hazardous Waste Regulation 2005 Waste (England & Wales) Regulation 2011 Consolidate European Waste Catalogue Bio-System Guidelines produced by SRL 16.0 REVIEW The agreed policy shall be reviewed in 2019 or when significant legislative change requires. In the interim, the policy shall not be varied unless notified in writing and agreed with the Chief Executive

16 Appendix 1 Mercury Spillage Procedure On all occasions involving spilt mercury, contact with the skin or inhalation of vapour should be avoided by wearing gloves when handling and ensuring that the area is well ventilated. Small quantities of mercury such as from a broken thermometer or a small spillage arising from a damaged sphygmomanometer should be disposed of by using the Mercury Spillage Kit obtainable from the Pharmacy Department. Detailed instructions on the use of the Mercury Spillage Kit are contained within the kit. Out of normal Pharmacy opening hours, a kit can be obtained from the Hospital Reserve cupboards. Once a spillage kit has been used and bagged correctly, the bag should be disposed of by contacting Waste Services who will take it to the Waste Compound, MDGH for safe storage. Larger spillages may be considered a hazard and should only be cleared by reference to the Pharmacy Department. Quantities of mercury held in a container must not be treated as routine waste and must be disposed of via Waste Services. All mercury waste will be treated and disposed of as Hazardous Waste. Spillages involving a damaged sphygmomanometer which still contains most of the mercury, or equipment that has been contaminated, should be where possible, closed up into its own carrying case or container, sealed and double bagged in black bags. In order to ensure that that the contents are not inadvertently disposed of as general household waste, the bags should be clearly marked "MERCURY CONTAMINATED EQUIPMENT - DO NOT INCINERATE". The bags should also be clearly labelled identifying the department involved. Waste Services should then be advised to collect and transport to the Waste Compound, MDGH. The Transport Manager, will then arrange for proper disposal by direct collection by a specialist disposal contractor

17 Appendix 2 Waste Disposal Flow Chart

18 Appendix 3 Specification and Traceability of Waste Containers No WASTE CONTAINER COLOUR SPECIFICATION CATEGORY 1 Clinical Plastic bag Yellow 381mm x 711mm x 990mm 26 micron (5kg max) 2 Clinical eg Anatomical, Dialysis and Plastic bag Yellow 381mm x 711mm x 990mm 55 micron (10kg max) Pathology Services 3 Infectious (not Plastic bag Orange containing chemicals or medical contamination) 4 Offensive (healthcare) Plastic bag Yellow and Black Stripe 5 Non-clinical Plastic bag Black 381mm x 711mm x 990mm 6 Glass Plastic bag, with orange Caution Broken Glass label to reflect contents. Contents prewrapped to protect handler from injury Black 7 Sharps Yellow Plastic box Yellow lid 8 Sharps - Cytotoxic Yellow Plastic box Purple lid or Cytostatic 9 Non-Hazardous Yellow Plastic box Blue lid Medicines 9 Products of Flat pack with White Conception impervious lining 10 Placentae Plastic bag into oneway Clear Yellow Plastic container Red lid 30 micron 381mm x 711mm x 990mm 30 micron 55mm x 60mm x 75mm high, approx 16" x 15" 30 micron 11 Waste arising from One way container Yellow 30 or 60 litres amputations, Pathology radioactive formalin-held tissues, specified body fluids from orthopaedics 12 Confidential Plastic bag White 406mm x 635mm x 914mm 50 micron printed NHS Confidential Waste for Shredding

19 No WASTE CONTAINER COLOUR SPECIFICATION CATEGORY 13 Office Paper/ Recycling Plastic bag Clear 381mm x 735mm x 990mm 24 micron 14 Infected Mattress Plastic bag Yellow with tie 945mm x 1160 x 2984mm 125 micron 15 Electrical, Electronic (WEEE) Waste Services Clinical Waste Containers Manufactured to NHS Performance Specification, January 1993 All sacks comply with the Carriage of Dangerous Goods (Classification, Packaging and Labelling) and the use of Transportable Pressure Receptacles Regulations 1996 (S.I ) Yellow bags used for the storage of clinical waste other than those areas already mentioned as needing specialist handling. As per Table - 26 Micron Clinical Waste Medium Duty, size 381mm x 711mm x 990mm (5kg max). Yellow bags used in high risk areas, such as human dialysis units, and for the disposal of human tissue. As per Table - 55 Micron Clinical Waste Heavy Duty, size 381mm x 711mm x 990mm (10kg max). Black bags used for non-clinical waste general household waste, marked 'NHS Property' As per Table - 30 Micron Normal Household Waste, size 381mm x 711mm x 990mm. Clinical waste sack holders will be designated with a yellow lid. Household waste sack holders will be designated with a black lid. Traceability of Contained Clinical Waste To comply Section 34 of the Environmental Protection Act 1990 (EPA 90), all clinical waste deposited in the storage/transfer area must be traceable. A suitable identifier will be used, either a label, a tag or other such device, which will enable the waste to be traceable. Identity tags are available on request from Domestic Services. Exceptionally, where the collector cannot trace the source, then the label 'SOURCE UNKNOWN' must be used before collection and then reported to the Line Manager

20 Appendix 4 Procedure for the use of waste bags, One Way Containers & Bio-Systems 1. Correct Filling and Identification of Waste Bags and Containers The Ward Manager/Department Head should ensure that: All bags are only filled to a maximum of three-quarters full before sealing All yellow/orange/tiger bags will have an identity label/tie attached. This will be the responsibility of the person removing the bag from the sack holder; black bags do not have to be labelled Unlabelled yellow/orange/tiger bags and prescribed containers will not be removed from site and the waste operative will escalate an unlabelled bag to their Manager for further investigation 2. Correct Use of One-Way Containers The Ward Manager/Department Head should ensure that: One-way containers are used only for the purpose specified The correct size and type is used Staff in the department are not involved in lifting over-filled and over-capacity containers, as stated in the Manual Handling Policy which is available on the Infonet All containers are properly labelled Unlabelled containers are not removed from site One-way container lids are properly fastened down before removal from site, and that no attempt is made to reopen 3. Correct Use of Reusable Bio-Systems Containers Bio-systems containers are reusable and are subject to different closing mechanisms to single use containers. All bio-systems containers are delivered assembled and ready for use The Ward Manager/Department Head should ensure that:- Reusable containers are only used for the disposal of contaminated sharps, syringes, scalpels, empty vials, razors and contaminated slides The containers are installed in a secure area (e.g. lockable wall bracket or other suitable location) The correct size and type of container is used Reusable containers are not filled over the maximum fill line, as indicated on the container The lid of the reusable container is closed when not in use Full reusable containers do not need to be signed or dated, simply attached a yellow identification tie for traceability

21 When ¾ full and ready for final closure, the reusable container cap lock must be activated. To activate the lock, press and click the red cap in place and press and slide the black tab clockwise to the locked position The reusable containers must not be placed in waste bags/bins All full reusable containers are taken to the designated reception points for collection by the Waste Operative Reusable containers are carried by the correct method of using the handle provided near the red tabs Reusable containers cannot be written on, or anything stuck to them e.g. sticky tape as this severely decreased the life of the container

22 Appendix 5 Colour Coding Key to Segregation System Colour Yellow Description Waste which requires disposal by incineration Indicative treatment/disposal required is incineration in a suitably permitted or licenced facility Orange Purple Waste which may be treated Indicative treatment/disposal required is to be rendered safe in a suitably permitted or licensed facility, usually alternative treatment plants (ATPs). However this waste may also be disposed of by incineration Cytotoxic and Cytostatic Waste Indicative treatment/disposal require is incineration in a suitable permitted or licenced facility Yellow/Black Offensive/hygiene waste Indicative treatment/disposal required is landfill or municipal incineration/energy from waste at a suitable permitted or licenced facility Red Anatomical waste for incineration Indicative treatment/disposal required is incineration in a suitably permitted facility Black Blue Domestic (municipal) waste Minimum treatment/disposal required is landfill, municipal incineration/energy from waste or other municipal waste treatment process at a suitably permitted or licensed facility. Recyclable components should be removed through segregation. Clear/opaque receptacles may also be used for domestic waste Medicinal waste for incineration Indicative treatment/disposal required is incineration in a suitable permitted facility

23 Equality Analysis (Impact Assessment) Please START this assessment BEFORE writing your policy, procedure, proposal, strategy or service so that you can identify any adverse impacts and include action to mitigate these in your finished policy, procedure, proposal, strategy or service. Use it to help you develop fair and equal services. Eg. If there is an impact on Deaf people, then include in the policy how Deaf people will have equal access. 1. What is being assessed? Waste Policy Policy on the Management of Healthcare Waste Details of person responsible for completing the assessment: Name: Sarah Haigh-Turner Position: Facilities Contract & Performance Manager Team/service: Facilities (Soft FM) State main purpose or aim of the policy, procedure, proposal, strategy or service: (usually the first paragraph of what you are writing. Also include details of legislation, guidance, regulations etc which have shaped or informed the document) This Policy provides guidance to all staff, contractors and sub-contractors regarding the arrangements for the management of healthcare waste, including the generation, segregation, handling and disposal of all waste on Trust premises. 2. Consideration of Data and Research To carry out the equality analysis you will need to consider information about the people who use the service and the staff that provide it. Think about the information below how does this apply to your policy, procedure, proposal, strategy or service 2.1 Give details of RELEVANT information available that gives you an understanding of who will be affected by this document Cheshire East (CE) covers Eastern Cheshire CCG and South Cheshire CCG. Cheshire West & Chester (CWAC) covers Vale Royal CCG and Cheshire West CCG. In 2011, 370,100 people resided in CE and 329,608 people resided in CWAC. Age: East Cheshire and South Cheshire CCG s serve a predominantly older population than the national average, with 19.3% aged over 65 (71,400 people) and 2.6% aged over 85 (9,700 people). Vale Royal CCGs registered population in general has a younger age profile compared to the CWAC average, with 14% aged over 65 (14,561 people) and 2% aged over 85 (2,111 people). Since the 2001 census the number of over 65s has increased by 26% compared with 20% nationally. The number of over 85s has increased by 35% compared with 24% nationally. Race: In 2011, 93.6% of CE residents, and 94.7% of CWAC residents were White British 5.1% of CE residents, and 4.9% of CWAC residents were born outside the UK Poland and India being the most common

24 3% of CE households have members for whom English is not the main language (11,103 people) and 1.2% of CWAC households have no people for whom English is their main language. Gypsies & travellers estimated 18,600 in England in Gender: In 2011, c. 49% of the population in both CE and CWAC were male and 51% female. For CE, the assumption from national figures is that 20 per 100,000 are likely to be transgender and for CWAC 1,500 transgender people will be living in the CWAC area. Disability: In 2011, 7.9% of the population in CE and 8.7% in CWAC had a long term health problem or disability In CE, there are c.4500 people aged 65+ with dementia, and c.1430 aged 65+ with dementia in CWAC. 1 in 20 people over 65 has a form of dementia Over 10 million (c. 1 in 6) people in the UK have a degree of hearing impairment or deafness. C. 2 million people in the UK have visual impairment, of these around 365,000 are registered as blind or partially sighted. In CE, it is estimated that around 7000 people have learning disabilities and 6500 people in CWAC. Mental health 1 in 4 will have mental health problems at some time in their lives. Sexual Orientation: CE - In 2011, the lesbian, gay, bisexual and transgender (LGBT) population in CE was estimated at18,700, based on assumptions that 5-7% of the population are likely to be lesbian, gay or bisexual and 20 per 100,000 are likely to be transgender (The Lesbian & Gay Foundation). CWAC - In 2011, the LGBT population in CWAC is unknown, but in 2010 there were c. 20,000 LGB people in the area and as many as 1,500 transgender people residing in CWAC. Religion/Belief: The proportion of CE people classing themselves as Christian has fallen from 80.3% in 2001 to 68.9% In 2011 and in CWAC a similar picture from 80.7% to 70.1%, the proportion saying they had no religion doubled in both areas from around 11%-22%. Christian: 68.9% of Cheshire East and 70.1% of Cheshire West & Chester Sikh: 0.07% of Cheshire East and 0.1% of Cheshire West & Chester Buddhist: 0.24% of Cheshire East and 0.2% of Cheshire West & Chester Hindu: 0.36% of Cheshire East and 0.2% of Cheshire West & Chester Jewish: 0.16% of Cheshire East and 0.1% of Cheshire West & Chester Muslim: 0.66% of Cheshire East and 0.5% of Cheshire West & Chester Other: 0.29% of Cheshire East and 0.3% of Cheshire West & Chester None: 22.69%of Cheshire East and 22.0% of Cheshire West & Chester Not stated: 6.66% of Cheshire East and 6.5% of Cheshire West & Chester Carers: In 2011, nearly 11% (40,000) of the population in CE are unpaid carers and just over 11% (37,000) of the population in CWAC. 24

25 2.2 Evidence of complaints on grounds of discrimination: (Are there any complaints or concerns raised either from patients or staff (grievance) relating to the policy, procedure, proposal, strategy or service or its effects on different groups?) No, there have been no complaints raised in relation to waste on the grounds of discrimination. 2.3 Does the information gathered from indicate any negative impact as a result of this document? No, policy applies equally. 3. Assessment of Impact Now that you have looked at the purpose, etc. of the policy, procedure, proposal, strategy or service (part 1) and looked at the data and research you have (part 2), this section asks you to assess the impact of the policy, procedure, proposal, strategy or service on each of the strands listed below. RACE: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, racial groups differently? Yes No x Explain your response: Policy applies to all racial groups. GENDER (INCLUDING TRANSGENDER): From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, different gender groups differently? Yes No x Explain your response: Policy applies equally to both men and women. DISABILITY From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, disabled people differently? Yes No x Explain your response: Policy applies equally regardless of disability. AGE: From the evidence available does the policy, procedure, proposal, strategy or service, affect, or have the potential to affect, age groups differently? Yes No x Explain your response: Policy applies equally to all age groups. LESBIAN, GAY, BISEXUAL: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, lesbian, gay or bisexual groups differently? Yes No x Explain your response: Policy applies equally regardless of sexual orientation. 25

26 RELIGION/BELIEF: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, religious belief groups differently? Yes No x Explain your response: Policy applies equally regardless of religion/belief. CARERS: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, carers differently? Yes No x Explain your response: Policy applies equally. OTHER: EG Pregnant women, people in civil partnerships, human rights issues. From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect any other groups differently? Yes No x Explain your response: Policy applies equally. 4. Safeguarding Assessment - CHILDREN a. Is there a direct or indirect impact upon children? Yes No x b. If yes please describe the nature and level of the impact (consideration to be given to all children; children in a specific group or area, or individual children. As well as consideration of impact now or in the future; competing / conflicting impact between different groups of children and young people: c. If no please describe why there is considered to be no impact / significant impact on children Policy applies equally. 5. Relevant consultation Having identified key groups, how have you consulted with them to find out their views and that the made sure that the policy, procedure, proposal, strategy or service will affect them in the way that you intend? Have you spoken to staff groups, charities, national organisations etc? Consulted with Trust Waste Contractor to ensure Trust compliance with all relevant legislation. Waste Policy was sent to relevant users. 6. Date completed: Review Date: Any actions identified: Have you identified any work which you will need to do in the future to ensure that the document has no adverse impact? 26