Waste Management Procedures
Reference Number: NCAE031(19) Version Number: 1 Issue Date: 29/07/2019 Page 1 of 58
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Waste Management Procedures
Lead Author: Paul Corr, Portering & Waste Manager (Oldham CO)
Additional author(s) Paul Huxley, Portering & Waste Manager (Salford CO)
Division/ Department: Facilities Division
Applies to: Northern Care Alliance Group
Date approved: 16/07/2019
Expiry date: 15/07/2022
Contents
Contents
Section Page 1 What is the procedure about? 3
2 Where will this document be used? 3
3 Why is this document important? 3
4 What is new in this version? 4
5 What is the Procedure? 4
5.1 General Waste Handling and Storage Procedures 4
5.2 Domestic Waste (Clear or Black Bags) 5
5.3 Offensive/non-infectious waste / Tiger Stripe Bags 6
5.4 Clinical Waste / infectious Waste (Orange Bags) 6
5.5 Category A infected clinical waste (Yellow Bags) 7
5.6 Suction Containers 7
5.7 Yellow Sharp Bins 7
5.8 Pharmaceutical Waste 8
5.9 Pharmaceutically Contaminated Waste 8
5.10 Non-pharmaceutically Active IV fluid Waste 9
5.11 Anatomical & Blood Contaminated Waste 9
5.12 Cytotoxic/Cytostatic Waste 10
5.13 Confidential Waste 11
5.14 Waste Paper (non-confidential) 11
5.15 Cardboard 11
5.16 Printer inkjet cartridges 12
5.17 Large, bulky waste items, medical equipment and electrical/electronic equipment
12
5.18 Waste Chemicals 12
5.19 Fluorescent Tubes 13
5.20 Batteries 13
5.21 Radioactive Waste 14
Departmental Procedures
5.22 Infectious Diseases – Category ‘A’ Pathogens 14
5.23 Theatres 15
Group arrangements:
Salford Royal NHS Foundation Trust (SRFT)
Pennine Acute Hospitals NHS Trust (PAT)
Waste Management Procedures
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5.24 Obstetrics and Gynaecology 16
5.25 Pharmacy 17
5.26 Pathology Department 18
5.27 Autoclaves 19
5.28 Human tissue/anatomical waste – Histology 19
5.29 Human tissue/anatomical waste – Mortuary 19
5.30 Chemically Contaminated Waste 20
5.31 Unused Kits and Reagents 20
5.32 Sharps 21
5.33 Medicinally Contaminated Waste 21
5.34 Maxillo-facial Unit 21
5.35 Radiology 21
5.36 A & E / Fracture Clinic 22
5.37 Community Services - Treatment in Patients’ Homes 22
5.38 Waste Generated in Health Centres / Clinics 23
5.39 EBME / MEMS Department 23
5.40 Estates Department 24
5.41 Catering Department 25
5.42 IM&T Department 28
5.43 Waste from Third Parties 28
6 Roles and responsibilities 29 - 35
7 Monitoring document effectiveness 35
8 Abbreviations and definitions 36
9 References and Supporting Documents 36
10 Document Control Information 38
11 Equality Impact Assessment (EqIA) screening tool 39
12 Appendices
Appendix 1 Monitoring and Review Arrangements 41
Appendix 2 Waste Description, Packaging and Disposal Methods 43
Appendix 3 Colour Coding of Waste 51
Appendix 4 Recognised list of Cytostatic Medicines (November 2015) 56
Appendix 5 Recognised list of Cytotoxic medicines (November 2015) 58
Waste Management Procedures
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1. What is this procedure about? 1.1 These procedures should be read in conjunction with the Waste Management Policy
NCAE030(19)
Both documents provide the reader with their responsibilities in relation to the management
of our healthcare waste; this includes collection, segregation, removal, transport and
disposal of all waste which is generated on our premises through our daily activities
1.2 If you have any concerns about the content of this document please contact the author or
advise the Document Control Administrator.
2. Where will this document be used?
2.1 This document contains summarised instructions for the identification, segregation, collection, storage and transportation of healthcare waste produced by The Northern Care Alliance.
2.2 These procedures apply to all premises owned or leased by the Alliance and to all staff
(including contractors employed by the NCA and those working in the patient home environment).
2.3 If the healthcare premises is shared with other NHS Organisations and the NCA is not the
landlord, the waste management policy and procedures should be followed as directed by the Landlord i.e. NHS Properties
3. Why is this document important?
3.1 All members of staff have a Duty of Care to ensure that all waste generated within each Care Organisation, is dealt with appropriately, safely and in accordance with the Waste Management Policy NCAE030(19) and these Waste Management Procedures NCAE031(19)
4. What is new in this version?
4.1 This document is a New Document for use throughout the whole of the Northern Care Alliance. It replaces EDE023 Policy for Waste Management at Pennine Acute Hospitals
5. What is the Procedure?
Strategy to Reduce Waste To ensure a data collection system is in place for all waste streams at all Care Organisations in order to monitor waste and the success or otherwise of this waste prevention/reduction strategy.
Identify resources required to ensure correct and appropriate equipment, bins and bags are
in place.
Ensure a robust staff training and awareness programme is in place.
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Provide contingency arrangements for waste disposal.
Wherever possible to identify space, equipment and facilities to allow proper segregation to
take place as a basis for making progress.
Identify no cost / low cost opportunities for preventing waste / recycling waste or waste
recovery.
Identify “quick hits” to prevent waste arising in the first place, to reduce waste and the cost
of waste disposal for the NCA.
Identify performance indicators for waste prevention, re-use, recycling, and recovery
targets across Care Organisations.
5.1 General Waste Handling and Storage Procedures
All staff must observe the following general procedures and precautions when handling waste:
Handle all waste bags and containers with care to avoid injury or risk of infection to yourself
or others.
Handle waste bags by the neck only. Do not clasp bags to the body when
moving/handling.
Use yellow numbered cable ties to identify the source of the clinical waste bags. If for
whatever reason ties are not available then you must write on the bag, using permanent
marker, to identify the hospital and ward or department
Only fill waste bags to ¾ capacity to allow tying or sealing to take place safely.
Check to ensure waste bags/containers are not split or leaking – if they are, re-package the
waste correctly.
Assemble sharps containers properly, ensuring that the lid is securely in place before
using. Indicate on label the person assembling the container, the ward / dept. and date of
assembly.
Fill sharps containers only to the indicated fill line and then seal by pulling the permanent
closure across; indicate on the label the name of the person closing the container and the
date before placing in the designated wheeled container or storage area.
Under no circumstances should sharps containers be placed in yellow wheeled containers
containing other clinical waste.
Place each separate stream of clinical waste in its dedicated yellow wheeled container
which should be tagged to identify the waste contained.
Remember under no circumstances should waste in different coloured bags or containers
be mixed together during storage or transportation as it is an offence to mix waste.
Keep all yellow wheeled containers locked at all times.
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The Portering Waste Teams will ensure that the correct label is placed on the yellow
wheeled container to identify the waste contained inside it. As a failsafe the operatives
placing the wheeled containers in the main compound MUST physically lift the lid on the
wheeled containers to ensure the label attached reflects the contents, failure to do so could
lead to financial penalties.
Keep waste storage areas/containers locked and secure at all times and accessible only to
authorised persons. Each ward/department has their own bin key as have Domestics and
Porters.
Domestic waste (i.e. clear or black bags) should be stored in black / Grey, Green wheeled
containers. Any waste which cannot be stored in wheeled bins should be stored safely and
securely either in locked rooms or cupboards.
Under no circumstances should clinical waste be placed in these containers.
No waste should be stored on main corridors, along fire escape routes or blocking fire exits.
5.2 Domestic Waste (Clear or Black Bags)
The following procedures and precautions shall be followed when handling domestic waste:
Clear or black bags should be placed in the appropriate wheeled container or storage area.
Waste contaminated with patient bodily fluids must not be placed in a domestic waste bag.
Under no circumstances should domestic waste bags be mixed with any other wastes
(such as orange bags, yellow lidded sharps bins, medicinal containers or purple lidded
cytotoxic /cytostatic waste containers)
Glass must not be placed in the domestic waste bags
All domestic glass waste such as drinks bottles, coffee jars etc should be placed in an
empty cardboard box lined with a domestic waste bag.
It is recommended that these boxes be stored above waist height and not on the floor
to ensure compliance with moving and handling guidelines.
When full (taking account of the weight) the box should be sealed and marked with the
content description “glass for disposal as domestic waste”. The boxes should then be
placed with the clear/black domestic waste bags for disposal or put directly in to a
domestic
Waste wheeled container. Cardboard boxes should not be left outside as they deteriorate
quickly in adverse weather conditions.
5.3 Offensive/non infectious waste / Tiger Stripe Bags (Black & Yellow Stripe)
The following procedures and precautions will be followed when handling offensive/non-infectious waste (black & yellow stripe bags also known as tiger stripe bags):
All tiger stripe bags must have a orange numbered cable tie (identification tag) attached
before placing in the appropriate yellow wheeled bin, or designated storage area.
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If numbered cable ties are not available the ward and hospital name should be written on
the bag with a permanent marker
Under no circumstances should tiger stripe bags be mixed with any other wastes (such as
clear/black bags, orange bags, yellow lidded sharps containers, blue medicinal containers
(BioBins) or purple lidded cytotoxic/cytostatic waste containers).
The wheeled bins / storage areas will be exchanged / cleared on a regular basis by the
Portering Department. However, if the wheeled bin /storage area is full and a collection is
not due, wards/departments should contact the Portering Department.
All tiger stripe bags can be disposed of via deep landfill and must not contain any clinical,
pharmaceutical, anatomical or chemical wastes, as these wastes must be disposed of by
other means
5.4 Clinical Waste / infectious Waste (Orange Bags)
The following procedures and precautions will be followed when handling clinical / infectious waste (orange bags):
All orange bags must have a orange numbered cable tie (identification tag) attached before
placing in the appropriate yellow wheeled bin, or designated storage area.
If numbered cable ties are not available the ward and hospital name should be written on
the bag with a permanent marker
Under no circumstances should orange bags be mixed with any other wastes (such as
clear bags, yellow lidded sharps containers, blue medicinal containers (BioBins) or purple
lidded cytotoxic/cytostatic waste containers).
The wheeled bins / storage areas will be exchanged / cleared on a regular basis by the
Portering Department. However, if the wheeled bin /storage area is full and a collection is
not due, wards/departments should contact the Portering Department.
All orange bags (clinical/infectious waste) can be disposed of via alternative treatment and
must not contain any pharmaceutical, anatomical or chemical wastes, as these wastes
must be disposed of by incineration.
5.5 Category A infected clinical waste (Yellow Bags)
The following procedures and precautions will be followed when handling category A infected clinical waste (yellow bags):
All yellow bags must have a numbered cable tie (identification tag) attached before placing
in the appropriate yellow wheeled bin, or designated storage area.
If numbered cable ties are not available the ward and hospital name should be written on
the bag with a permanent marker
Under no circumstances should yellow bags be mixed with any other wastes (such as clear
bags, orange bags, yellow lidded sharps containers, blue medicinal containers (BioBins) or
purple lidded cytotoxic/cytostatic waste containers).
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The wheeled bins / storage areas will be exchanged / cleared on a regular basis by the
Portering Department. However, if the wheeled bin /storage area is full and a collection is
not due, wards/departments should contact the Portering Department.
All yellow bags Cat A infected waste (yellow) must be disposed of via incineration
5.6 Suction Containers
The following procedures and precautions must be followed when handling suction containers:
It is recommended that suction containers with solidifying gel are used.
A maximum of 2 suction containers (contents solidified) should be placed in each orange
bag.
5.7 Yellow Sharp Bins
The following procedures and precautions must be followed when handling sharps containers:
Only items that are considered to have a ‘sharp’ should be placed in these bins, NO
packaging, swabs, gauze etc.
All sealed, yellow lidded sharps bins should have the label completed before placing in the
appropriate yellow wheeled bins, or designated storage area.
Under no circumstances should yellow lidded sharps bins be mixed with any other wastes
(such as clear/black bags, orange bags, yellow bags, blue medicinal containers or purple
lidded cytotoxic/cytostatic waste containers).
The wheeled bins / storage areas will be exchanged / cleared on a regular basis by the
Portering Department. However, if the wheeled bin /storage area is full and a collection is
not due, wards/departments should contact the Portering Department.
5.8 Pharmaceutical Waste (Blue)
The following procedures and precautions must be followed when handling pharmaceutical waste:
Pharmaceutical waste includes both liquid and solid dose medicines, such as loose tablets,
blister packs and bottles of medicine. It also includes unused, part used and out of date
pharmaceuticals and medicinal patches.
Where appropriate, medicines that may be suitable for recycling should be returned to the
Pharmacy Department, via the secure Pharmacy bags/boxes. A list of items that can be
recycled will be provided by the Pharmacy Department; items that cannot be recycled
should be disposed of at ward level in the blue BioBins.
Pharmaceutical waste in points a. – c. (below)should be disposed of at ward level in blue
lidded rigid containers or medicinal BioBins and not returned to pharmacy
a. Any opened, part used or empty vials or ampoules that are considered to have a
‘sharp’ edge must be disposed of in yellow lid sharps bins.
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b. Any opened, part used or empty vials or ampoules that are not considered to have a
‘sharp’ edge and dropped tablets may be disposed of in the medicinal blue lidded
rigid containers or medicinal BioBins.
c. Any denaturing kits used for the disposal of controlled drugs at ward level must be
placed in the medicinal BioBin or blue lidded rigid container.
All sealed, medicinal BioBins or blue lidded rigid containers should have the label
completed before placing in the appropriate yellow wheeled bins, or designated storage
area.
Under no circumstances should medicinal BioBins / blue lidded rigid containers be mixed
with any other wastes (such as clear/black bags, orange bags, yellow bags, sharps bins or
purple lidded cytotoxic/cytostatic waste containers).
The wheeled bins / storage areas will be exchanged / cleared on a regular basis by the
Portering Department. However, if the wheeled bin /storage area is full and a collection is
not due, wards/departments should contact the Portering Department.
5.9 Pharmaceutically Contaminated Waste
The following procedures and precautions must be followed when handling pharmaceutically contaminated waste e.g. part used infusions/injections, broken ampoules, empty medicine bottles and IV bags, tubing, etc contaminated with pharmaceuticals).
This waste shall be disposed of at ward level and not returned to Pharmacy:
Pharmaceutically contaminated waste includes items such as: IV bags and tubing – this
waste must NOT be placed in orange bags destined for alternative treatment it should be
placed in the blue BioBins
Any pharmaceutically contaminated waste that has a ‘sharp’ must be disposed of in yellow
lid sharps bins.
De-sharping of any kind is not permitted
Any pharmaceutically contaminated waste that does NOT have a ‘sharp’ must be disposed
of in a medicinal BioBin / blue lidded rigid container.
All sealed, medicinal BioBins or blue lidded rigid containers should have the label
completed before placing in the appropriate yellow wheeled bins, or designated storage
area.
The wheeled bins / storage areas will be exchanged / cleared on a regular basis by the
Portering Department. However, if the wheeled bin /storage area is full and a collection is
not due, wards/departments should contact the Portering Department.
5.10 Non-pharmaceutically Active IV fluid Waste
The following procedures and precautions must be followed when handling non-pharmaceutically active intravenous (IV) fluids:
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Non-pharmaceutically active IV fluids include saline and glucose (without any
pharmaceuticals added).
The liquid content from non-pharmaceutically active IV fluid bags may be discharged to foul
sewer and the empty packaging containing a sharp should be placed in the yellow lidded
sharps bin, with large aperture.
All sealed, yellow lidded sharps bins should have the label completed before placing in the
appropriate yellow wheeled bins, or designated storage area.
The wheeled bins / storage areas will be exchanged / cleared on a regular basis by the
Portering Department. However, if the wheeled bin /storage area is full and a collection is
not due, wards/departments should contact the Portering Department.
Quantities of non-pharmaceutically active IV fluids should not be placed into the domestic
waste stream as the disposal of liquids to landfill is not permitted.
Care should be taken to ensure that no leakages occur during disposal.
5.11 Anatomical & Blood Contaminated Waste (Red)
The following procedures and precautions must be followed when handling anatomical or blood contaminated waste:
Anatomical waste must be disposed of in red lidded rigid containers.
Any blood bags, containing blood as a liquid, that contain a sharp must be disposed of in a
yellow lidded sharps bin, with large aperture.
Any blood bags, containing blood as a liquid, without a sharp must be disposed of in red
(anatomical) lidded rigid containers.
Any empty blood bags, including those that may have trace elements of blood, if containing
a sharp, should be disposed of in a yellow lidded sharps bin, with large aperture.
Any empty blood bags, including those that may have trace elements of blood, without a
sharp, should be placed orange clinical waste bags.
De-sharping of any kind is not permitted
All sealed, red lidded rigid containers should have the label completed before placing in the
appropriate yellow wheeled bins, or designated storage area.
Under no circumstances should red lidded containers be mixed with any other wastes
(such as clear/black bags, orange bags, yellow bags, sharps bins, blue medicinal
containers or purple lidded cytotoxic/cytostatic waste containers).
The wheeled bins / storage areas will be exchanged / cleared on a regular basis by the
Portering Department. However, if the wheeled bin /storage area is full and a collection is
not due, wards/departments should contact the Portering Department.
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5.12 Cytotoxic/Cytostatic Waste (Purple)
The following procedures and precautions must be followed when handling cytotoxic/static waste:
Check the cytotoxic/cytostatic waste information poster provided by Pharmacy to determine
which medicines are classed as ‘cyto’ (see Appendix 2).If your ward/department does not
have a cytotoxic/cytostatic waste poster, contact the Pharmacy Department
All sharp or medicinal items contaminated with cytotoxic/cytostatic pharmaceuticals should
be placed in purple lidded cytotoxic/cytostatic waste containers and the label on the
container completed in full.
All ‘soft’ items contaminated with cytotoxic/cytostatic pharmaceuticals should be placed in a
yellow bag which has a purple stripe or purple writing on it.
All ‘cyto’ waste bags should be sealed using a numbered yellow cable tie
All cytotoxic/cytostatic waste bags/containers must be stored separately to other wastes in
the ward/department.The Portering Department should be contacted to arrange a separate
collection of this waste.
‘Cyto’ bags and/ or purple lidded containers must not be mixed with any other wastes (such
as clear/black bags, orange bags, yellow lidded sharps bins or blue medicinal containers).
Cytotoxic and Cytostatic medicines appearing on the Cytotoxic/Cytostatic medicines list
that are not suitable for reuse should be disposed of at ward level
5.13 Confidential Waste
The following procedures and precautions must be followed when handling confidential waste:
All confidential paper waste should either be shredded by a cross cut shredder or disposed
of in red confidential waste bins.
If confidential paper waste is cross-cut shredded, it should be placed in the waste paper
recycling stream.
In the main, locked red bins should be used, however, where large or bulky volumes are
generated an open red bin can be provided
The confidential waste red bins must be kept secure at all times. Bins must not be left in
any areas accessible to the general public
Everybody using the confidential waste red bin is responsible for its security
Contact the Portering Department when the red bins require emptying / exchanging
It is important that the confidential waste bins are located in an area where the bin and its
contents do not present a fire hazard e.g. blocking emergency exits (for further advice
contact the Fire Officer on your site).
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For non-paper confidential waste disposal (i.e. x-rays, videos, CDs, DVDs etc) the
Portering & Waste Manager should be contacted.
If any items placed in the red bins require retrieval please contact the Portering & Waste
Manager
Return all computer hard drives, floppy discs and other computer storage items to IM&T to
be wiped clean and destroyed
5.14 Waste Paper (non-confidential)
The following procedures and precautions must be followed when handling waste paper:
All non-confidential waste paper (including cross cut shredded confidential waste) should
be disposed of in green 240L wheelie bins.
Contact the Portering Department when the green bins require collecting / exchanging
Green bins must not be left in any areas accessible to the general public. It is important that
the green waste paper bins are located in an area where they do not present a fire hazard
e.g. blocking emergency exits (for further advice contact the Fire Safety Advisor at your
Care Organisation).
5.15 Cardboard
The following procedures and precautions must be followed when handling cardboard waste:
Empty cardboard boxes must, wherever possible, be flat packed by the person disposing of
the box
Any boxes held together by large industrial staples should not be flat packed due to the risk
of injury
Flat packed cardboard waste should either be placed in designated storage areas, returned
to the ‘stores’ cage or placed in designated ‘cardboard waste’ wheeled containers where
available.
It is important that the cardboard does not present a fire hazard e.g. is accessible by the
general public or blocking emergency exits (for further advice contact the Fire Safety
Advisor).
5.16 Printer inkjet cartridges
The following procedures and precautions must be followed when handling printer inkjet cartridges:
Used printer cartridges, with all external packaging removed, should be taken to the
identified storage point(s) on site or to the Portering Department.
5.17 Large, bulky waste items, medical equipment and electrical/electronic equipment
The following procedures and precautions must be followed when handling large bulky items, medical equipment or electrical / electronic waste:
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Wards and departments should contact the Portering Department if they require the
removal of large, bulky waste items (e.g. furniture and non-medical equipment) for disposal.
Any items awaiting collection by the Portering Department for disposal must be stored
within the ward/department. They should not be left on corridors, where they may restrict
general access, fire escape routes and fire exits.
For items of medical equipment, EBME/MEMS should be contacted for advice.
Any items of equipment being sent to EBME/MEMS for disposal must first be
decontaminated by the ward/department. A completed Decontamination Certificate must
accompany the item.
5.18 Waste Chemicals
The following procedures and precautions must be followed when handling waste chemicals:
All chemicals used should be disposed of safely and properly, with advice sought from the
Portering & Waste Manager when required.
COSHH data sheets should be consulted and risk assessments undertaken to determine
the hazardous properties of each chemical substance used and disposal
recommendations.
Under no circumstances should any chemicals or associated containers be disposed of in
the clinical or domestic waste streams, guidance should be sought from Portering & Waste
Manager
Users of chemicals should be aware that all chemical containers, unless completely empty
(i.e. rinsed out) are generally contaminated and classified as the chemical they contain,
unless determined otherwise by risk assessment
Any waste chemicals, paints and solvents awaiting collection must be stored in a secure
area (preferably in a designated, chemical store). Care should be taken to ensure that no
incompatible products are stored together.
5.19 Fluorescent Tubes
The following procedures and precautions must be followed when handling waste fluorescent tubes:
Fluorescent tubes are removed from wards/departments by Estates staff for recovery by a
specialist contractor.
All fluorescent tubes for disposal must be stored in the specially designed containers in the
Estates Department compound – under no circumstances must tubes be placed on the
ground (where they could smash and leach hazardous substances)
The fluorescent tube containers must be kept secure at all times.
Arrangements will be made by the Estates Department for a collection or onsite disposal of
fluorescent tubes, when the containers are nearly full.
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A hazardous waste consignment note must be completed by Estates staff and the disposal
contractor for every movement of waste and records maintained for at least 3 years. A copy
of the hazardous waste consignment notes should forwarded to the Portering Manager for
inclusion in the hazardous waste consignment note site register.
5.20 Batteries
The following procedures and precautions must be followed when handling battery waste:
All batteries are deemed to be hazardous and must be segregated from other waste
streams and arrangements made to take them to the Estates Department who will arrange
for an authorised contractor to collect them for disposal. They must not be disposed of as
domestic or clinical waste.
All batteries should be removed from redundant medical equipment, prior to disposal.
Any batteries contaminated with body fluids, will require decontamination prior to disposal.
All spent, portable batteries used by EBME/MEMS must be taken to the Estates
Department for disposal via their battery recycling arrangements
All spent, portable batteries used by the Estates Department must be placed in the battery
recycling container.
When the battery container is nearly full, Estates will contact an approved contractor to
arrange a collection.
A hazardous waste consignment note must be completed by Estates staff and the disposal
contractor for each collection and records maintained for at least 3 years. A copy of the
hazardous waste consignment notes should forwarded to the Portering Manager for
inclusion in the hazardous waste consignment note site register.
All spent, portable batteries used by the IM&T Department must be taken to the recycling
point in the Estates Department
5.21 Radioactive Waste
Wards / Departments disposing of patient derived waste generated by in-patients that have
been injected with radioactive material should ensure that the waste is segregated and
retained for 72 hours to allow it to dissipate, before placing it in the orange bag clinical
waste stream.
Information and advice relating to this waste stream is available by contacting the Nuclear
Medicine Department
Any spillages of this waste stream should be dealt with according to the departmental
procedures.
In the event of a suspected or known leakage of radioactive waste (including patient
derived), Nuclear Medicine and the Portering & Waste Manager must be informed and will
notify the Environment Agency when necessary.
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5.22 Infectious Diseases – Category ‘A’ Pathogens
Handling of Waste in the Isolation Unit
A heavy duty yellow clinical waste bag will be used from the onset. When ¾ full, the yellow
bag is tied off and placed inside another yellow waste bag containing absorbent granules,
this bag is then tied off. Cable ties should be used to secure both waste bags. Care must
be taken when tying off the waste bags to ensure that they will fit easily inside a 60L
container.
Utilizing the buddy system, the sealed bag is placed carefully by the nurse within the room
(wearing appropriate PPE) into the 60 litre container. The container does not enter the
contaminated room but stays within the ‘clean’ area directly outside the patients’ room
The 60 litre container, when full, must be locked by the ‘buddy’ nurse in the ‘clean’ area,
and then wiped with either Chlor-Clean 1,000ppm or Virusolve Plus.
If the containers require collection while results are awaited the Portering Department will
provide a 770L yellow wheeled bin, the sealed yellow containers should be placed in the
bin which should then be locked. The Porter will then remove the 770L bin to an agreed
secure location.
If VHF positive the Category ‘A’ waste special collection procedure must be triggered by
contacting the Waste Management Co-ordinator
Collection of Waste from the Isolation Unit
If results are VHF negative the sealed yellow containers or bags should be collected by the
Portering Department in a 770L yellow wheeled bin and identified as infectious waste using
the appropriate label and taken to the main compound to be included in scheduled
collections.
If results are VHF positive the Portering Department will provide a 770L yellow wheeled bin,
the sealed yellow containers should be placed in the bin which should be locked. The
Porter will then remove the 770L bin to a secure location for special collection.
Security
Security must be contacted to oversee all movements of Category ‘A’ 770L bins from the
isolation area to the secure storage container and also for all collections by the approved
contractor from the secure storage container.
Siting of Secure Waste Storage Containers
The storage containers must only be sited in an agreed area as close as possible to
Isolation Unit to limit the distance it will have to be transported. The storage container must
be secured with a high security level padlock and be covered by CCTV.
Collection for Disposal
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The Portering & Waste Manager will complete the required documentation in liaison with
the contractor to allow safe collection, transportation and disposal of the waste.
5.23 Theatres
Set up waste
Set up waste is clean packaging, etc produced during the “set up” of theatres, prior to the
patient entering the clinical area. This waste must be disposed of in a recycling container
for paper or in domestic waste bags.
Suction Containers
It is recommended that suction containers with solidifying gel are used. A maximum of two
(solidified) suction containers should be placed in each orange bag for disposal.
Human tissue, limbs, organs and teeth
Where limbs or organs require disposal, they should be carefully packaged in appropriate
sized red lidded sealed containers and labelled “anatomical waste”.
Placentas for disposal should be placed into small, yellow, plastic bags and then into the
red lidded placenta bins.
The sealed units/placenta bins must be labelled identifying the origin of the waste and date.
The sealed containers / placenta bins should be placed into dedicated anatomical waste
yellow wheeled bins.
The yellow wheeled containers containing anatomical waste should be moved to the main
collection compound as soon as possible to avoid unpleasant odours.
Under no circumstances should sealed units/placenta bins be placed in the yellow wheeled
bins used for clinical infectious (orange) waste bags or any other waste.
Anatomical waste will be collected by the waste contractor on a regular basis from the main
waste compound.
Teeth not containing amalgam may be disposed of as non-anatomical waste, in the general
infectious waste stream (orange bags), providing they are not sharp. Any teeth that are
sharp should be placed in a sharps container for disposal.
Any teeth containing amalgam should be disposed of with other amalgam waste and sent
for recovery via a specialist contractor. The Waste Management Co-ordinator should be
contacted for advice
Radioactive/Radio-isotope Waste
Any radioactive waste must be securely segregated and retained for 72 hours to allow it to
dissipate, before placing it in the orange bag clinical waste stream.
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5.24 Obstetrics and Gynaecology
Placentas
Placentas for disposal should be placed into small, yellow, plastic bags and then into the
red lidded placenta bins.
When the placenta bins are full they should be sealed, labelled with the ward/department
details and date and placed in dedicated anatomical waste yellow wheeled bins.
Under no circumstances should red lidded placenta bins be placed in the yellow wheeled
bins used for clinical infectious (orange) waste bags / containers or any other waste.
The yellow wheeled containers containing anatomical waste should be moved to the main
collection compound as soon as possible to avoid unpleasant odours.
Anatomical waste will be collected by the waste contractor on a regular basis from the main
waste compound
Foetal tissue and remains
Disposal of foetal tissue and remains will be managed in accordance with the NCA
“Guideline for the Sensitive Disposal of Foetal Tissue up to 24 Completed Weeks
Gestation” (CPWC010) available on the Alliance Intranet.
Waste produced from home births
Placentas for disposal should be placed into small yellow plastic bags and then into the red
lidded “placenta bins”.
All associated clinical infectious waste produced from the home birth should be placed into
an orange rigid container, sealed and labelled with the patient’s NHS number.
The orange rigid container and red lidded placenta bin should then be removed by the
midwife for disposal at his/her base.
The orange container must be placed in a designated infectious waste yellow wheeled bin
The red lidded placenta bin must be placed in a designated anatomical waste yellow
wheeled bin.
Any sharps used during the birth should be placed in the midwife’s sharps container, which
will be removed by the midwife. Once the sharps container is full, it should be sealed,
labelled with the midwife’s name and taken by the midwife for disposal at his/her base in a
designated sharps waste yellow wheeled bin.
It is important to note that all clinical/infectious waste being transported in community staff
vehicles, must be contained within UN approved rigid containers (this includes sharps
containers, placenta bins and orange rigid containers). Loose waste bags (orange or
yellow) are not appropriate.
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5.25 Pharmacy
General medicines
The outer packaging (i.e. cardboard boxes) should be removed from all waste
pharmaceuticals and be placed in the confidential waste stream if containing patient details
or recycled as waste paper/card if not.
Solid dose medicines must not be “de-blistered” prior to disposal, as this constitutes waste
treatment which is a licensable activity. The tablets, including the foil blister packs must be
disposed of together and placed in the blue pharmi bins / medicinal BioBins.
Any liquid pharmaceuticals must be disposed of in their bottles/containers which should be
placed in the blue pharmi bins / medicinal BioBins.
The Pharmacy Department must ensure that all medicinal containers (blue lidded pharmi
bins / medicinal BioBins) are placed in the appropriate yellow wheeled container in the
pharmacy disposal room / waste compound.
Cytotoxic / Cytostatic waste
A list of the cytotoxic/static pharmaceuticals should be displayed in the Pharmacy
Department.
Any additions / deletions to the list should be circulated to all wards and relevant
departments.
A copy of any updated lists should be provided to the Waste Management Co-ordinator
who will provide a copy for the clinical waste contractor.
Pharmacy must ensure that all cytotoxic/cytostatic waste containers from the department
are placed in the appropriate yellow wheeled container in the pharmacy disposal room /
waste compound.
Feeds/Nutritional Supplements
The liquid content from waste feeds/nutritional supplements may be discharged to foul
sewer and the empty packaging placed in the domestic waste stream.
Quantities of liquid feed/nutritional supplements should not be placed into the domestic
waste stream as the disposal of liquids to landfill is not permitted.
Care should be taken to ensure that no leakages occur during disposal.
Disposal to sewer
Checks should be made of the Alliance’s Discharge Consent (issued by the local Water
Company) prior to any pharmaceutical waste being disposed of to sewer/sink, etc.
Saline and glucose solutions are considered inert and may be disposed of to sewer.
Disposal of empty containers
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Any empty containers/primary packaging which have contained cytotoxic/static
pharmaceuticals should be disposed of into the cytotoxic waste stream
Any empty containers/primary packaging which has contained pharmaceuticals which are
non- cytotoxic/cytostatic, should be disposed of into the medicinal waste stream.
Controlled Drugs
All waste controlled drugs must be rendered irretrievable (i.e. by denaturing) prior to
disposal.
Denatured controlled drugs should be disposed of in the medicinal waste stream.
Under no circumstances must controlled drugs be flushed to sewer
Controlled and Recorded Drugs that are suitable for re-use should be returned to pharmacy
by a registered pharmacist or pharmacy technician. Controlled and Recorded Drugs that
are not suitable for re-use should be disposed of in accordance with the EDC025 Policy for
the ordering, storage and administration of Recorded Drugs
5.26 Pathology Department
General
All offices, kitchens, toilets and non-laboratory areas within the Pathology Department
should have domestic waste bins only. Sanitary bins should be provided in female toilets as
required.
Domestic waste bins should be provided adjacent to all hand wash sinks, for the disposal of
wet, non-infectious paper hand towels.
Uncontaminated glass e.g. coffee jars, should be placed in a cardboard box lined with a
clear bag
to prevent seepage, marked ‘glass for disposal’ and placed in the domestic waste stream
Orange bags should be used for any infectious or potentially infectious waste that is not
contaminated with anatomical items, chemicals or pharmaceuticals
Yellow bags should be used for chemically contaminated waste, however, contaminated
glass items should be placed in yellow lidded rigid containers.
Sharps bins should be used for any sharp items including contaminated broken glass
Medicinal BioBins or blue containers should be used for medicinally contaminated waste
Further information is provided in the Department of Pathology’s ‘Treatment and Disposal
of Laboratory Waste’ (P-HS-2).
5.27 Autoclaves
All autoclaved waste should be placed into orange bags for disposal. In the event of the
autoclave breaking down, all of the waste which would normally be autoclaved (i.e.
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microbiological cultures, specimen containers, etc) must be placed in heavy duty, yellow
plastic bags for disposal via incineration only.
Separate 770 litre bins should be identified and used for the containment of the waste, the
orange bag waste bin should be tagged for alternative treatment and the yellow bag waste
bin tagged to identify disposal by incineration only.
5.28 Human tissue/anatomical waste – Histology
All samples, specimens, biopsies of human tissue/anatomical waste must be kept
segregated from all other types of waste.
These items should be placed in red lidded rigid plastic containers for disposal. The label
on the container must be completed in full
The full containers must be placed in a yellow ‘anatomical’ waste wheeled bin.
5.29 Human tissue/anatomical waste – Mortuary
All items of human tissue/anatomical waste must be segregated from all other types of
waste.
These items should be placed in red lidded rigid plastic containers for disposal.
The label on the container must be completed in full
The full containers must be placed in a yellow ‘anatomical’ waste wheeled bin.
5.30 Chemically Contaminated Waste
This waste should be segregated from all other types of waste
Non-glass chemically contaminated waste should be placed in yellow bags for disposal,
secured with a yellow numbered cable tie
Glass chemically contaminated waste should be placed in yellow lidded rigid containers
with the label completed in full / if no label a yellow numbered cable tie should be used to
identify the origin of the waste
Users of chemicals should be aware that all chemical containers, unless completely empty
(i.e. totally rinsed out) are generally contaminated and classified as the chemical they
contain, unless determined otherwise by risk assessment.
Both yellow bags and yellow containers must be placed in a yellow ‘chemical’ waste
wheeled bin
5.31 Unused Kits and Reagents
Under no circumstances must any chemicals be disposed of to sewer, unless supported by
a relevant Discharge Consent (issued by the local Water Company). An up to date copy of
the Discharge Consent should be available within the Pathology Department.
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An audit and risk assessment of all liquids discharged to sewer should be undertaken by all
laboratories. For those machines discharging dilute substances to sewer, checks should be
made of the above Discharge Consent.
COSHH Data Sheets should be consulted and risk assessments undertaken to determine
the hazardous properties of each chemical substance used and disposed
recommendations
All chemicals used should be disposed of safely and properly, with advice sought from the
Health & Safety Adviser or Waste Management Co-ordinator, as and when required.
Any waste chemicals awaiting collection must be stored in a secure area (preferably in a
designated chemical store). Care should be taken to ensure that no incompatible products
are stored together.
When hazardous chemical waste needs to be collected a full list, detailing the product,
packaging and any approximate volume remaining, should be sent to the Waste
Management Co-ordinator who will arrange a collection by an appropriately licensed
contractor.
A waste consignment note must be completed by Pathology staff and the disposal
contractor for every movement of waste and records maintained for at least 3 years – the
chemical waste contractor will supply this paperwork and assist staff with its completion. A
copy of the consignment note should be sent to the Portering manager for inclusion in the
site register.
5.32 Sharps
All sharps must be disposed of in a sharps bin
The label on the bin must be completed on assembly and again when closed for collection.
The sharps bins should be placed in a designated holding area for collection by Portering
staff who will then place them in a yellow ‘sharps’ waste wheeled bin
Note: There is a full managed service of reusable sharps across the wards and dept’s at Salford Royal
5.33 Medicinally Contaminated Waste
All medicinally contaminated waste must be placed in a medicinal BioBin (blue) or a blue
rigid container
The label on the BioBin or container must be completed in full when closed for collection.
Care should be taken to ensure that the medicinally BioBin is not too heavy to be collected.
The medicinal BioBin / blue containers should be placed in a designated holding area for
collection by Portering staff who will then place them in a yellow ‘medicinal’ waste wheeled
bin
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5.34 Maxillo-facial Unit
Orthodontic wires
Orthodontic wires should be disposed of as sharps waste, into the yellow lid sharps
containers.
Teeth
Teeth not containing amalgam may be disposed of as non-anatomical waste, in the
infectious waste stream (orange bags), providing they are not sharp. Any teeth that are
sharp should be placed in a sharps container for disposal.
Any teeth containing amalgam should be disposed of with other amalgam waste and sent
for recovery via a specialist contractor.
5.35 Radiology
Film recovery
Old x-ray film being sent for silver recovery should be packaged securely and safely
according to the contractor’s requirements.
Waste transfer note must be completed by Radiology staff and the disposal contractor for
every movement of waste and records maintained for at least 2 years.
Barium enemas
Under no circumstances should barium enemas be disposed of into sinks/WCs
Bags should be clipped and placed in rigid yellow sealed units for disposal.
Radioactive/radio-isotope waste
Wards / Departments disposing of patient derived waste generated by in-patients that have
been injected with radioactive material should ensure that the waste is segregated and
retained for 72 hours to allow it to dissipate, before placing it in the orange bag clinical
waste stream.
Information and advice relating to this waste stream is available by the contacting Nuclear
Medicine Department
Any spillages of this waste stream should be dealt with according to the departmental
procedures.
In the event of a suspected or known leakage of radioactive waste (including patient
derived), Nuclear Medicine and the Waste Management Co-ordinator must be informed.
The Portering & Waste Manager will notify the Environment Agency when necessary.
5.36 A & E / Fracture Clinic
Gypsum
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Gypsum waste must be segregated and disposed of separately to other waste streams.
The bag / box should be labelled “Gypsum Waste” and The Portering Department
contacted to arrange a special collection, they will take it to the designated ‘gypsum’ yellow
wheeled container
5.37 Community Services - Treatment in Patients’ Homes
Infectious Waste
This is clinical waste arising from a patient known or suspected to have an infection or
where an infection is not known or suspected, but a potential risk of infection is considered
to exist.
Infectious waste must be placed into rigid orange containers
Any infectious bodily fluids (not solidified) should be placed into rigid yellow containers
Rigid containers must be sealed and left with the patient for collection
DNs must follow the procedure for registering collections from a patient’s home
Sharps Waste
sharps used must be placed in a sharps bin for disposal and be returned to the DNs base
for disposal
Medicinal Waste
Patients or their carers / relatives should return waste/medicines no longer required to their
local community pharmacist.
Any medicinal waste generated by the District Nurse should be placed in a blue rigid
container and returned to the DNs base for disposal.
DOOP kits used to denature Controlled Drugs should be placed in a blue rigid container
and returned to the DNs base for disposal.
Cytotoxic / Cytostatic Waste
Patients or their carers / relatives should return waste/medicines no longer required to
Christies or their local community pharmacist.
Any ‘cyto’ waste generated by the District Nurse should be placed in a purple rigid
container and be returned to the DNs base for disposal
Non-Infectious Waste
Any waste generated by the DN should be bagged and given to the patient for them to
place in their domestic waste bin.
Disposal of Collected Waste from Patients Homes
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The collection driver will maintain the segregation of the waste and return to their base. The
waste will then be placed into the appropriate designated containers sited in the main
waste compound at North Manchester General Hospital. When full they will be collected
with the other clinical waste containers from the hospital.
5.38 Waste Generated in Health Centres / Clinics
The Alliance has a service level agreement with NHS Property Services covering HCs and
clinics in the North Manchester area. The North Manchester CO pays them for the waste
services provided and all NCA staff working in these areas should comply with the
requirements of the NHS Property Services’ Waste Policy.
5.39 EBME / MEMS Department
General Medical Equipment
Wards/departments discarding medical equipment of any kind should ensure that the
equipment has been cleaned and/or decontaminated prior to removal and a
decontamination status certificate must be completed prior to devices being removed from
the area of use.
EBME/MEMS may be able to refurbish or redeploy the equipment. If the equipment is
obsolete or condemned EBME/MEMS will dispose of it via a reputable and assessed
contractor. All medical equipment disposal / recycling will be in accordance with Waste
Electronic and Electrical Equipment (WEEE) regulations.
Any items of equipment considered beyond repair will be removed from the NCA Asset
Register prior to disposal.
All removable hazardous components, i.e. batteries, should be removed from the
equipment prior to disposal/recovery
Items of WEEE should be placed in the WEEE storage area. Non WEEE items should
either be placed in the general waste open skip or scrap metal skip.
Disposal of equipment via the manufacturer will require appropriate documentation (i.e.
waste transfer/consignment notes).
Any items of usable, but redundant medical equipment will be sold by EBME/MEMS via an
appropriate third party. Such items of equipment must have all removable hazardous
components, i.e. batteries, removed from the equipment prior to being resold.
Equipment Containing / Contaminated With Mercury
EBME/MEMS should be advised of any redundant and/or broken equipment containing /
contaminated with mercury, who will arrange for it to be collected.
EBME/MEMS will liaise with Pharmacy for the disposal of mercury
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Where possible EBME/MEMS will remove the mercury containing part or any leaking
mercury and store it in an appropriate container in the department’s fume cupboard. If
necessary a mercury spillage kit will be used.
The Waste Management Co-ordinator should be contacted to arrange a collection of
mercury waste, as and when required.
A hazardous waste consignment note must be completed by EBME/MEMS staff and the
disposal contractor for every movement of waste and records maintained for at least 3
years.
Copies of any hazardous waste consignment notes should be sent to the Portering
Manager for inclusion in the hazardous waste consignment note site register.
Batteries
All batteries should be removed from redundant medical equipment, prior to disposal.
Any batteries contaminated with body fluids, will require decontamination prior to disposal.
All spent, portable batteries used by EBME/MEMS must be taken to the Estates
Department for disposal via their battery recycling arrangements.
5.40 Estates Department
General Waste Skip
The general waste open skips should only be used for waste which cannot be compacted,
such as broken furniture and other large, bulky items, as well as non-hazardous Estates
Department wastes such as air filters.
The open skips should be kept secure at all times to prevent unauthorised use and fly-
tipping.
Arrangements will be made by the Estates Department or Porters for a collection/exchange
of the skip when it is full or nearly full.
The waste contractor provides a collection note each time a collection of the skip/container
occurs. The collection note must be signed by a member of the Estates / Portering
Department and a copy kept as a record.
An annual waste transfer note is provided by the contractor for this waste stream. These
records must be maintained for at least 2 years.
Batteries
All spent, portable batteries used by the Estates Department must be placed in the battery
recycling container.
When the battery container is nearly full, Estates will contact an approved contractor to
arrange a collection.
A hazardous waste consignment note must be completed by Estates staff and the disposal
contractor for each collection and records maintained for at least 3 years. A copy of the
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hazardous waste consignment notes should forwarded to the Portering Manager for
inclusion in the hazardous waste consignment note site register.
Fluorescent tubes
All fluorescent tubes for disposal must be stored in the specially designed containers in the
Estates Department compound – under no circumstances must tubes be placed on the
ground (where they could smash and leach hazardous substances).
The fluorescent tube containers must be kept secure at all times.
Arrangements will be made by the Estates Department for a collection or onsite disposal of
fluorescent tubes, when the containers are nearly full.
A hazardous waste consignment note must be completed by Estates staff and the disposal
contractor for every movement of waste and records maintained for at least 3 years. A copy
of the hazardous waste consignment notes should forwarded to the Portering Manager for
inclusion in the hazardous waste consignment note site register.
Waste electrical and electronic equipment (WEEE)
It is the responsibility of various wards/departments to ensure that all WEEE items are
removed from the NCA Asset Register (where relevant) and are suitably decontaminated
(where relevant).
Storage containers/areas are available on each site for WEEE items. Segregation of
hazardous WEEE for example fridges, and non-hazardous WEEE must be maintained at all
times.
Any removable hazardous components, e.g. batteries, should be removed prior to storage.
Arrangements will be made by the Estates Department for a collection of WEEE, when
there is a sufficient amount for removal.
It should be noted that the contractor used will arrange for the recovery/recycling of items
and their components where possible.
A hazardous waste consignment note or waste transfer note must be completed by Estates
staff and the disposal contractor for every movement of waste and records maintained for
at least 3 years (hazardous) or 2 years (Non-hazardous). A copy of the hazardous waste
consignment notes should forwarded to the Portering Manager for inclusion in the
hazardous waste consignment note site register.
Chemicals, Paints and Solvents
All chemicals, paints and solvents used should be disposed of safely and properly, with
advice sought from a suitably qualified person as and when required.
COSHH Data Sheets should be consulted and risk assessments undertaken to determine
the hazardous properties of each chemical substance used and disposal recommendations
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Under no circumstances should any chemicals, paints or solvents or associated containers
be disposed of into the clinical or domestic waste streams, without risk assessments being
undertaken or guidance sought from a suitably qualified person.
Users of chemicals, paints and solvents should be aware that all associated containers,
unless completely empty (i.e. rinsed out) are generally contaminated and classified as the
substance they contain, unless determined otherwise by risk assessment.
Any waste chemicals, paints and solvents awaiting collection must be stored in a secure
area (preferably in a designated, chemical/flammable store). Care should be taken to
ensure that no incompatible products are stored together.
The Estates Department will contact a appropriately licensed contractor to collect and
dispose of waste chemicals, paints and solvents
A waste consignment note must be completed by Estates staff and the disposal contractor
for every movement of waste and records maintained for at least 3 years. A copy of the
hazardous waste consignment notes should forwarded to the Portering Manager for
inclusion in the hazardous waste consignment note site register.
Scrap metal
All scrap metal items must be placed in the appropriate scrap metal skip.
All scrap metal in the skip/storage area must be stored securely.
Collections will be made by arrangement with a licensed scrap metal dealer
A waste transfer note must be completed by staff and the disposal contractor for every
movement of waste and records maintained for at least 2 years.
Contractors waste
Arrangements should be made in all contractual documents agreed with third parties
carrying out works on the Care Organisation site for the disposal of waste.
Where feasible, contractors should be made responsible for the disposal of their own
waste.
It is essential that all contractors use reputable, fully licensed/permitted disposal companies
and that the appropriate legal paperwork (such as waste transfer/consignment notes) is
provided.
It is recommended that the NCA (Estates Department) receives a copy of any such legal
paperwork.
All contractors must agree a suitable, safe and secure location for any waste containers
(e.g. skips, FELs etc) with the Estates and Facilities Departments.
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It remains the contractor’s responsibility to ensure the security of the waste containers
whilst they are located on NCA property and it is therefore suggested that all waste
containers are lockable or can be made secure in some way.
Under no circumstances must contractors be allowed to dispose of waste items in the Care
Organisation’s clinical or domestic waste bins.
Asbestos waste
Asbestos waste must be dealt with by a specialist waste contractor. This service is
arranged by the Estates Department.
A hazardous waste consignment note must be completed by Estates staff and the disposal
contractor for every movement of waste and records maintained for at least 3 years. A copy
of the hazardous waste consignment notes should forwarded to the Portering Manager for
inclusion in the hazardous waste consignment note site register.
5.41 Catering Department
Food Waste
Where possible, food waste should be disposed of via waste disposal units located in the
kitchen areas.
Where a waste disposal unit is not available, food waste should either be returned to the
main kitchen for disposal or double bagged and collected with general waste for disposal
Cooking Oil
Under no circumstances must use cooking oil be disposed of via the sink/sewer or into
clear domestic waste bags.
Waste cooking oil must be poured back in to the original container and placed in the
external secure waste store, ready for collection by the waste oil contractor.
In the event of a spillage of cooking oil, the spillage must be dealt with immediately using
the appropriate spillage kit.
A waste transfer note must be completed by Catering staff and the disposal contractor for
every movement of waste and records maintained for at least 2 years.
5.42 IM&T Department
IM&T Equipment
For any unwanted or faulty IT equipment contact the IM&T Department who will arrange
collection and provide a receipt. This will only be done on request.
The hard drives of all computers are destroyed by the IM&T Department.
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The IM&T Department will arrange for the secure storage of all IT equipment awaiting
disposal and will arrange collection and disposal by an appropriately licensed contractor.
A waste transfer note must be completed by IM&T staff and the disposal contractor for
every movement of waste and records maintained for at least 2 years.
Batteries
All spent, portable batteries used by the IM&T Department must be taken to the recycling
point in the Estates Department
5.43 Waste from Third Parties
Other NHS Trusts on NCA premises
Where other NHS Trusts are based on Northern Care Alliance premises and have their
waste collected and disposed of via the Care Organisation no legal paperwork is required
to transfer the waste between the 2 parties. However the other NHS Organisation must
supply a description of the wastes concerned. It is recommended that this information is
provided on an annual basis.
Other Trusts must register as Hazardous Waste Producers with the Environment Agency, if
they produce 500 kg or more hazardous waste over a 12 month period, regardless of
whether the Trust manages their waste or they make their own arrangements. Information
relating to Hazardous Waste Producer registration should be supplied to the Northern Care
Alliance
Information must be supplied to the waste contractor to indicate that waste from other
Trusts is included within the NCA waste being sent to them.
Wastes from North West Ambulance NHS Trust
The North West Ambulance Service retain their own waste and dispose of it at their base site.
Waste from the general public
Waste brought to our Care Organisations by the general public, must not be accepted by
wards and departments unless the item originated here e.g. sharps bins provided to
patients.
Members of the general public should be instructed to take their sharps waste to either their
own GP or local community Pharmacy. Pharmaceutical waste should be taken to their
local community Pharmacy.
Patients producing waste in their own homes should be instructed to contact their Local
Authority or healthcare worker for advice relating to waste collection and disposal.
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6. Roles and responsibilities
6.1 Domestic Staff are responsible for the emptying of domestic waste bins, tying the bags
and removal to the relevant waste storage area. Domestic Staff will observe the following
procedures and precautions when handling and moving waste:
Remove from the pedal bins any clinical waste bags that are ¾ full, securing the neck of the bag with a numbered cable tie (if for whatever reason cable ties are not to hand the origin of the waste must be written on the bag with a permanent marker)
Will place the clinical waste bags in the designated wheeled containers or segregated from other waste in the clinical waste disposal room
Will ensure that clinical waste wheeled containers are locked after use.
Will have access to keys for clinical waste wheeled containers.
Will regularly clean the ward/department pedal bins and keep the waste storage areas clean and tidy.
Will ensure that adequate supplies of the numbered cable ties used to identify the origin of waste bags are available at all times.
Will not be permitted to handle sharps bins, medicinal containers or ‘Cytotoxic / Cytostatic bags or containers, this is the responsibility of nursing (or other clinical support) staff.
6.2 Portering Department are responsible for the collection of various waste streams from
wards/departments and for the transportation of these wastes to dedicated storage
compounds. They will observe the following procedures and precautions when handling
and moving waste:
Will not remove any sharps containers or cyto bins which have not been securely sealed and labelled by ward/department staff
Shall not remove any clinical (orange), Cyto (yellow/purple) or domestic waste bags which are split and/or leaking, until the contents have been re-bagged by ward/department staff.
Will have access to bin keys and must ensure that all bins being transported / stored for collection are locked.
Will ensure that the brakes are applied to all bins sited internally or externally.
On delivery of new, clean bins from the clinical/infectious waste contractor(s) the porters will check that all bins can be locked and are generally in good repair. Where this is not the case the bin(s) must be rejected and a “Bin Fault” tag attached.
Will ensure that all clinical waste wheeled containers have the appropriate label attached to the bin to reflect the waste stream they contain, prior to collection of the bin by the waste contractor. A visual check should be made.
Will be responsible for the completion of the waste consignment notes for the removal of all clinical waste; further guidance is provided in the appendix 3. Wastes will not be collected from site by our contractor without a completed hazardous waste consignment for each collection.
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Internal waste collections will be carried out on a regular, scheduled basis for clinical and domestic waste streams, although ad hoc collections may be requested where required.
Additional collections will be made for special waste streams such as cytotoxic /
cytostatic waste.
For bulky wastes, such as waste electrical and electronic equipment (WEEE) etc
collections are generally made on an ad hoc request basis by wards/departments
and should be completed as soon as practically possible.
Will be responsible for ensuring that all requests for confidential paper waste red
bins are carried out as soon as possible and all full bins are collected and
transported to the designated collection point.
Will be responsible for ensuring that all requests for non-confidential paper waste
green bins are carried out as soon as possible and all full bins are collected and
transported to the designated collection point.
Will be responsible for ensuring that the waste compound is kept clean, tidy and secure at all times.
Will ensure that the waste compactor is secured when not in use, to prevent unauthorised access.
It is recommended that when the compactor is removed for emptying, porters
should clear the waste compound of any loose waste/litter, etc. It is essential, wherever possible, that the handover of the clinical waste to the
contractor is supervised by a member of the Portering Department.
6.3 Operation of Waste Handling Equipment
All relevant staff will receive training in the operation of waste handling equipment, including vehicles, tugs, trailers, compactors, balers.
Waste handling equipment must not be used by untrained or unauthorised staff.
When not in use, all waste handling equipment must be kept secure.
All relevant staff will receive training in the manual handling of waste and waste containers.
Training records should be maintained for all staff involved in the operation of waste handling equipment.
6.4 All Managers & Staff
6.4.1 Risk Assessments for Waste Management Activities
All managers (or other designated competent persons) must carry out Risk
Assessments to identify and assess the risks to their staff (as well as patients and
the general public) from any waste related duties and activities (including waste
handling, collection, storage, movement and disposal).
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These risks should be eliminated where possible and managed and monitored
effectively, with Risk Assessments reviewed on a regular basis.
The frequency for the completion of Risk Assessments will be determined by the
Health and Safety Manager and relevant manager for the area concerned.
Risk Assessments will also be completed after any reported incident involving waste.
Risk Assessments should only be undertaken by staffs who have received appropriate
training. For further information contact the site Health and Safety Adviser.
6.4.2 Accident and Incident Reporting
If an accident occurs involving any waste items, the incident should be reported to the
relevant manager/supervisor immediately.
If an injury has occurred the employee should go to the Occupational Health
Department.
If the injury has occurred out of hours or is an emergency, the employee should go to
the A & E Department for medical attention.
As soon as possible an Incident Report Form should be completed, following internal
procedures.
The Facilities Department and Health and Safety Department will be informed via the
incident reporting system, of any incident involving waste and will take any necessary
measures to investigate the cause of the incident in order to guard against a
recurrence.
6.4.3 Personal Protection
It is the responsibility of all managers to ensure their staff are issued/supplied with appropriate protective clothing, to complete their waste related duties
Managers should also periodically monitor staff to ensure they are wearing appropriate items of protective clothing.
Risk Assessments will indicate the level of protective clothing required depending on the waste duties carried out, and may include; disposable gloves and aprons, heavy duty or sharps proof gloves, overalls/uniform, safety shoes, masks and eye protection.
It is the responsibility of all employees to ensure that protective clothing is worn, as required by their manager and any Risk Assessments, practices and/or procedures.
Staff handling clinical/infectious should be offered immunisation, including hepatitis B and tetanus.
6.4.4 Waste Spillages
All spillages must be regarded as potentially hazardous and dealt with immediately. Under no circumstances shall patients or members of the general public be allowed
to assist or be involved in any way in the clearing or cleaning up of spillages When dealing with spillages, appropriate protective clothing should be worn.
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Where required, another member of staff shall assist in keeping the spillage area
safe, until the area can be barricaded off. It is essential that waste produced from dealing with any spillage is packaged and
disposed of appropriately. In the event of spillages of particularly hazardous wastes such as pharmaceuticals
and/or chemicals, the advice and assistance of specialist departments or persons
may be required, e.g. Estates Department, Pharmacy, Pathology Department,
Health and Safety Department. For further, more detailed information in relation to clinical/infectious spillages, please
refer to the Infection Control Manual/Policy where appropriate or to Policy NCPDI001
‘Spillage in the Operating Department’.
6.4.5 Waste Training
The NCA will provide specific training for waste operatives as well as waste training for all staff as part of the mandatory training programme. The NCA is committed to ensuring training provided is accessible for all following disclosure and training packages will be amended to suit the learners needs; the Care Organisation Porter & Waste Managers will be able to assist with this
Mandatory Training can be completed either by attending:
Classroom based sessions accessed via the Training Bulletin
Workplace sessions which should be arranged with the Portering & Waste Managers
The relevant E-learning programme accessed via the Alliance Intranet.
A Waste Management poster presentation
6.5 Portering & Waste Managers
6.5.1 Waste Contracts and Legal Paperwork
Any waste removed from The Northern Care Alliance for disposal must be accompanied by the relevant legal paperwork, i.e. waste transfer or consignment note.
Full details of how to complete a consignment note will be provided by the Portering &
Waste Manager
All hazardous waste consignment notes must be completed in full by relevant, authorised personnel for sections A, B and D.
Regular checks will be made with regard to the accurate completion of this
paperwork, as part of the auditing process.
Records must be kept of all waste transfer notes for 2 years and hazardous waste consignment notes for 3 years.
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A Site Register must be maintained by the Portering Department for any
hazardous wastes produced. This should include; copies of consignments notes,
copies of any rejection notes, consignee returns for each hazardous waste
stream.
All specialist departments producing/completing hazardous waste consignment
notes for the disposal of hazardous waste must send a copy of each
consignment note to the Portering & Waste Manager for inclusion in the Site
Register.
The Portering & Waste Managers will ensure that their Care Organisations are
registered as Hazardous Waste Producers, on an annual basis with the
Environment Agency.
Regular reviews will be completed of all waste contracts, with regard to the changing
needs of the sites, legislative compliance, sustainable waste management and value
for money. This process will be undertaken by the Portering & Waste Managers
Provide waste training which is accessible to all and amend training packages
accordingly
Ensure waste bins are labelled to inform the user what waste should be placed in
each bin in patient areas in preparation for PLACE assessments
6.5.2 Auditing
All aspects of waste management across the NCA Care Organisations will be
audited and monitored by the Portering & Waste Managers, with any issues of non-
compliance or poor practice recorded and prioritised in action plans with the
relevant CO General Manager Estates & Facilities
Annual “Duty of Care” checks or audits will be carried out for all waste contractors
employed; this is the responsibility of the Portering & Waste Managers and relevant
specialist departments.
The Infection Control Teams will carry out regular audits which will include aspects
of waste management.
Audits of legal paperwork will be carried out by the Portering & Waste Managers
All departments producing and completing their waste consignment notes for their
wastes must send a copy of each completed note to the Portering & Waste
Managers.
Training records will be monitored by the Education & Training Department and/or
individual departmental managers.
6.6 General Manager Estates & Facilities will
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Ensure that all staff within their Care Organisation is aware of and comply with this
procedure and Waste Management Policy.
Be responsible in providing assurances to the Group Deputy Director of Capital,
Estates & Facilities that key employees are trained and competent in waste
management
Ensure sufficient resources are available so that all waste is handled and disposed of
safely and in accordance with the relevant legislation.
Ensure that waste disposal complies with the appropriate codes of practice, e.g.
correct use of coloured bags.
Ensure systems are in place for the accurate identification of wastes, and that all
waste transfer / disposal documentation is maintained and records kept.
Introduce and deliver waste reduction initiatives
6.7 Chief Pharmacist / Head of Pharmacy will
Assist in the formation and implementation of this policy. They, along with the Head of Pharmacy on each site will provide advice and guidance as required on safe procedures for the handling and disposal of pharmaceutical waste materials regarded as clinical or hazardous.
6.8 Procurement Department will
Ensure that all purchases are made bearing in mind the impact of packaging with the aim
to eliminate secondary packaging. The packaging type should be specified on tender
criteria with a view to making suppliers responsible for the removal of their own
packaging where possible and to ensure they are compliant with Packaging Regulations
(essential requirements) 1998.
Ensure that all purchases of electrical and electronic equipment are made bearing in
mind end of life disposal in accordance with the Waste Electrical and Electronic
Equipment Directive 2007 and NHS guidance.
6.9 Waste Contractors
The Facilities Division is responsible for the various contracts for waste collection and
disposal services.
Licensed/permitted contractors are responsible for removing waste and waste containers
from storage locations at each site to licensed/permitted waste disposal, recovery or
treatment sites as required.
They are also responsible for the provision of relevant legal paperwork (i.e. waste
transfer or consignment note) and supplying the Care Organisation with consignee
returns for hazardous waste.
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The Portering & Waste Managers or delegate is required to regularly complete waste
transfer and consignment notes for waste movements. Copies of all legal paperwork will
need to be kept for a period not less than 3 years
6.10 Care Organisation Waste Group Meetings
The Waste Group meetings at each Care Organisation provides a forum for discussing any issues relating to the treatment of waste and the implementation and monitoring of this document. Any unresolved issues will be escalated to Group
Discuss initiatives to reduce waste and promote recycling
6.11 Group Deputy Director of Capital, Estates & Facilities has delegated responsibility from the Group Director of Capital, Estates & Facilities for ensuring NCA compliance with regard to the management of all wastes produced on each Care Organisation.
6.12 Group Director of Capital, Estates & Facilities has delegated authority from the Chief Executive to ensure that the NCA complies with relevant waste and environmental legislation with regard to the management of all wastes produced at each Care Organisation.
6.13 Group Chief Executive Officer
The Group Chief Executive Officer has overall responsibility for providing a safe environment for patients and staff and for ensuring the adoption of safe working practices and compliance with relevant legislation
7. Monitoring document effectiveness
Key standards: 100% staff will have completed waste training at the commencement of employment and as and when changes in practice and legislation dictates
Method(s)*: Training and compliance statistics are available on the Organisation mandatory database and are updated regularly. Staff are responsible for ensuring they attend mandatory training
Team responsible for monitoring: Managers shall monitor attendance of their staff
Frequency of monitoring: Managers shall monitor staff attendance at mandatory training monthly
Process for reviewing results and ensuring improvements in performance: The Alliance mandatory training database records attendance and statistics and all staff can access their training records from the intranet
8. Abbreviations and definitions
Clinical waste Waste that is clinical waste as defined by the Controlled Waste Regulations
CO Care Organisation
COSHH Control of Substances Hazardous to Health
Cytotoxic and cytostatic
Classification of medicinal waste used in the List of Wastes Regulations for medicinal products with one or more of the hazardous properties toxic,
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carcinogenic, toxic for reproduction or mutagenic.
CQC Care Quality Commission
Hazardous waste Waste classified as hazardous waste by the Hazardous Waste Regulations and the List of Wastes Regulations.
Healthcare waste Relates to waste that is produced by healthcare activities, and of a type specifically associated with such activities.
HTM Health Technical Memorandum
NCA Northern Care Alliance
PAT Pennine Acute Hospitals NHS Trust
PPE Personal Protective Equipment
SOP Standard Operating Procedure
SRFT Salford Royal NHS Foundation Trust
UN United Nations
WEEE Waste Electrical and Electronic Equipment
9. References and Supporting Documents
9.1 References
Department of Health, (2006 and updated 2013). HTM 07-01 ‘Safe Management of
Healthcare Waste’. Crown Copyright, London.
Water UK (April 2011) National Guidance for Healthcare Waste Water Discharges
The Hazardous Waste (England and Wales) Regulations (2005). Crown Copyright,
London.
Environment Agency (2015) Technical Guidance WM3: Hazardous Waste – Interpretation of the definition and classification of hazardous waste. Crown Copyright, London.
The Waste Electrical and Electronic Equipment Regulations (2013). Crown Copyright,
London.
Department of Health (2007) HTM 07-05: The Treatment, Recovery, Recycling and Safe Disposal of Waste Electrical and Electronic Equipment. Crown Copyright, London.
Department of Health (2008 updated 2015) The Health and Social Care Act: Code of practice on the prevention and control of infections and related guidance. Crown Copyright, London.
The Environmental Protection Act (1990). Crown Copyright, London.
The Controlled Waste (England and Wales) Regulations 2012. Crown Copyright,
London.
The Control of Substances Hazardous to Health Regulations (COSHH) (2002 updated 2003, 2004). Crown Copyright, London.
Health and Safety at Work etc. Act 1974. Crown Copyright, London.
Management of Health and Safety at Work Regulations 1992. Crown Copyright, London
The Management of Health and Safety at Work (Amendment) Regulations 2006. Crown
Copyright, London
The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013. Crown
Copyright, London
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9.2 Associated Documents NCA
NCAE030(19) Waste Management Policy
Control and Safe Management of Contractors (Estates, Capital & Facilities) Policy
SRFT
TWCG04(15) - Issue No 2 - Disposal of medicines in Intermediate Care
TG21(05) - Issue No 3.2 - Health and Safety Policy
RM10(06) Prevention and Management of Potential Exposure to Blood Borne Viruses
Including Needlestick and Sharps Injuries
PAT
EDQ026 Guidance to Prevent Sharps Injury/Exposure to Blood Borne Viruses
CPDI018 Accidental Inoculation Policy
EDQ007 Health & Safety Policy
CPDI018 Accidental Inoculation Policy
EDQ026 Guidance to Prevent Sharps Injury/Exposure to Blood Borne Viruses
EDC025 Policy for the ordering, storage and administration of Recorded Drugs
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It is the author’s responsibility to ensure that all sections below are completed in relation to this version of the document prior to submission for upload.
Nominated Lead author:
Paul Corr Portering & Waste Manager
Lead author contact details:
0161 778 5182 [email protected]
Lead Author’s Manager:
Name: Nigel Wylie Role: General Manager Estates & Facilities (Oldham CO)
Applies to:
Salford CO Oldham CO North Manchester CO
Bury & Rochdale CO
Northern Care Alliance Group (NCA)
Document developed in consultation with :
Pharmacy Managers Portering & Waste Managers General Managers Estates & Facilities Infection Prevention & Control Medical Devices EBME/MEMS Health & Safety Advisors Group Deputy Director of Capital, Estates & Facilities IM&T
Keywords/ phrases:
Waste, rubbish, bags, yellow, black, clinical, household, Porter, training, PPE, risk assessment, HTM, environment, hazardous, duty of care, WEEE, legislation, recycle, collection
Communication plan:
This policy will be available on the NCA staff web pages of the intranet and will be disseminated to staff via staff meetings. This policy will also be referred to in waste handling training
Document review arrangements:
This document will be reviewed by the author, or a nominated person, at least once every three years or earlier should a change in legislation, best practice or other change in circumstance dictate.
Approval: Add name of Committee and Chairpersons name and role: Rob Jepson, Group Deputy Director of Capital, Estates & Facilities, Estates and Facilities 3P General Managers Mtg
Insert full approval date: 16/07/2019
How approved: Chair’s actions Formal Committee decision
10. Document Control Information
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11. Equality Impact Assessment (EqIA) screening tool Legislation requires that our documents consider the potential to affect groups differently, and eliminate or minimise this where possible. This process helps to reduce health inequalities by identifying where steps can be taken to ensure the same access, experience and outcomes are achieved across all groups of people. This may require you to do things differently for some groups to reduce any potential differences.
1a) Have you undertaken any consultation/ involvement with service users, staff or other groups in relation to this document? If yes, specify what.
Yes – staff and service users
1b) Have any amendments been made as a result? If yes, specify what.
Yes – training packages and signage/labels
2) Does this policy have the potential to affect any of the groups listed below differently? Place an X in the appropriate box: Yes, No or Unsure This may be linked to access, how the process/procedure is experienced, and/or intended outcomes. Prompts for consideration are provided, but are not an exhaustive list.
Protected Group Yes No Unsure
Age (e.g. are specific age groups excluded? Would the same process affect
age groups in different ways?) X
Sex (e.g. is gender neutral language used in the way the policy or
information leaflet is written?) X
Race (e.g. any specific needs identified for certain groups such as dress,
diet, individual care needs? Are interpretation and translation services required and do staff know how to book these?)
X Communication
Religion & Belief (e.g. Jehovah Witness stance on blood transfusions;
dietary needs that may conflict with medication offered.) X
Sexual orientation (e.g. is inclusive language used? Are there different
access/prevalence rates?) X
Pregnancy & Maternity (e.g. are procedures suitable for pregnant and/or
breastfeeding women?) X
Marital status/civil partnership (e.g. would there be any difference
because the individual is/is not married/in a civil partnership?) X
Gender Reassignment (e.g. are there particular tests related to gender? Is
confidentiality of the patient or staff member maintained?) X
Human Rights (e.g. does it uphold the principles of Fairness, Respect,
Equality, Dignity and Autonomy?) X
Carers (e.g. is sufficient notice built in so can take time off work to attend
appointment?) X
Socio/economic (e.g. would there be any requirement or expectation that
may not be able to be met by those on low or limited income, such as costs incurred?)
X
Disability (e.g. are information/questionnaires/consent forms available in
different formats upon request? Are waiting areas suitable?) Includes hearing and/or visual impairments, physical disability, neurodevelopmental impairments e.g. autism, mental health conditions, and long term conditions e.g. cancer.
X Written labels on bins-not all have symbols
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Are there any adjustments that need to be made to ensure that people with disabilities have the same access to and outcomes from the service or employment activities as those without disabilities? (e.g. allow extra time for appointments, allow advocates to be
present in the room, having access to visual aids, removing requirement to wait in unsuitable environments, etc.)
X
3) Where you have identified that there are potential differences, what steps have you taken to mitigate these? The E&F SMT will discuss the format of signage on bins to ensure they meet public sector requirements
for inclusivity. Waste training packages will be amended as and when required to meet learners needs and packages
emailed to learner as required Unsure if standard NHS England colour may affect those with a visual impairment; appropriate training
will be provided to those in need Information only available in English; direction required from E&F SMT and ED&I strategy
4) Where you have identified adjustments would need to be made for those with disabilities, what action has been taken? Escalated to E&F SMT to discuss the way forward for signage, labels and posters etc Waste training packages amended to each learners needs including face to face training, poster training and e-learning
Will this policy require a full impact assessment? Yes / No (a full impact assessment will be required if you are unsure of the potential to affect a group differently, or
if you believe there is a potential for it to affect a group differently and do not know how to mitigate
against this - Please contact the Inclusion and Equality team for advice on [email protected]) Author: Type/sign: Paul Corr Date: 25.04.19
Sign off from Equality Champion: Date: 31/05/19
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Audit / Monitoring requirement
Method of Audit / Monitoring Responsible person
Frequency of Audit
Monitoring committee
Evidence Location
To monitor waste management activity across all sites in order to ensure that statutory and legislative compliance relating to waste management and handling is being adhered to across all CO premises.
Visual and verbal assessment through site visits to each area across the Alliance that generates waste (i.e. Wards and departments). Discussions with Managers / supervisors of each area will also be required. Walk through the wards / departments looking at individual bin locations ward bays, office areas, toilets, bathrooms, kitchens, etc
Portering & Waste Manager Independent Clinical Waste Auditors
Each waste generating area to be visited at least once every twelve months (annually).
Care Organisation Waste Group
Audits Reports stored centrally All Risks to be reported. All significant risks to be discussed and forwarded as necessary
Audits to be stored electronically and hard copies of reports to be kept by the Portering & Waste Manager
Visual assessment through site visits to each interim storage areas for waste
Each interim waste compound area to be visited at least once every six months
Visual assessment through site visits to each main site storage /collections area for waste and full assessment of waste related paperwork held on site.
Each main waste compound area to be visited at least once every six months.
To monitor waste disposal tonnages and associated financial expenditure against annual budgets.
Assessment of issued tonnages for waste disposal from Care Organisation Data to be provided via waste disposal contractors within the first six working days of each month with data relating to the previous month.
Portering & Waste Manager
Monthly Care Organisation Waste Group Estates & Porter & Waste Managers
Assessment files to be stored centrally
Copies of Waste divisional Budget Statements showing performance to be kept by the Portering & Waste Manager
12. Appendices
Appendix 1 - Monitoring and Review Arrangements
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Duty of Care site visit to contractors waste handling premises.
To visually assess management of NCA waste by contractors is as described in formal SLA & contract documentation. Checks on paperwork and certification to be included within.
Portering & Waste Manager
Each waste handling contractor to be audited at least annually.
Exception reporting to Estates & Facilities General Manager
Documentation and evidence of audit to be written up and stored centrally Any significant risks identified to be escalated
Audits to be stored electronically by Portering & Waste Manager
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Waste management legislation sets out mandatory requirements for the description, packaging and disposal of waste. Each type of waste is given a European Waste Catalogue (EWC) Code which must be used when describing the waste on all relevant documents. There are specific storage and disposal requirements, which will depend on the EWC Code/waste description. It is essential that the NCA complies with these mandatory requirements.
The following table shows the EWC codes, storage, packaging/colour coding and disposal methods that apply to the types of waste likely to be generated by the various wards/departments of the Alliance. All staff produces waste and so all have a legal responsibility to ensure that the waste they produce is disposed of correctly by adhering to the controls and procedures in the NCAE030(19) Waste Management Policy and these Procedures
EWC Code (European waste
catalogue)
Description
Example
Container/ Packaging
Picture
Comments
Disposal Method
20 03 01
(non- hazardous)
Domestic or household waste, similar to the type of waste produced at home.
Packaging, hand towels, food remains / cartons
Clear plastic bag Or Black waste bag
Place in dedicated wheeled domestic waste bins where available or at a designated collection point. Keep separate from all clinical waste streams
Recycling or used as Refuse Derived Fuel (RDF)
20 03 01
(non- hazardous)
Domestic glass containers
Glass jars, bottles, etc.
Cardboard box lined with a clear/black bag
N/A
Must NOT include any medicine bottles.
Recycling or used as Refuse Derived Fuel (RDF)
18 01 03
(hazardous)
Category A pathogen contaminated waste
Anything that has come into contact with a VHF patient
Double bagged in thick yellow plastic bags, placed
inside a yellow rigid plastic container
Complete segregation from other waste streams must be maintained, kept inside isolation area until collected. Follow NCA’s emergency action cards at all times
Incineration only
Appendix 2 Waste Description, Packaging and Disposal Methods
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18 01 03 (hazardous)
Infectious or potentially infectious clinical waste
Soiled dressings, swabs, incontinence pads, gloves, aprons, etc contaminated with blood or body fluids, empty catheter bags, suction tubing.
Orange plastic bag
Must not contain anatomical or pharmaceutical or chemical waste. Keep separate from all other waste streams
Alternative treatment (or incineration)
18 01 03 (hazardous)
Infectious or potentially infectious clinical waste In patient’s homes in the COMMUNITY
Soiled dressings, swabs, gloves, aprons etc. contaminated with blood or body fluids, solidified suction canisters / drains.
Orange Infectious Waste BioBin
District Nurse to arrange collection from patient’s home
Alternative treatment (or incineration)
18 01 03 (hazardous)
Infectious or potentially infectious clinical waste In patient’s homes in the COMMUNITY
Suction canisters / drains that contain blood / bodily fluids as a liquid.
Yellow Infectious Waste BioBin
District Nurse to arrange collection from patient’s home
Incineration only
18 01 02 / 03 (non-hazardous and/or hazardous)
Non-infectious / infectious anatomical waste
Amputated limbs, placentas, blood bags containing a quantity of blood
Yellow container with red lid.
Keep separate from orange bags and all other waste streams
Incineration only
18 01 03 & 18 01 09 (hazardous)
Sharps (non- cytotoxic/cytostatic)
Needles, scalpels, blades
Yellow sharps container with yellow lid
Keep separate from orange bags and all other waste streams District Nurse to return sharps bins to base for disposal
Incineration only
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18 01 03 & 18 01 09
Medicinally contaminated waste (non-cytotoxic/cytostatic) that contain a sharp.
IV bags, lines, tubing, etc containing a sharp
Yellow sharps container with yellow lid – large aperture
Store with other yellow sharps containers with yellow lids
Incineration only
18 01 08 & 18 01 03 (hazardous)
Sharps and other potentially infectious items contaminated with cytotoxic/cytostatic pharmaceuticals
Needles etc. contaminated with cytotoxic/static pharmaceuticals
Yellow container with purple lid
Keep separate to orange bags and other waste streams. Request separate collection by Portering Department.
Incineration only
18 01 08 (hazardous)
Cytotoxic/Cytostatic pharmaceuticals
Cytotoxic/Cytostatic pharmaceuticals including tablets, medicines, etc
Yellow container with purple lid or Cyto BioBin
Keep separate from all other waste streams and request a special collection by the Portering Department.
Incineration only
18 01 08 (hazardous)
Cytotoxic/Cytostatic pharmaceuticals Generated by the District Nurse in patients’ homes in the COMMUNITY
Cytotoxic/Cytostatic pharmaceuticals (see list at Appendix B)
Yellow container with purple lid or Cyto BioBin
Patients or their carers / relatives should return waste/medicines no longer required to Christies or their local community pharmacist. District Nurse to return the waste they generate back to base for disposal
Incineration only
18 01 09 (non- hazardous)
Pharmacy general pharmaceuticals
General pharmaceuticals including, tablets, medicines, etc part used, unused and out of date.
Blue rigid container or blue Medicinal BioBin
Packaged into pharmi bins / medicinal BioBins
Incineration only
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18 01 09 (non- hazardous)
Wards / Departments medicines & medicinally contaminated items that are not returned to Pharmacy
Pharmaceuticals including, tablets, medicines, empty infusion bags with no sharps etc
Blue rigid container or blue Medicinal BioBin
Keep separate to orange bags and all other waste streams.
Incineration only
18 01 09 (non- hazardous)
Medicinally contaminated items that do not contain a sharp. Generated by the District Nurse in patients’ homes in the COMMUNITY
IV lines / bags
Blue rigid container or blue Medicinal BioBin
Patients or their carers / relatives should return waste/medicines no longer required to their local community pharmacist. District Nurse to return the waste they generate back to base for disposal
Incineration only
18 01 06 (hazardous)
Chemically contaminated waste from Path Labs, ESLs and Theatres
Plastic bottles of formalin, soda lime crystals
Yellow rigid container or yellow BioBin
Keep separate to orange bags and all other waste streams.
Incineration only
18 01 10 (hazardous)
Amalgam waste
Extracted teeth containing amalgam (from Maxillo Facial Department)
Waste contractor’s white containers
To be disposed of via specialist waste contractor
Specialist recovery
18 01 03 or 20 03 99 (hazardous or non-hazardous)
Mattresses There is an agreement with the Supplier that any mattresses that are not contaminated they take back for disposal
Mattresses from patient care which are infectious
Orange Mattress bag
N/A
A notice must be attached giving reason for disposal before collection by Portering Seek guidance from Infection Control Team, Tissue Viability Nurse or Waste Management Co-ordinator.
Alternative Treatment
Waste Management Procedures
Reference Number: NCAE031(19) Version Number: One Issue
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20 01 01
Cardboard
Cardboard boxes and packaging
‘Cardboard Only’ waste bins where provided or Cages
Please ensure that boxes are flattened wherever possible
Recycling - earning revenue
20 01 01 (non- hazardous)
Confidential waste
Any Papers containing staff or patient personal details e.g. patient records, paper diaries, patient lists or potentially sensitive information about the organisation such as; financial records etc.
Confidential waste red bin. Cross cut shredder can be used and the waste put in paper recycling stream.
Contact the Portering Department for collection when full
Securely shredded and then recycled
20 01 01 (non- hazardous)
Confidential waste
Any Non-Paper items containing staff or patient personal details or sensitive information about the organisation, such as; CDs, floppy disks, slides, etc.
N/A.
N/A
Contact the Waste Management Co-ordinator for collection. The items must be kept secure until they are collected.
Securely shredded before disposal to landfill
20 01 01
Paper
Non-confidential paper newspapers, magazines, any cross cut shredded confidential waste
Green bins
Contact the Portering Department for collection when full
Recycling – earning revenue
16 02 14
Waste printer, toner and inkjet cartridges
Various printer cartridges
Collection boxes are provided in designated areas.
Only cartridges, toner - no packaging should be put in the collection boxes
Recycling
20 01 04
Scrap metal
Broken beds (non-electric), filing cabinets
Waste skip / Compound
N/A
Request collection by Porters
Recycling
Waste Management Procedures
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Various
Batteries
From general equipment used in wards and departments
Small cardboard box
Batteries should be taken to Estates
Recycling
16 06 01 16 06 02 16 06 03 20 01 33 20 01 33
Batteries: Lead acid (haz) Ni-cad (haz) Mercury containing (haz) Above mixed batteries (haz) Mixed batteries excluding above (may be haz)
Various batteries from vehicles and specialist electronic items and equipment (mainly from Estates and EBME/MEMS/MEMS)
Designated containers in Estates
N/A
Contact Estates.
Specialist disposal
18 01 06 (may be Hazardous) 18 01 07 (non- hazardous)
Chemicals
Chemicals with hazardous properties
Various
N/A
To be disposed of via specialist waste contractor. Contact Waste Management Co-ordinator for advice.
Specialist disposal
20 01 21 (hazardous)
Mercury
Mercury waste and items contaminated with mercury.
Various
To be disposed of via a specialist waste contractor. Contact Waste Management Co-ordinator for advice.
Special disposal see COSHH data sheet.
20 01 36 (non- hazardous)
Mixed electric and electrical equipment (not containing hazardous components)
Computers, printers, keyboards
Designated IT Waste Storage Facility
Contact IT to arrange collection – do not leave on corridor
Specialist recovery / recycling
Waste Management Procedures
Reference Number: NCAE031(19) Version Number: One Issue
Date: Page 49 of 58
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20 01 36 (non-hazardous)
Mixed electric and electrical equipment (not containing hazardous components)
Fans, microwaves, toasters etc.
Estates WEEE container
N/A
Request collection by Porters – do not leave on corridor
Specialist recovery / recycling
20 01 35 (hazardous)
Mixed electric and electrical equipment (containing hazardous components)
TVs, etc
Estates WEEE container
N/A
Request collection by Porters – do not leave on corridor
Specialist recovery / recycling
20 01 23 (may be hazardous)
Discarded equipment containing chlorofluorocarbons (CFCs)
Fridges, freezers and other refrigeration equipment.
Estates WEEE container
Request collection by Porters – do not leave on corridor
Specialist recovery or disposal
20 01 21 (hazardous)
Fluorescent tubes
Fluorescent lighting tubes (from Estates & Facilities Department)
Designated container in Estates
Contact site Works Department
Specialist recovery or disposal
20 03 07 (non- hazardous)
Bulky waste
Items such as chairs, tables and other large non- hazardous furniture or equipment
N/A
Do not leave on corridors. Contact Porters for removal. Keep within ward / department whilst awaiting collection.
Reuse, recycling or landfill
Waste Management Procedures
Reference Number: NCAE031(19) Version Number: One Issue
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Various (non- hazardous)
Building and engineering wastes
Items such as construction and demolition waste, etc (from Estates Department)
Waste compound
Generated by work carried out by Estates staff. Contractors should have own process for waste disposal.
Specialist recovery and/or disposal
17 06 01 and/or 17 06 05 (may be hazardous)
Insulation material containing asbestos/construction material containing asbestos
Items consisting of or containing asbestos (from Estates & Facilities Department).
Estates waste skip or contractors container
N/A
Generated from work carried out by Estates staff or appointed contractors. Contact site works department.
Specialist disposal
20 02 01 (non- hazardous)
Garden waste
Garden waste for composting
Compost store or open skip
Generated by Grounds & Gardens staff
Composting or landfill
Waste Management Procedures
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Appendix 3 Colour Coding of Waste
Title of document; Waste Management Procedures
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Title of document; Waste Management Procedures
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Title of document; Waste Management Procedures
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Title of document; Waste Management Procedures
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Title of document; Waste Management Procedures
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Appendix 4 Recognised list of Cytostatic Medicines (November 2015)
The following medicines are classed as cytostatic and are required to be disposed of via the purple waste stream. Staff do not require specific training, as for cytotoxic medicines, to administer cytostatic medicines but should use appropriate PPE as per policy. In addition staff should refer to the summary of product characteristics (SPC) (http://emc.medicines.org.uk/) or package insert for any additional handling instructions. Solid dosage forms of hazardous medicines should not be crushed without seeking advice from pharmacy. The presence of a medicine in the below list does not imply that this medicine is available for use on the North of Tyne Formulary or is stocked in NUTH pharmacies.
Abacavir Estrone Norelgestromin
Abiraterone Estropipate Norethisterone
Acitretin Ethinylestradiol Norgestimate
Adalimumab Ethinylestradiol/desogestrel Obinutuzumab
Afatinib Ethinylestradiol/drospirenone Oestrogens
Aldesleukin Ethinylestradiol/etonogestrel Ofatumumab
Alemtuzumab Ethinylestradiol/gestodene Oxytocin
Alitretinoin Ethinylestradiol/levonorgestrel Panitumumab
Ambrisentan Ethinylestradiol/norelgestronim Pazopanib
Anastrozole Ethinylestradiol/norethisterone Pembrolizumab
Atazanavir Ethinylestradiol/norgestimate Pentamidine
Atripla® Etonogestrel Pertuzumab
Axitinib Etravirine Plerixafor
BCG - connaught Etynodiol Podophyllum
BCG Tice Everolimus Pomalidomide
BCG vaccine Eviplera® Ponatinib
Belimumab Exemestane Raloxifene
Bevacizumab Finasteride Raltegravir
Bexarotene Fingolomod Ranubizumab
Bicalutamide Flutamide Regorafenib
Boceprevir Fosamprenavir Rezolsta®
Bosentan Foscarnet Ribavirin
Bosutinib Fulvestrant Rilpivirine
Buserelin Ganciclovir Riociguat
Cabozantinib Gefitinib Ritonavir
Ceritinib Gemeprost Rituximab
Certolizumab Gestodene Ruxolitinib
Cetrorelix Golimumab Saquinavir
Cetuximab Goserelin Sirolimus
Chloramphenicol Harvoni® Simeprevir
Title of document; Waste Management Procedures
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Ciclosporin Histrelin Sorafenib
Cidofovir Ibrutinib Stavudine
Colchicine Idelalisib Stribild®
Combivir® Imatinib Sunitinib
Crizotinib Ingenol mebutate Tacrolimus
Dabrafenib Indinavir Tamoxifen
Daclatasvir Infliximab (Remicade®/Inflectra® /Remsima®)
Targretin
Darunavir Ipilimumab Telaprevir
Dasatanib Kaletra® Temsirolimus
Defibrotide Kivexa® Tenofovir
Denosumab Lamivudine Teriflunomide
Desogestrel Lapatinib Testosterone
Didanosine Leflunomide Thalidomide
Dimethyl fumarate Lenalidomide Tibilone
Diethylstilbestrol Letrozole Tipranavir
Dinoprostone Leuprorelin Tocilizumab
Doletegravir Levonorgestrel Toremifene
Drosperidone Lopinavir Trametinib
Dutasteride Macitentan Trastuzumab
Dydrogesterone Maraviroc Tretinoin
Eculizumab Medroxyprogesterone Triptorelin
Efavirenz Megestrol Trizivir®
Emtricitabine Menotropins Truvada®
Enzalutamide Mestranol Ulipristal
Ergometrine Mifepristone Valganciclovir
Erlotinib Mycophenolate Vandetinib
Estradiol Nafarelin Vemurafenib
Estradiol/dienogest Nevirapine Viekirax®
Estradiol/nomegestrol Nilotinib Vismodegib
Estrogen-progesterone combinations
Nintedanib Zidovudine
Estrogens, conjugated Nivolumab
Title of document; Waste Management Procedures
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Appendix 5 Recognised list of Cytotoxic medicines (November 2015)
The following medicines are classed as cytotoxic and are required to be disposed of via the purple waste stream. Staff administering cytotoxic medicines should do so accordance with the Anticancer Medicines Policy AND Guidance on the Management of Patients receiving Cytotoxic Chemotherapy for Non Malignant Conditions. Solid dosage forms of cytotoxic medicines should not be crushed. The presence of a medicine in the below list does not imply that this medicine is available for use on the North of Tyne Formulary or is stocked in NUTH pharmacies.
Actinomycin D Dexrazoxane Oxaliplatin
Amsacrine Docetaxel Paclitaxel
Arsenic Trioxide Doxorubicin Peg-asparaginase
Azacitidine Emtricitabine Pegylated Liposomal Doxorubicin
Azathioprine Epirubicin Pemetrexed
Bendmaustine Eribulin Pentostatin
Bleomycin Estramustine Pixantrone
Bortezomib Etoposide Procarbazine
Brentuximab vedotin Fludarabine Raltitrexed
Busulfan Fluorouracil Streptozocin
Cabazitaxel Gemcitabine Tegafur Uracil
Capecitabine Gemtuzumab Temoporfin
Carboplatin Hydroxycarbamide Temozolomide
Carmustine Idarubicin Teniposide
Chlorambucil Ifosfamide Thiotepa
Cisplatin Irinotecan Tioguanine
Cladribine Lomustine Topotecan
Clofarabine Melphalan Trabectedin
Crisantaspase Mercaptopurine Trastuzumab emtansine
Cyclophosphamide Methotrexate Treosulfan
Cytarabine Mitomycin Vinblastine
Dacarbazine Mitotane Vincristine
Dacitabine Mitoxantrone Vindesine
Dactinomycin Nab-Paclitaxel Vinflunine
Daunorubicin Nelarabine Vinorelbine