WASTE HANDLING POLICY
Version
4
Name of responsible (ratifying) committee
Client Contractor Meeting
Date ratified
11 November 2014
Document Manager (job title)
Facilities Monitoring Manager, Development Team
Date issued
12 January 2015
Review date
01 December 2017
Electronic location
Management Policies
Related Procedural Documents
Waste Disposal Procedures
Key Words (to aid with searching)
Waste management; Waste disposal; Disposal
procedures; Clinical waste; Hazardous waste; Non
hazardous waste; Infectious; Offensive;
Cytotoxic/Cytostatic; Domestic; Confidential; Toxic
substances; Radioactive waste disposal; Medicines;
Sharps; Safe handling; Safe storage; Recycling; Health
and Safety; WEEE
Waste Handling Policy – version 4
Issue Date: 12 January 2015
Review date: 01 December 2017 (unless requirements change)
CONTENTS
1. INTRODUCTION
2. PURPOSE
3. SCOPE
4. DEFINITIONS
5. DUTIES AND RESPONSIBILITIES
6. PROCESS
7. TRAINING REQUIREMENTS
8. REFERENCES AND ASSOCIATED DOCUMENTS
9. EQUALITY IMPACT STATEMENT
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
Waste Handling Policy – version 4
Issue Date: 12 January 2015
Review date 01 December 2017 (unless requirements change)
Waste Segregation Quick Reference Guide
Is the waste “clinical” or
domestic in nature?
DOMESTIC
CLINICAL
YES
Is the waste made up of or
contaminated with medicines?
Is the waste suitable for
recycling?
Medicinal Waste Bin (blue
cardboard)
NO
NO
Domestic waste
(black bag)
NO
YES
Recycling waste
(clear bag)
YES
Is the waste Cytotoxic/
Cytostatic in nature?
YES
Cytotoxic waste (yellow bag with purple
stripe or purple lidded sharps bin)
NO
Is the waste made up of or
contaminated with chemicals?
YES
Incinerate-only Hazardous waste
(yellow bag or yellow burn-bin)
NO
Are there any sharps?
YES
Sharps bin:
Yellow-lid = contaminated with medicines or chemicals
Purple-lid = contaminated with Cytotoxics/Cytostatics
Orange-lid = not contaminated with anything other
than blood or non-medicinal additives
NO
Is the waste made up of
recognizable anatomical parts?
YES
Anatomical Waste Bin (red lid)
NO
Is the patient infectious/barrier nursed?
NO
Offensive waste (yellow bag
with black stripe)
YES
Infectious waste (orange bag)
Waste Handling Policy – version 4
Issue Date: 12 January 2015
Review date: 01 December 2017 (unless requirements change)
Page 3 of 10
1. Introduction
As a waste producer, Portsmouth Hospitals NHS Trust (PHT) has a duty of care to ensure that
all wastes produced on its sites are responsibly, effectively and safely managed, and that the
storage, handling, transportation and disposal of waste materials comply with current legislation
and take into account published best practice guidance.
This waste handling policy replaces all previous waste handling policies and is written in line
with the Controlled Waste Regulations 2012, Hazardous Waste Regulations 2005 and the
Department of Health Safe Management of Healthcare Waste version:2.0:England
The Controlled Waste Regulations 2012 replace and update the Controlled Waste Regulations
1992. They came into force on 6 April 2012.
Principle statutory requirements and guidance documents considered within this policy:
Legislation
The Hazardous Waste (England and Wales) Regulations 2005 (amended 2010)
The Waste Regulations (England and Wales) 2011
Controlled Waste Regulations (England and Wales) 2012
Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2011
Guidance
Health Technical Memorandum (HTM) 07-01
Safe Management of Healthcare Waste version:2.0:England, Department of Health 2012
Technical Guidance WM2, Environment Agency, SEPA, NI Environment Agency
2. PURPOSE
The intention of this policy is to ensure that waste generated at Queen Alexandra Hospital is
managed effectively and in accordance with the law. This policy sets out to: identify the legal
and statutory obligations of the organisation; provide a framework for healthcare waste
management, segregation and disposal; and identify an outline of responsibilities.
This policy should be read in conjunction with the associated operating procedures and
guidelines for the storage and collection of hazardous/non hazardous, Radioactive and
Domestic waste to be adopted by Portsmouth Hospitals NHS Trust.
3. SCOPE
This policy applies to all individuals involved in the production and collection of waste.
This policy applies to all staff (including voluntary workers, students, locums and agency) within
the Trust, the MDHU (Portsmouth) and Carillion, whilst acknowledging for staff other than those
of the Trust the appropriate line management or chain of command will be followed.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
Waste Handling Policy – version 4
Issue Date: 12 January 2015
Review date: 01 December 2017 (unless requirements change)
4. DEFINITIONS
The following definitions represent the main categories of waste generated at Portsmouth
Hospitals NHS Trust, but are not exhaustive. Full details of the waste streams and disposal
methods are clearly defined in the operational procedures document - Waste Disposal
Procedures
Clinical Waste
The definition of clinical waste is provided by the Controlled Waste Regulations (issued under
the Environmental Protection Act) and in Northern Ireland by the Waste and Contaminated
Land (Northern Ireland) Order.
Clinical waste is defined as:
1. “. . . any waste which consists wholly or partly of human or animal tissue, blood or other body
fluids, excretions, drugs or other pharmaceutical products, swabs or dressings, syringes,
needles or other sharp instruments, being waste which unless rendered safe may prove
hazardous to any person coming into contact with it; and
2. any other waste arising from medical, nursing, dental, veterinary, pharmaceutical or similar
practice, investigation, treatment, care, teaching or research, or the collection of blood for
transfusion, being waste which may cause infection to any person coming into contact with it.”
Offensive Waste (Non Hazardous)
Offensive waste, also known as human hygiene waste, consists of waste containing body
fluids, secretions and excretions but is not clinical waste because it is not infectious. Such
waste is liable to cause offense by virtue of odour or appearance. Examples would include
items contaminated with non-infectious body fluids e.g. swabs, dressings, gloves, aprons,
nappies, sanitary towels etc.
Infectious waste
Infectious waste consists of waste containing body fluids, secretions and excretions, which
originate from a patient known or suspected to be infectious, and where barrier nursing
procedures have been instigated. Examples would include items that have been in contact with
the infected patient, or are contaminated with their body fluids, e.g. swabs, dressings, gloves,
aprons, nappies, sanitary towels etc
Incinerate-only Hazardous Waste
Waste containing or contaminated by chemical or other substances which may generate
hazardous properties, and which should be segregated and packed according to specified
requirements
Medicinal Waste
Medicinal waste consists of medicinally contaminated products (other than those associated
with cytotoxic/cytostatic medicines).
This includes, but is not limited to: syringe bodies (no sharps), medicines bottles, full/partially
used blister packs, connecting tubing, intravenous drip bags infused with medicinal products
Cytotoxic/cytostatic waste
Classification of medicinal waste used in the List of Wastes Regulations for medicinal products
with one or more of the hazardous properties toxic, carcinogenic, toxic for reproduction or
mutagenic.
Cytotoxic waste is to be known as hazardous waste
Anatomical Waste
Body parts or other recognisable items, including all human and animal tissue and waste
bones, which may be offensive to those who come into contact with such items. This excludes
Waste Handling Policy – version 4
Issue Date: 12 January 2015
Review date 01 December 2017 (unless requirements change)
very small unidentifiable pieces of skin or flesh (known as “trimmings”) which may be treated as
standard clinical waste
Sharps Waste
Sharps are items that could cause cuts or puncture wounds. They include, but not limited to:
needles; hypodermic needles; scalpels and other blades; knives; vials; broken medicine bottles.
Domestic waste
Domestic waste means mixed municipal waste from healthcare and related sources that is the
same as, or similar to, black-bag domestic waste from domestic households. Healthcare
premises must not place any hazardous waste in this waste stream. The waste should
therefore be non-hazardous and suitable for disposal by landfill (where pre-treatment
requirements are met), municipal incineration with or without energy recovery, alternative
municipal treatment processes, or via recycling streams.
Recycling
Recyclable waste includes: paper; cardboard; plastic bottles; cans; newspapers/magazines.
Healthcare organisations are prohibited from mixing domestic-type waste in the clinical waste
stream and vice versa.
5. DUTIES AND RESPONSIBILITIES
Trust Board
The Trust Board has overall accountability for the activities of the organisation, which includes
waste management.
The Trust Board will ensure that they receive appropriate assurance that the requirements of
current waste management legislation are being met.
The Trust Board discharges the responsibility for waste management through the Chief
Executive.
Chief Executive
The Chief Executive will, on behalf of the Board, be responsible for ensuring that current waste
management legislation is complied with and where appropriate, DoH Safe Management of
Healthcare Waste guidance is implemented.
The Chief Executive discharges the day to day operational responsibility for waste
management through the Head of Estates and Facilities.
The Hospital Company (THC) General Manager
THC General Manager has overall responsibility for ensuring that Carillion provide waste
services as detailed in the contract at the site of the Queen Alexandra Hospital.
Head of Estates and Facilities
The Head of Estates and Facilities is responsible for ensuring that waste management issues
are highlighted at Board level.
This responsibility will extend to the proposal of waste elimination, minimisation, recycling and
recovery as well as addressing the carbon impact related to waste through resource efficiency,
transport impacts and disposal arrangements.
At an operational level the Head of Estates and Facilities will;

Assist the Chief Executive with responsibilities for waste management matters.

Ensure that the Trust has in place a clearly defined waste management policy and relevant
supporting procedures.
Waste Handling Policy – version 4
Issue Date: 12 January 2015
Review date 01 December 2017 (unless requirements change)

Ensure that the Trust, through the day to day management of waste, complies with current
legislation and employs best practice guidelines as appropriate.

Ensure through senior management and line management structures that staff participation in
waste management training is maintained.
PHT Waste Representative and Carillion Services Ltd (CSL) Environment Manager
The Trust Waste Representative (to be appointed by the Head of Estates and Facilities), and
the CSL Environment Manager (for Queen Alexandra Hospital site only) will be responsible for:

Raising awareness of all waste management procedures and their purpose throughout the
Trust.

The operational management of waste management.

Compliance with legislation in relation to waste management and the Carriage of Dangerous
Goods Act.

Reporting of non-compliance with legislation, policies and procedures to the Head of Estates
and Facilities.

The development, implementation and review of the organisation’s waste management policy
and procedures.

The reporting of waste management incidents in accordance with Trust policy and external
requirements.

Monitoring and reporting of incorrect waste disposal.

Ensuring Duty of Care and pre-acceptance audits are carried out.

Liaison with external enforcing authorities.

Registering the hospital site with the appropriate authorities.

Liaison with Trust Managers.

Monitoring of external waste provider contracts.

Obtaining expert technical advice on the application and interpretation of waste management
guidance, including Safe Management of Healthcare Waste, Department of Health.

Providing a link to the relevant Trust Committees.

Ensuring an appropriate level of management is always available to all employees of the
hospital premises.
Local Management
Matrons, Heads of Service and PHT and CSL Departmental Managers are responsible for:
Monitoring waste management within their respective workplaces and ensuring that
contraventions of waste segregation and disposal do not take place.

Ensuring that this document and relevant waste management procedures are brought to the
attention of staff through local induction and ongoing staff briefings.

Ensuring that all new and temporary staff, on their first day in the Ward/Department, are given
basic familiarisation training within their workplace with regards to all relevant waste
segregation and disposal procedures.
All Staff, Contract Staff and Volunteers
All staff, contractors and volunteers shall;

Comply with the Portsmouth Hospitals NHS Trust waste management protocols and
procedures.

Participate in waste management training and awareness.

Report waste management incidents, and breaches in accordance with Trust procedures.
Waste Handling Policy – version 4
Issue Date: 12 January 2015
Review date 01 December 2017 (unless requirements change)

Ensure the promotion of waste management at all times to help reduce the volume of waste
produced and the associated carbon impact
Contact details
Contact Officer
Carillion Environment Manager
PHT Waste Representative
Pharmacy Manager
Occupational Health
Accident & Emergency
Radiation Protection Advisor
Carillion Helpdesk
Extension number
3466
023 9228 6603
6105
023 9228 3641
6380 & 6062
3299 or aircall via Switchboard
6321
6. PROCESS
In England and Wales it is a legal requirement of the Hazardous Waste Regulations to
segregate infectious waste (that is subject to special requirements in order to prevent infection)
from other wastes. It is also a requirement not to mix other types of waste for disposal, for
example, domestic waste and clinical waste.
The disposal processes for each of the following types of waste (as described in the Safe
Management of Healthcare Waste Version 2) are clearly defined in the operational procedures
document - Waste Disposal Procedures:








Infectious healthcare waste for incineration (anatomical)
Infectious healthcare waste for incineration (clinical waste)
Infectious healthcare sharps – incinerate (sharps / medicine)
Infectious healthcare waste for alternative treatment (clinical waste)
Hazardous healthcare medicine for incineration (cytotoxic / cytostatic)
Non hazardous healthcare medicines for incineration
Infectious healthcare waste contaminated with chemicals
Non infectious healthcare waste (offensive waste)
The processes for disposal of the following specific types of waste are also included in the
‘Waste Disposal Procedures’ document:
 Highly Contaminated / Infectious waste –hazardous - category 4 pathogens.
 Toxic/chemical waste
 Radioactive waste
 Gypsum waste
 Aborted Foetuses - product of termination; product of miscarriage
 Domestic waste
 Confidential waste
 Recycling
 Other wastes (bulky, glass, aerosol, batteries, etc.)
 Waste Electrical and Electronic Equipment (WEEE)
 Waste from outside Queen Alexandra Hospital
Detailed in the ‘Waste Disposal Procedures’ document are the following requirements for the
safe disposal of waste:
 Container labeling and handling
 Storage of waste
Waste Handling Policy – version 4
Issue Date: 12 January 2015
Review date 01 December 2017 (unless requirements change)





Spillages
Consignment
Contingency planning
Registering
Monitoring
Incidents
Incidents such as spillage, damage to containers, inappropriate segregation or any incident
involving sharps should be reported to Occupational Health Dept and the CSL Environment
Manager/PHT Waste Representative. Investigation will be undertaken to establish the cause of
the incident and the remedial action to be taken. All accidents and injuries must be reported to
the Occupational Health Department, who will initiate the appropriate action.
7. TRAINING REQUIREMENTS
Staff shall be made aware of appropriate processes for the segregation, storage, handling and
transportation of waste.
Staff who are required to handle and move clinical waste shall be trained in procedures for
dealing with spillages or other incidents for their area or work.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
In addition to the Safe Management of Healthcare Waste version:2.0:England, Department of
Health, setting out best practice for the segregation, handling and disposal of waste, this policy
should be read in conjunction with the Trusts operational procedures of waste management as
described in the ‘Waste Disposal Procedures’ which can be found on the Trust intranet.
https://www.gov.uk/government/publications/guidance-on-the-safe-management-of-healthcarewaste
9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
Waste Handling Policy – version 4
Issue Date: 12 January 2015
Review date 01 December 2017 (unless requirements change)
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
This document will be monitored to ensure it is effective and to assurance compliance.
Minimum requirement
to be monitored
Waste Segregation within
QAH
Waste Segregation PreAcceptance Audit
Environment Agency Audit
Lead
Tool
PHT Waste
Representative
CSL Waste
Manager
Workplace
Audits
External Waste
Consultant
PHT Waste
Representative
CSL Waste
Manager
Structured
Workplace Audit
Environment Agency Structured
Representative(s)
Workplace Audit
PHT Waste
Representative
CSL Waste
Manager
.
Waste Handling Policy – version 4
Issue Date: 12 January 2015
Review date 01 December 2017 (unless requirements change)
Frequency of
Report of
Compliance
Quarterly
Annually
Upon Request of EA
Reporting arrangements
Policy audit report to:

Client Contractor Group

Patient Partnership
Environment Group
Policy audit report to:

Client Contractor forum

Patient Partnership
Environment Group
Policy audit report to:

Client Contractor forum
 Patient Partnership
Environment Group
Lead(s) for acting on
Recommendations
CSC Leads, Heads of Nursing
and Modern Matrons
PHT Waste Representative
CSL Waste Manager
CSC Leads, Heads of Nursing
and Modern Matrons
PHT Waste Representative
CSL Waste Manager
CSC Leads, Heads of Nursing
and Modern Matrons