Cardiff and Vale NHS Trust/ Ref No: 109/Waste Management Policy
CARDIFF AND VALE NHS TRUST
YMDDIRIEDOLAETH GIG CAERDYDD A’R FRO
E/2
Waste Management Policy
Author
Trust Waste
Management Group
Policy ratified by
Responsible Officer
(Lead of Group)
Classification
Area Applicable
Ref No:
Gwenda Raybould
Trust Health & Safety
Committee
Director of Corporate
Management
Waste Management
Trust wide
109
Trust Waste Manager
Peter Welsh
Date Issued
Review Date
Version No:
Aug 2004
Aug 2007
1
Disclaimer
When using this document please ensure that the version you are using is the most up to
date either by checking on the Trust database for any new versions or if the review date
has passed please contact the author.
Out of date policy documents must not be relied on
________________________________________________________________________________________________
Occupational Safety, Health & Environment Unit/Revised December 2004/Waste Management 04
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Cardiff and Vale NHS Trust/ Ref No: 109/Waste Management Policy
Contents
Page No.
3
1
Disposal Policy
2
Legal & Statutory Obligations
3
3
Guidance and Directives
3
4
Identification, Description & Segregation of waste
4.1
Identification of Waste
4.2
Description of Waste
4.3
Segregation of Waste
4.3.1 Safe Segregation
4.3.2 Further Guidance
4.4
Types of Waste for Segregation
4.4.1 Special Waste
4.4.2 Clinical Waste
4.4.3 Domestic Waste
4.4.4 Confidential Waste
4.4.5 Scrap Waste
3
4
5
Collection and Transportation of Waste
6
Training in the Handling of Waste
6.1
General awareness training
6.2
Spillages
7
Storage of Waste
7.1
Security of Waste Storage
7.2
Containers for Storing Waste
8
Disposal of Waste
9
Resources
10
Tracking, Auditing and Monitoring
11
Further Guidance
Appendix 1: Waste Management Reporting - Flow Chart
5
6
7
8
9
10
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Cardiff and Vale NHS Trust/ Ref No: 109/Waste Management Policy
1
Disposal Policy
It is Cardiff and Vale NHS Trust / Cardiff University - Wales College of Medicine’s (herein after
referred to as the Organisation) responsibility to limit the amount of waste production through the
Organisation’s activities, insofar as is reasonably and economically practicable. This is to be
achieved by careful consideration of the disposal implications of all purchases and donations.
Where the production of waste is unavoidable it is the Organisation’s policy to ensure the safe
segregation, handling and disposal of waste and that all persons handling any such waste will
exercise care to avoid injury or risk of harm to themselves or others, including the general public. It
is the producers’ responsibility to ensure that all waste is disposed of in the correct manner.
2
Legal & Statutory Obligations
The following legislation has been taken into account when formulating this Policy:
 Health and Safety at Work etc. Act, 1974
 Environmental Protection Act ,1990
 Control of Substances Hazardous to Health (COSHH) Regulations, 2002
 Management of Health and Safety at Work Regulations, 1999
 Manual Handling Operations Regulations, 1992
 Special Waste Regulations, 1996
 Environmental Protection (Duty of Care) Regulations, 1991
 Carriage of Dangerous Goods (Classification, Packaging and Labelling) and Use of
Transportable Pressure Receptacles Regulations 1996
 Data Protection Act 1998
The ‘Duty of Care’ can be construed as that degree of care, which does not cause injury to your
neighbour. In the Environmental Protection Act 1990, the duty is limited to requiring one to take all
measures as are reasonable in the particular circumstances. Reasonable care MUST be taken to
avoid acts or omissions, which can be reasonably foreseen as likely to injure a neighbour.
The term “neighbour” refers to those persons who are so closely and directly affected by an act that
the person causing the act ought reasonably to have foreseen that they would be so affected when
contemplating the act or omission subject to question in the court.
Implicit in the above regulations is the general duty to dispose of all waste in such a manner, as to
protect anyone working with, or near, or handling articles or substances which are wastes and
which constitute a reasonably foreseeable risk of injury, or may cause ill health to anyone.
Given the special risks associated with the handling of waste, any accidents/injuries involving
waste must be reported immediately in accordance with the Organisation’s procedures for the
reporting of accidents and untoward incidents, utilizing the Incident Report Form HS/IDO/04.
3
Guidance and Directives
Where Government and Department* guidance, directives or procedures are issued to
cover the way in which waste arisings are dealt with by the Organisation, it is the
Organisation’s policy to ensure that these are complied with.
[* refers to Department of Health, NHS Estates, Environment Agency, DEFRA, HSE etc]
4
Identification, Description & Segregation of Waste
It is the policy of the Organisation for all waste arisings to be segregated at source. Where
practicable, segregated waste will be recycled as part of a cost improvement programme and also
to reduce adverse environmental effects.
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4. 1
Identification of Waste
Waste is defined from the point of view of that person discarding it. Each person discarding an
item should ask the question:
a.
Is this what would ordinarily be described as waste?
b.
Is it a scrap material?
c.
Is it an effluent or other unwanted substance?
d.
Does it require to be disposed of as broken, worn out, contaminated?
If the answer to any of these questions is yes, then the item to be discarded is a waste.
4.2
Description of Waste
The producer of waste must be able to describe the waste for disposal. The description should
include:
a.
The name of the waste.
e.g. Special, Clinical; Domestic, Confidential, Scrap etc.
b.
Where did the waste arise?
e.g. The location - Ward A7 - UHW, Cystic Fibrosis Unit - Llandough, Tegfan Day Hospital
- Whitchurch Hospital etc.
Where waste is identified as problematical, it is the producer’s duty to establish what special
precautions for handling and transporting of that waste are required, and to ensure that the waste
is bagged securely, tied with the appropriate tie and labelled clearly with the place of origin.
4.3
Segregation of Waste
4.3.1 Safe Segregation
In order to ensure the safe segregation of waste it is the Organisation’s policy to use coloured
plastic bags and safety containers. Trolleys will be provided, yellow with red lids / symbol for
special waste, yellow for clinical waste and black for domestic and general waste, where possible
within the waste areas allocated. Confidential waste should be shredded at source or for larger
quantities arrangements should be made via the Waste Management office. Scrap waste should be
programmed for collection via the Waste Management office.
All bags used for waste are to be sealed at the neck, utilising the ‘swan neck method’ with an
identification tie stating the origin and its source. All bags should not be more than two thirds full,
nor so heavy that they are unable to be lifted, by a lightly built person using one hand
The colour-coding for bags is as follows:
Colour of Bag
Type of Waste
Yellow
All Clinical Waste
Black
All Domestic Waste incl. Residences
Brown
Food Waste (UHW, Rookwood only)
Grey
Bottles and Aerosols
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There will be non-clinical waste arisings in some clinical areas (i.e. offices) where possible black
bags will be introduced in these areas. Waste must be segregated into clinical (yellow bag) and
non clinical (black bag) waste.
4.3.2 Further Guidance
Segregation of waste is practiced to different levels throughout the Organisation. For further
information, please refer to the Waste Charts Section of the Waste Management - Policies and
Operational Procedures Manual, which is available via the Organisation’s Intranet / Internet
websites :
Trust - Planning and Asset Management Department Website - direct link to Manual
http://cav-est01/contents.asp?id=2123
University – Occupational, Safety, Health and Environment Unit Website
www.cf.ac.uk/safty
4.4
Types of Waste for Segregation
4.4.1 Special Waste
The Organisation’s policy concerning special waste is formulated to comply with the Special Waste
Regulations 1996.
Special waste is categorised as :
 Certain pharmaceutical waste e.g. controlled drugs, prescription only medicines -– (POMs) etc.
 Residue of pharmaceutical waste from vials, ampoules etc.
 Discarded syringes, needles, cartridges etc. All sharps should be disposed of in a special
Sharps Safety Containers, provided for that purpose. Broken glass and any other sharp
instruments should also be contained in sharps containers. Sharps containers must not be filled
more than ¾ full and are to be properly secured to manufacturer’s instruction and appropriately
labeled with source of origin.
On no account should sharps containers be placed in Clinical Waste Bags
4.4.2 Clinical Waste
The Organisation’s policy concerning clinical waste is formulated to comply with the HSE Guidance
Note “SAFE DISPOSAL of Clinical Waste”, Department of Environmental Waste Management
Paper 25 “Clinical Waste” and HN82/22 “Disposal of Clinical Waste”.
Clinical waste is categorized as: any waste originating from a clinical activity, generated in the
treatment or diagnosis of patients; in laboratory areas; and in other areas where the following
apply:
 Soiled surgical dressings, swabs and all other contaminated waste from treatment areas;
 Materials other than linen from cases of infectious disease;
 All human tissues (whether infected or not), animal carcasses and tissues
from laboratories, and all related swabs and dressings.
 Laboratory and post-mortem room waste.
 Used disposable bed-pan liners, urine containers, incontinence pads and stoma bags.
Where waste has been autoclaved prior to final disposal it should be placed in a yellow clinical
waste bag, after autoclaving and appropriately sealed.
Where human tissue, limbs and other items are to be disposed of they should be placed in
a specialist yellow container specifically designed for the purpose and sealed.
4.4.3 Hygienic Waste Generated In The Community Setting
Where Clinical Waste has been generated in a community setting i.e at home, as long as the waste
is adequately wrapped and free from excess liquid and the waste is not considered infectious
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waste the householder may put it in their domestic waste. Note, this excludes sharps which must
be placed in a sharps container.
Any clinical waste generated by Trust employees based in a G.P Premise must be treated as
clinical waste and put for collection by the Trust Waste Contractor.
4.4.4 Domestic Waste
These are waste arisings of the type normally found in a domestic household, such as paper,
newspapers, spent flowers, packaging, cans, plastic drinking cups, paper towels containers,
plastics, unwanted textiles, general refuse etc. Domestic waste is generated in all areas,
particularly office areas and is non-contaminated waste which is disposed of via landfill.
4.4.5 Confidential Waste
Where waste is considered to be of a confidential nature then it should either be shredded at
departmental level or arrangements made via the Waste Management Office for the waste to be
taken away for shredding and disposal by a specialist contractor, who will supply a certificate of
destruction as proof of shredding. It is the responsibility of the producer of the waste to fund the
disposal; of confidential waste.
4.4.6 Scrap Waste
Scrap waste is categorized as condemned items of furniture and equipment such as tables, chairs,
cupboards, filing cabinets, tables, desks and other bulky items. Scrap waste must not be placed in
wheeled containers or stored where it could cause an obstruction, but must be programmed in for
collection via the Waste Management Office. It is the responsibility of the producer of the waste to
fund the disposal; of scrap waste.
5
Collection and Transportation of Waste
The labeling, tagging and removal of waste bags from bins to waste collection points, is the
responsibility of the medical, nursing, and facilities staff. In laboratory areas it will be the
responsibility of the laboratory staff to secure the waste bags and to transport them to the waste
collection point. The trolley lid will remain locked, and the access key retained by an authorised
person for each area. All waste areas are to be kept as secure as possible to prevent unauthorised
access.
Waste will be collected from authorised collection points at regular intervals, using electric tugs
whenever practical, in accordance with local circumstances. Wherever possible, containers will be
replaced on a one for one basis.
6
6.1
Training in the Handling of Waste
General Awareness Training
Waste Management training forms an integral part of the Organisation’s mandatory /
obligatory training and staff induction programme, which each member of staff MUST
attend. Mandatory training is carried out on a regular basis throughout the Trust and
induction for new staff at Whitchurch Hospital. Training will also be undertaken as part of
the University Induction Day and through the networked Statutory and Mandatory training
programme.
All training will include the following :
 Outline of current waste management legislation and penalties for non compliance
 Responsibilities of individuals for the safe management of waste, including ‘duty of care’
obligations
 segregation of waste
 waste containers and storage arrangements
 waste identification
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 transportation of waste
 disposal arrangements
Those supervising the waste handling procedures should ensure that those persons
handling the waste:
 are fully aware of any dangers which may arise in handling that waste
 have the necessary mechanical aids and equipment, to handle that waste safely
 are trained in the procedures associated with segregation and waste handling
appropriate to their work environment.
6.2
Spillages
All spillages of waste must be cleaned without delay. Waste spillages should not be left
unattended or unsecured. Where spillages occur in the ward or laboratory it is the responsibility of
persons working in that area to clean up the spillage. Where spillages occur in “common areas”
i.e. corridors etc then Facilities must be notified immediately.
Further information on spillages is contained in Local Waste Management Procedures of the Waste
Management - Policies and Operational Procedures Manual, and also within the Decontamination
Policy – Infection and Control Committee April 2002, which is available via the Organisation’s
Intranet / Internet websites :
Trust - Planning and Asset Management Department Website - direct link to Manual
http://cav-est01/contents.asp?id=2123
University – Occupational, Safety, Health and Environment Unit Website
www.cf.ac.uk/safty
The Decontamination Policy also provides advice on the use of disinfection for clearing the type of
spillage that has occurred.
7
Storage of Waste
It may be necessary to store waste temporarily prior to disposal.
Duty of Care under the E.P.A. (1990) requires that waste holders must introduce and maintain such
housekeeping measures in order to keep any waste safe from:
a.
corrosion or wear of waste containers;
b.
accidental spillage or leakage;
c.
accident or weather, breaking contained waste open, and allowing it to escape;
d.
waste blowing away or falling while stored, transported or handled;
e.
scavenging of waste by vandals, thieves, children, trespassers or animals.
Highly Flammable Waste at departmental level must be stored in a secure Highly Flammable
cabinet and must not contain vessels (empty or full) which are capable of storing more than 50
litres of highly flammable substances. No more than 500ml. of flammable substance may be held
on an open bench dealt with in the “Policy for the Storage of Highly Flammable Substances”
In order to satisfy the Duty of Care and the Fire Safety Requirements, it will be policy for all types of
waste to be placed into the correct containers which will be stored at authorised collection points
and the designated waste areas.
The precise arrangements for the storage of waste will vary for different hospitals throughout the
Organisation. For a more detailed description, refer to specific Waste Charts in the Waste
Management- Policies and Operational Procedures Manual.
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7.1
Security of Waste Storage
Security precautions at sites where waste is stored should prevent theft, vandalism or scavenging
of the waste. Holders should take particular care to secure waste materials arisings from building
and demolition works, where totally enclosed skips capable of being secured are to be used.
Segregation of different categories of waste where they are produced may be necessary to prevent
the mixing of incompatible wastes. The waste holder must ensure that all the staff permitted in
those areas of segregation are aware of the locations and use of each segregated waste container.
7.2
Containers for Storing Waste
All waste that is stored and to be handed on to another person must be in a container. Waste
containers must suit the waste placed in them, e.g. plastic sacks are not suited to liquid, jagged or
hot waste, and be of sufficient integrity to enable the waste to be safely contained.
All clinical waste containers will be in accordance with UN specification.
8
Disposal of Waste
All special waste arising within the Organisation including, laboratory waste, pharmaceutical waste,
hazard category 3 and above; radioactive waste; cytotoxic waste will be transported off site by the
specialist waste contractor and incinerated at an approved waste disposal site. Special waste is
categorised as :
 Certain pharmaceutical waste e.g. controlled drugs, prescription only medicines -– (POMs) etc.
 Residue of pharmaceutical waste from vials, ampoules etc.
 Discarded syringes, needles, cartridges etc. All sharps should be disposed of in a special
Sharps Safety Containers, provided for that purpose. Broken glass and any other sharp
instruments should also be contained in sharps containers. Sharps containers must not be filled
more than ¾ full and are to be properly secured to manufacturer’s instruction and appropriately
labeled with source of origin.
All clinical waste arisings within the Organisation will be collected and disposed of at a licensed
incinerator plant by a Specialist Waste Contractor. The ash residue from the process is then sent
for landfill for disposal.
All domestic waste arising within the Organisation is collected by a combination of waste
contractors, including local authority, and disposed of at a licensed landfill site facility.
Waste Charts are contained within the Waste Management - Policies and Operational Procedures
Manual, and provide requisite guidance for the disposal of the various types of waste generated
within the organisation.
If a particular waste needing disposal does not fit into one of the waste sections, the Waste
Manager, or the Health, Safety and Environment Unit should be contacted for further advice.
9
Resources
10
Tracking, Auditing and Monitoring
The Organisation currently produces over 4,269 tonnes of waste per annum (exclusive of building
works waste and scrap materials). Of this total, 2,205 tonnes (51.7%) is classified as ‘domestic’
waste whilst 2,064 tonnes (48.3%) is classified as ‘clinical / special’ waste. The revenue costs
associated with the provision of the above, and to implement this Policy, are included within the
existing Waste Management revenue budget allocation.
The “audit trail” must be carefully controlled and maintained to ensure protection against escape or
unlicensed handling or disposal. It is the responsibility of all staff involved in the production,
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Cardiff and Vale NHS Trust/ Ref No: 109/Waste Management Policy
transport or disposal of waste to maintain the integrity of the waste management policy and its
audit trail requirements.
Waste will be continuously monitored by the Waste Manager on a regular basis. Infringement
notices will be issued where non-compliance is identified. These will be reported to the relevant
Directorate, the Trust Joint Management and Staff Health and Safety Committee and the University
Occupational Safety, Health, and Environment Committee.
11
Further Guidance
Further guidance and information on all aspects of waste management may be obtained by
reference to the Waste Management - Policies and Operational Procedures Manual, which is
available via the Organisation’s Intranet / Internet websites :
Trust - Planning and Asset Management Department Website - direct link to Manual
http://cav-est01/contents.asp?id=2123
University – Occupational, Safety, Health and Environment Unit Website
www.cf.ac.uk/safty
The Manual contains sections on the following aspects:

Introduction

Waste Management Policy

Clinical Waste Disposal Policy

Local Waste Management Procedures

Opportunities to Reduce the Waste Produced

Practical Tips for Reducing Waste

Publicity Material

Waste Charts

Legislation and Regulatory Developments

Abbreviations, Definitions and Glossary of Terms
The Manual will be updated to take account of the latest developments and guidance available with
respect to waste management, and to reflect best practice
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Appendix 1
Waste Management Reporting - Flow Chart
Trust Board
Trust Health
and Safety
Committee
Trust Risk
Management
Group
Environmental
Management
Steering Group
Chaired by Director of
Corporate Management Board Member
Chaired by Director of
Corporate Management Board Member
Chaired by Director of
Development - Board
Member
Internal
Influences







Policies, Procedures &
Guidance
Infection Prevention &
Control
Environmental
Management System EMS
Waste Surveys and
Audits
Health, Safety &
Environment Unit
Periodic Reviews
WRM 35 : Waste
Management Standard
Trust Waste
Management
Group
Focal point of contact
for Waste Management
- Membership includes
Directorates of the
Trust and support
services including
UWCM
External
Influences









Legislation &
Guidance
Environment Agency
Local Authority EHO
H M Government
Welsh Assembly
Government
NHS Executive
H&SE
Waste Consortium
Benchmarking /
Performance
Management
Waste Producers within the Organisation
Primary route
Secondary route
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