A) B) C) D) A) B) C)

BARNSLEY HOSPITAL NHS FOUNDATION TRUST
POLICY/PROCEDURE CONTROL SHEET
Policy/Procedure Title: Draft updated waste management policy

Sponsoring Director: J Petty
Implementation Lead: G C Steedman
Impact: a) To patients
b) To staff
c) Financial
d) Other
Additional Costs: a) Training: Budget: Lead: R/NR
b) Implementation: Budget: Lead: R/NR
c) Capital: Budget: Lead: R/NR
d) Other Budget: Lead: R/NR

Training Implications:
Date of Consultation: Trust Board:
Management Executive:
Governance Committee:
Joint forum:
Infection Control Committee:
Health & Safety Committee:
Alignment: HR:
Strategic Direction:
Board Assurance:
Clinical Governance:
Date of Final Version:
Implementation Date:
Date of Last Review:
Date of Next Review:
Circulation Date:
Circulated Staff:
Yes No
Directors:
Clinical Directors:
Medical Staff
Committee/SMSF:
Patient Service Managers:
General Managers:
H & S Committee Members:
Heads of Department:
Waste Policy page 1 of

38Waste Management Policy Page 1 of 38
Policy Title
WASTE POLICY
and ID number
Sponsoring Director: Chief Operating Officer

Implementation Lead: Head of Estates and Facilities
(a) To patients
Safe collection and disposal of waste, enhanced
environment
(b) To Staff Guidance to ensure compliance with legislation
Impact: Possible reduction in the cost of disposal, by good
(c) Financial
segregation
(d) Other
Revenue
Budget Code
or Non Revenue
(a) Training: £
Additional Costs:
(b) Implementation: £
(c) Capital: £
(d) Other £
To be incorporated into induction: Other: Delivered via mandatory training
Training implications: Yes
Board of Directors
Senior Management Team
Clinical Directors
General Managers/Heads of Department
Board Committee
Date of consultation at:
JNCC:
LNC
Infection Control Committee:
Health & Safety Committee 12th September 2007
Other (state name/s):
HR:
Strategic Direction:
Alignment
Board Assurance:
Clinical Governance: 3rd October 2007
Issue
Date of Final Draft:
Number:
Date of Final Approval: Approved by:
Implementation Date:
Date of last review: Date of next review: 24th October 2011
Circulation Date:
Circulation: Yes Comment
Directors √
Non Executive Directors
Clinical Directors √
Medical Staff Committee/SMSF

Patient Service Managers √
General Managers √
Heads of Department √
H&S Committee Members √
Policy database/warehouse
Others (to be listed): √
Modern matrons and ICT team
WASTE POLICY
April 2010
SPONSORING DIRECTOR: Chief Operating Officer

CONTENTS
1.0 Responsibility and Accountability
1.1 Chief Executive’s Responsibility and Delegation

1.2 Infection Control Management Team
responsibilitiesManagement responsibilities
1.3 Waste Officer/DGSA responsibilitiesStaff
responsibilities
1.4 Management responsibilities
1.5 Staff responsibilities
2.0 Compliance with Statutory Requirements and other Guidance
2.1 Legislation
2.2 Statutory Records
2.3 Dangerous Goods Safety Adviser
3.0 Categories of Waste
3.1 Hazardous and Non-hazardous waste

3.2 Infected/used Medical Devices
3.3 Offensive/hygiene waste
3.4 Domestic waste
3.5 Food waste
3.6 Confidential waste
3.7 Low level radioactive waste
3.8 Construction waste
3.9 Waste Electrical and Electronic Equipment
4.0 4.0 Impact Assessment (Equality and Diversity)
5.0 Assessment of Waste

Assessment of waste

65.0 Segregation of Waste
76.0 Personal protection and hygiene
87.0 Sharps injuries
98.0 Emergencies
109.0 Storage of waste
110.0 Disposal of Waste
121.0 Waste Audits
132.0 Staff Training
13.0 Record keeping
15.0 Policy monitoring and Review

14.0 policy monitoring and review
Appendix 1: Summary Table for the disposal of waste

LIST OF ABBREVIATIONS
Waste Management guidance 2 WM2
Health Technical Memorandum 07-01 HTM 07-01
Dangerous Goods Safety Advisor DGSA
Environmental Protection Act EPA
Definitions
Anatomical waste –
Any Waste containing body parts or recognisable body parts including samples
taken for laboratory analysis
Cytotoxic/Cytostatic waste –
Any medicinal product that possesses one or more of the hazardous properties
-Toxic, Carcinogenic, Toxic for Reproduction, Mutagenic. This may include drugs
from a number of medicinal classes, for example Antineoplastic agents, antivirals,
immunosuppressant’s, a range of hormonal drugs and others.

Draft
Waste Management Policy
February 2007
Date of Implementation
Date due for revision
Two years after above date
Policy Statement of Intent
The Trust aims to ensure that the waste management processes of the Trust
enhance the care provided to patients and provide a pleasant environment do not
pose a risk to for patients, visitors, staff, refuse collectors or any other person. The
Trust is committed to waste minimisation and recycling wherever practicable.
This policy identifies the wide range of waste produced in the hospital setting. This
waste will be segregated, sorted, handled, transported and disposed of as safely
and efficiently as possible and in accordance with HTM 07-01 “Safe management of
healthcare waste”. Directorates and departments must ensure that their local
policies conform to this waste management policy.
The principles of this Waste Management Policy apply to all Trust premises
and sites.
Introduction
This policy has been produced to enable the Trust to positively promote and
safeguard the management of waste and to develop a Pro - environmental aware
Culture within the organisation.

It is the Trust’s aim to create a safe and environmentally sound working
environment for everyone. This includes employees, contractors, visitors and
patients.
Related Trust policies/procedures:

Health and Safety Policy
Control of Substances Hazardous to Health Policy
Control of Infection Policy/Needlestick Injuries Policy
Occupational Health Policy/Personnel Policies and Procedures
Approved by
Date of approval
Originator
Name and signature of accountable Executive Director of Trust

CONTENTS
1.1 Chief Executive’s Responsibility and Delegation

2.0 Compliance with Statutory Requirements and other Guidance
2.1 Legislation
2.3 Dangerous Goods Safety Adviser
3.1 Hazardous and Non-hazardous waste

3.2 Infected/used Medical Devices
3.4 Domestic waste
3.5 Food waste
4.0 Assessment of waste
7.0 Sharps injuries
8.0 Emergencies

9.0 Storage of waste
10.0 Disposal of Waste
11.0 Waste Audits
12.0 Staff Training
13.0 Record keeping
16.0 Policy monitoring and Review
Appendix 1: Summary Table for the disposal of waste

1.1 1.1 Chief Executive’s Responsibility and Delegation
Whilst the Chief Executive accepts overall responsibility for the

management of waste generated on Trust premises, responsibility will
be delegated via the Chief Operating Officer Director of Estates and
Facilities to a designated waste control officer.
1.2 Infection Control Management Team
The Infection Control team will provide support, advice and guidance to
managers on all matters relating to infection controls, segregation and
the definition of appropriate waste categories, to assist them in making
the final decision on whether waste is Infectious or not.
`
1.3 Waste officer /DGSA
The Trust Waste officer/DGSA will provide advise, support and

guidance on all matters relating to the segregation, collection,
transportation and final disposal of all waste arisings Contracts
manager/Waste officer/Dangerous Goods Safety Advisor (DGSA).
2896
Management responsibilities
All managers will be responsible for ensuring that their work areas
comply with the requirements of this policy and that their staff are
appropriately trained and receive sufficient information to be able to
handle and dispose of waste correctly. This training can be accessed

via the Trust mandatory training programme. Where necessary,
managers will carry out risk assessments in order to identify any
necessary precautions/control measures that may need to be
implemented.
All staff, volunteers and contractors will comply with the requirements
of this policy and report any hazards and incidents immediately to their
manager/supervisor.
2.0 Compliance with Statutory Requirements and Other Guidance
2.1 Legislation
Waste Management will be organised in accordance with the prevailing

legal framework, EC directives and other recognised guidelines
including the following:
 The Health and Safety at Work Act 1974

 The Control of Substances Hazardous to Health Regulations
2002
 The Management of Health and Safety at Work Regulations
1999
 The Carriage of Dangerous Goods and Use of Transportable
Pressure Equipment Regulations 2004
 The Waste Electrical and Electronic Equipment Regulations
2007
 The Hazardous Waste Regulations 2005
 The Medical Devices Regulations 2002
 The Pollution Prevention and Control Regulations 2000

 Environmental Protection Act 1990
 Controlled Waste (Registration of Carriers and Seizure of
Vehicles) Regulations 1991
 Environmental Protection (Duty of Care) Regulations 1991
 Controlled Waste Regulations 1992
Safe management of healthcare waste HTM07-01
2.1 Work practice will be designed to prevent unauthorised or

harmful action, prevent escape of waste, secure transfer of waste to an
authorised person and provide a written description of all transferred
waste. Developments where waste storage areas are to be included
will be designed and built to comply with the current legislation.
All regulatory paperwork associated with the movement of waste

(Waste arisings register) from the hospital sites will be maintained on
site by the appropriate manager, who has disposed of the waste, a
copy of this information should then be sent to the facilities manager,
to ensure complete compliance with legislation. This Register is held
within the Facilities department, and can be accessed by contacting the
Hotel Services An audit of disposal facilities used will be conducted
annually to ensure compliance with required operational and
environmental standards. (See Section 11) Each waste container will
be tagged, labelled or marked prior to removal from disposal points so
that the waste generation source can always be identified up to the
point of final disposal/destruction and an audit trail is complete.
2.2.1 CA central waste register will be kept within the Facilities department,
this register will contain the following documentation: -

 White and Blue copy consignment notes
 Quarterly E.A returns
 All Rejected load consignment notes
 All Monthly and quarterly waste audits
 Hazardous waste producers registration
 All Hazardous waste arisings
 Annual Transfer documentation
 All Licenses and permits????

2.3 Advice and support on all matters relating to the carriage of dangerous
materials can be obtained from the Trusts Contracts manager/Waste
officer/The Trust employs a Dangerous Goods Safety Advisoers
(DGSA). 2896 Mr G C Steedman, who will provide advice and
support on all matters relating to the carriage of dangerous materials.

3.1 Examples of waste produced by the health care sector include:
Hazardous waste e.g.
Infectious waste
Fluorescent tubes
Laboratory chemicals
Cleaning chemicals
Oils
Batteries
Waste electronics
Paints
Solvents
Cytotoxic and Cytostatic waste
Mercury
Non-hazardous waste e.g.
Domestic waste
Food waste
Offensive/hygiene waste
Prescription only Medicines not containing dangerous chemicals
or Cytotoxic or Cytostatic medicines
Packaging waste
Furniture
General Construction waste
Confidential waste
Clinical waste is historically described in the Controlled waste

Regulations as

a) 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 to be hazardous to any person coming into contact with it
and
b) any other waste arising from medical, nursing, dental,

pharmaceutical, veterinary 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.
Under the new Hazardous Waste Regulations 2005, clinical waste is

now referred to as Infectious Waste or Potentially Infectious waste
and defined as ‘substances containing viable micro-organisms or their
toxins which are known or reliably believed to cause disease in man or
other living organisms’.
The other form of clinical waste is Medicinal Waste which is classified

into two categories:
a. Cytotoxic and Cytostatic medicines

b. Medicines other than those classified as cytotoxicCytotoxic and
cytostaticCytostatic
Other hazardous wastes include Amalgam and Mercury.
It is important that a proper assessment of the hazardous properties of

each waste medicine is undertaken in accordance with WM2, reference
should be made to the pharmaceutical products material safety data
sheets.

Other non Cytotoxic and Cytostatic medicinal products may cause harm
and although not considered hazardous should still be segregated at
source sent for appropriate disposal, which will normally be incineration.
The segregation of non Cytotoxic or Cytostatic Medicinal waste requires

specialist knowledge and as such should be carried out by a qualified
pharmacist. All products returned to Pharmacy will in all likelihood
contain a mixture of all categories; such mixing is considered to be as a
result of preparation or use and therefore does not require to be
separated, especially if it is unsafe to do so. Great care must be taken
to ensure that such mixing does not create further hazards, e.g.
development of toxic fumes, explosive mixtures or flammable mixtures.
3.2 Infected/used medical devices
Where implanted medical devices have been in contact with infectious

bodily fluids and have been assessed to be infectious they should be
classified and treated as infectious waste.
Disinfected medical devices should be classified as non-infectious

waste.
Waste which is non-infectious and does not require specialist treatment

or disposal, but which may cause offence to those coming into contact
with it. Examples include, incontinence and other waste produced from
human hygiene, sanitary waste, nappies and items of equipment which
do not pose a risk of infection including gowns, plaster casts etc.
3.4 Domestic waste

This could be Non Hazardous Wwaste which may includes paper,
aerosols, non-contaminated glass, cardboard, outer packaging etc,
plastics and other similar materials.
.These materials will be pre treated prior to land fill or disposal, e.g
recovered, recycled or reused.
3.5 Waste food
Accumulated food waste generated from catering facilities, including

central dish-washing facilities. All waste foodstuff will be disposed of
via the ward kitchen disposal units or the main Kitchen waste disposal
unit.
Material, often patient or staff records, which that requires to be made

unintelligible prior to shredding prior to final disposal EgE.g. patienor
staff records, will be designated confidential shall be clearly identified
and disposed of via a separate waste stream agreed by the waste
control officer. The Departmental Manager or Head of Department who
generates the waste is responsible for the decision will decide whether
waste is confidential. As a guide if the information contains any details
that may identify a person then it is likely to be regarded as
confidential.
Electronic or magnetic data media, e.g floppy disk, CD ROMs, Hard

drives, USB memory sticks, etc will be collected separately to ensure
that all potential confidential or personal data is destroyed. The types
of electronic materials will be destroyed by shredding.
All confidential waste must be stored under secure facilities;

departments will These devices will be required to be stored by the
department producing the waste. AdviseAdvice can be obtained from
the Trusts Waste officer/Dangerous Goods Safety Advisor (DGSA).
2896
Material containing low levels of radioactivity usually generated from a

pharmacy department, radiotherapy unit or from certain clinical
procedures in a ward/clinic. Such waste may be disposed of under
specific supervision and controls via a designated drainage route or,
appropriately packaged, labelled and monitored, via incineration.
3.8 Construction waste
Construction waste must be assessed to ensure that all hazardous

materials have been separated where this is technically
feasible,feasible; if not possible to separate then the whole waste will
be deemed hazardous and must be disposed of accordingly. General
building debris will be normally non hazardous.
Construction Waste plans – These plans must be in place prior to the

contract award and be updated for each phase, these plans to include
the type of waste, the amount, how much was recycled, reused or
recovered, the waste carrier, and the final disposal site. Copies of
waste carriers license, transfer stations or final disposal sites must also
be held on file.
3.9 Procedure for the disposal of Waste Electrical and Electronic

Equipment (WEEE) EWC Code 160209/16
It is illegal for waste electrical goods to be disposed of by landfill. All

such waste must be recycled. The WEEE Regulations place a

requirement on all manufacturers of such equipment to provide for the
recycling. Generally all suppliers of such equipment now have
procedures in place to take back the old equipment – regardless of
where it was purchased originally – in exchange for the new. Where
this does not happen or where this is not practical then the Trusts will
remove the WEEE for storage and recycling. Any queries should be
referred to the Trusts Waste officer/Dangerous Goods Safety Advisor
(DGSA). 2896
3.10 Disposal of retained tissue/organs following Post Mortems
The Human Tissue Authority has now issued a code of practice on the
removal, storage and disposal of organs and tissue which includes
disposal of existing holdings prior to 1 st September 2006. [SOP-CP-
MORT-013 HTA Code of Practice 5 - The removal, storage and
disposal of human organs and tissue] – The trust has a protocol to
meet this requirement.
4.0 IMPACT ASSESSMENT

4.1 All relevant persons are required to comply with this policy and must
demonstrate sensitivity and competence in relation to diversity in race,
faith, age, gender, disability and sexual orientation. If you, or any other
groups, believe you are disadvantaged by this policy please contact the
person responsible as set out within the policy. The Trust will then
actively respond to the enquiry.
4.2 (1) Formal Impact Assessment: Date: November 2007
4.3 (2) Financial Implications Date: November 2007.

5.0 Assessment of waste
All healthcare waste must be clinically and specifically assessed by the producer, at
theAt the time of production for; medicinal properties, chemical properties and
infectious
propertiesProperties. In respect to chemical or COSHH related wastes the
Manufactures safety data sheet must be used. This assessment will assist in
determining the appropriate waste stream.
(i) Assessment and classification of Medicinal Waste:
 Does the waste contain cytotoxic or cytostatic material?

 Does the waste contain any other active medicinal material?
If YES, dispose of as Cytotoxic Waste and follow the Trust procedure or contact
Pharmacy for advice. A generic list of Cytotoxic and Cytostatic medicines can be
obtained from Pharmacy.
 Does the waste contain a Prescription Only Medicine (POM)

or material?

If YES, dispose of as potentially infected waste containing a Prescription only
Medicine (POM) or contact Pharmacy for advice.
(ii) Assessment and classification of Chemical Waste
 Does the waste contain any chemicals that are dangerous

substances?
 Does the waste contain any other chemicals?
If YES, contact the Waste Officer Manager for advice on

2896

(iii) Assessment and classification of Infectious Waste
 Does the waste arise from a patient that is know or

suspected to have a disease caused by a micro-organism or
its toxins?
 Will Might the waste cause infection to any person or other
living organism coming into contact with it?
 Is the waste a sharp or anatomical waste?
 Has the waste item been specifically assessed as infectious?
If YES, dispose of as Infectious Waste or contact Infection

Control management Team (2825) or the trusts waste officer
(2896) for advice
(iv) Assessment and classification of Offensive/Hygiene Waste
 Does the waste consist of non infectious material which may

cause offence to those coming into contact with it?
If YES dispose of as offensive waste
Segregation at source is essential to good waste management. The following

colour codes will be used for disposal purposes:
Waste which requires disposal by incineration
Waste which might be treated before disposal i.e. via ATP

Cytotoxic and Cytostatic waste requires disposal by incineration
Offensive/hygienic waste which can be disposed of via a deep

landfill site
Domestic waste disposed of via landfill site
Amalgam waste for recovery
The Trust will choose the most appropriate waste receptacle for the waste
generated in a particular area.
Confidential waste will be placed in the special opaque bags provided for this
waste stream. The confidential waste label must be completed and the
department keep the waste secure until collection. Bulk confidential waste will
be kept in a secure fully enclosed confidential waste container until collection.

Where a risk assessment identifies the need for personal protective

equipment this will be provided in accordance with the relevant legislation.
Any necessary information and training will also be provided to ensure its safe
use. Suitable Showering/changing washing and alternative hand hygiene
facilities will be provided in all areas where there is a need to handle and/or
store waste.
The Trust will offer immunisation to appropriate staff. (Advice can be sought
via the Occupational Health Department) (4939)
87.0 Sharps injuries
It is the responsibility of the individual to notify their manager/supervisor

immediately if they sustain a sharps injury. The individual must report to the
Occupational Health Department during working hours or to an Accident and
Emergency Department at any other time. The Contamination incident
procedure Needlestick Injuries Policy must be adhered to and an Incident
Reporting Form must be completed.
98.0 Emergencies
There may be occasions when an emergency situation occurs when handling

or storing waste for example, a spillage of a hazardous material. The COSHH
assessment process will help identify any potential risks and the manager of
the work area will ensure that appropriate procedures are put in place and
where necessary spill kits are provided with suitable information and training.
(See Appendix 1)

109.0 Storage of Waste
Each ward/department has a designated waste storage or disposal area and

waste must not be stored outside this area. Waste will be collected from
these areas at a frequency determined by local circumstances.
110.0 Disposal of Waste (See Appendix 1)
All infectious waste will be contained within sealed (Tie tag) ,and
labelledlabelled and Tie yellowtagged Yellowyellow clinical waste sacks are
and disposed of via incineration. These waste sacks will be stored and
transported to the incinerator plant in 770litre rigid plastic containers.
All Sharps will be disposed of within a suitable sharps container which is

appropriately labelled, tie tagged and stored separately to any clinical waste
sacks.
All Cytotoxic and Cytostatic waste will be disposed of in an appropriate sealed

container and transported separately back to Pharmacy.
All confidential waste shall be destroyed by shredding, paper will be shredded

and the recycled. Electronic media will be shredded then incinerated.
Any radioactive waste, electrical waste or waste for recovery will be collected
from the relevant work area and recycled or disposed of as required.
Chemical waste all chemical waste will be disposed of in accordance with the
data held in the Manufacturers safety data sheets. Each department will he

required to have a copy of the MSDS attached to the chemical waste to be
disposed off, no chemical waste will be collected without this. A special
Chemical waste store is used to store these wastes, but departments must
ensure these wastes are stored correctly and securely until collection by the
Portering department.
General equipment/furniture, etc. which is no longer required should be

disposed of in accordance with the Trusts Equipment Redundant equipment/
condemn/Disposal Policy. The equipment will be required to be
decontaminated and a decontamination certificate issued.
The trust will ensure that there are adequate contingency arrangements in
place for the collection, storage, transportation and disposal of all wastes, in
the event of an emergency that will delay the collection and disposal of waste.
112.0 Waste Audits
The Trust’s faciitiesFacilities department and the Dangerous Goods Safety

Adviser (see section 2.3) will carry out regular duty of care waste
management audits, as required under section 34 of the Environmental
Protection Act 1990. The results of these audits will help to provide assurance
of the effectiveness of any protective/control measures that are in place and
that the trust is compliant with the relevant legislation.
Each Head of department must also carry out a duty of care audit, e.g., IT
department disposal of IT equipment..
132.0 Staff Training
All staff will be trained in waste handling and segregation procedures in line

with this policy. All staff must attend the trusts mandatory training
programme, which is accessible through the trusts training department. This
training will ensure that all staff are to make them aware of the types of waste,
hazards, risks and the correct disposal procedures, including safe manual and
other handling techniques.
14.0 Record Keeping
The Trust will maintain the appropriate waste management records..
15.0 Policy Monitoring and Review
Monitoring arrangements
 This policy and its effectiveness will be monitored annually this will include -:
1. A comprehensive audit of staff training will be carried out annually; this

audit will include a random sample of training objectives and their
effective use in the day to day activities.
2. Quarterly reports of all waste and related incidents will be reviewed by

the Health and safety committee, which will include detailed trend
analysis, risk assessment and the effectiveness of any follow up action.
3. Patient and staff surveys, on the environment
4. Annual performance target review, e.g a reduction in Clinical waste,

household waste and an increase in recycled materials.
5. The Dangerous Goods Safety Advisor will produce an annual report, to

the trust board and this will be used to also monitor the effectiveness of

the policy, training and legislative requirements.
6. External verification of the effectiveness of the policy will be

undertaken.
 Where the above identifies deficiencies, there will be a requirement to

undertake a follow up audit and produce an updated risk assessment.
This policy will be reviewed in 2011 orbi-annually or more frequently, as required by

any significant changes in legislation or best practice guidance.
Legislation
Waste Management will be organised in accordance with the prevailing

legal framework, EC directives and other recognised guidelines
including the following:
 The Health and Safety at Work etc Act 1974

 The Control of Substances Hazardous to Health (amendment)
Regulations 20042
 The Management of Health and Safety at Work Regulations
1999
 The Carriage of Dangerous Goods and Use of Transportable
Pressure Equipment Regulations 20094
 The Waste Electrical and Electronic Equipment Regulations
2007
 The Hazardous waste Regulations 2005
 The Hazardous Waste (England and Wales) (Amendment)
Regulations 20095
 The Medical Devices Regulations 2002
 The Pollution Prevention and Control Regulations 2000

 Environmental Protection Act 1990
 Environmental Permitting (England and Wales) Regulations
2007
 Controlled Waste (Registration of Carriers and Seizure of
Vehicles) (amendment) Regulations 19981
 Environmental Protection (Duty of Care) (England)
(Amendment) Regulations 20031991
 Controlled Waste (Amendment ) Regulations 19932
 Safe management of healthcare waste HTM07-01
 The Health Care Act 2006 revised 2008
 Human Tissue Authority (HTA) Code of Practice 5 - The

removal, storage and disposal of human organs and tissue
 Protocol for disposal of retained tissue/organs (from Post

Mortems) – Standard Operating Procedure SOP-CP-D-1
(Cellular Pathology Department)

Appendix 1: SUMMARY TABLE – DISPOSAL OF WASTE
Type of Waste Appropriate Container Staff responsible for Method of Staff Action on Method of
Container available from sealing container sealing responsible for Spillage Disposal
transportation
All Infectious waste i.e. clinical Yellow Domestic Ward/Department Maximum ¾ full Portering Seal off area to Incineration
or 520kg Department prevent further
waste waste sack services staff
Fasten securely contamination.
Portering
with official
Department individually See Spillage
numbered Procedure
plastic tracer
ties.
DO NOT transfer
contents loose
from bag to bag
and handle by
neck ONLY.
All sharps including needles, Sharps box Materials Ward/Department Maximum ¾ full Portering Seal off area to Incineration
scalpel blades, giving sets etc management staff Lock/seal lid Department prevent further
Estates and contamination.
Supplies
Departments See Spillage
Procedure
Infected Sharps or Sharps

containing a Part Used
Prescription Only Medicine

transportation
Sharps box Materials Ward/Department Maximum ¾ full Portering Seal off area to Incineration
Potentially infected
management staff Lock/seal lid Department prevent further
Sharps that do not
contamination.
contain any Part used
POMS, e.g sharps used

See Spillage
for taking bloods etc
Procedure
High Temperature Orange Domestic Ward/Department Maximum ¾ full Portering Seal off area to Incineration
or 5kg prevent further
incinerationWard staffSeal off waste sack services staff Department
area to prevent further
with official
contamination.Yellow sharps individually See Spillage
box with Purple numbered
Procedure
lidPharmacyWard staffMaximum plastic tracer
ties.
¾ full
DO NOT transfer
contents loose
from bag to bag
and handle by
neck ONLY.
See Spillage Procedure

Lock/seal lid
Potentially infected waste which

transportation
may be pre treated rendered
safe then land-filled
Examples
 Soiled dressings
 Soiled swabs
 Soiled packaging
 Soiled disposable packs
 Autoclaved anatomical
waste
Autoclaved lab waste
Cytotoxic bag wasteCytotoxic Yellow bag Pharmacy Ward staff Maximum ¾ full Ward staff Seal off area to
or 5kg prevent further
sharps waste with Purple
strip
with official
individually See Spillage
numbered Procedure
plastic tracer
ties.
DO NOT transfer
contents loose
from bag to bag
and handle by
neck ONLY.

transportation
Offensive /hygiene waste Yellow & Domestic Ward/Departmental Maximum ¾ full Portering Deep Landfill

black sacks services staff or 520kg Department
 Nappies (Tiger Portering Fasten securely
 Disposable bags) Department with official
bedding individually
 Plaster casts numbered
 Sanitary plastic tracer
products ties.
 Liners

Type of Waste Appropriate Container Staff Method of sealing Staff responsible Action on Method
Container available responsible for for Spillage of
from sealing transportation Disposal
container
Domestic waste including paper and Clear plastic bag Domestics Ward Maximum ¾ full or Portering Replace Landfill
general waste from non-clinical areas, Department Dept/Domestics 520kg Department Rubbish site
flowers, etc. Fasten securely with into plastic
official individually bag or new
numbered plastic tracer bag if bag is
ties. split.
Securely
fasten.
Recycled waste - cardboard, outer N/A Portering All StaffN/A Break down until flat and Portering N/A Recycled
packaging DeptN/A place into Green 770 Department bailerCo
litre bin mpactor

Type of Waste Appropriate Container Staff Method of sealing Staff Action Method
Container available responsible responsible on of
from for sealing for Spillage Dispos
container transportati al
on
Recycled waste - Office paper White Environment Dept/Ward ¾ full contact Portering N/A Contrac
recycling bag Officer staff Environment officer to Department torRecy
collect cled
bailer
Confidential Waste including Brown Portering Ward/Depart Maximum ¾ full or 520 Estates Replace Contrac
material, often patient or staff records, confidential DomesicEsta mental staff kg. Department paper tor
which requires shredding prior to bagBrown tes Securely fasten. into bag Recycle
ultimate disposal. The Departmental bag Department or new d
Manager or Head of Department will bag if bailer
decide whether waste is confidential. split.
Securely
fasten.

Industrial Waste including Skip Suitable N/A N/A Portering N/A Contrac
 Waste from premises Contract and Estates t
where vehicles are Company Department Compa
maintained ny
 Laboratory waste which is
not clinical Policy
 Waste from workshops
 Construction and
demolition waste
 Waste oil or solvent not
classed as special waste
 Scrap metal
Example
of Trusts
Tie tag
system

NOTE: If bags are over-filled do not touch them but call the Helpdesk 2451 – The facilities department will arrange for the waste to be inspected
and where neccesarrynecessary the ward or originating department will be required to split the waste into separate containers .What action is
then taken?

A) B) C) D) A) B) C)

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BARNSLEY HOSPITAL NHS FOUNDATION TRUST

POLICY/PROCEDURE CONTROL SHEET

Policy/Procedure Title: Draft updated waste management policy

Additional Costs: a) Training: Budget: Lead: R/NR

b) Implementation: Budget: Lead: R/NR

c) Capital: Budget: Lead: R/NR

d) Other Budget: Lead: R/NR

Waste Policy page 1 of

Sponsoring Director: Chief Operating Officer

Waste Policy page 2 of

SPONSORING DIRECTOR: Chief Operating Officer

Waste Policy page 3 of

1.1 Chief Executive’s Responsibility and Delegation

2.0 Compliance with Statutory Requirements and other Guidance

3.0 Categories of Waste

3.1 Hazardous and Non-hazardous waste

4.0 4.0 Impact Assessment (Equality and Diversity)

5.0 Assessment of Waste

Waste Policy page 5 of

76.0 Personal protection and hygiene

87.0 Sharps injuries

109.0 Storage of waste

110.0 Disposal of Waste

121.0 Waste Audits

132.0 Staff Training

13.0 Record keeping

15.0 Policy monitoring and Review

Appendix 1: Summary Table for the disposal of waste

Waste Policy page 6 of

Waste Management guidance 2 WM2

Health Technical Memorandum 07-01 HTM 07-01

Dangerous Goods Safety Advisor DGSA

Environmental Protection Act EPA

Waste Policy page 7 of

Date due for revision

Two years after above date

Policy Statement of Intent

Waste Policy page 8 of

Related Trust policies/procedures:

Waste Policy page 9 of

1.1 Chief Executive’s Responsibility and Delegation

2.0 Compliance with Statutory Requirements and other Guidance

3.0 Categories of Waste

3.1 Hazardous and Non-hazardous waste

4.0 Assessment of waste

5.0 Segregation of Waste

6.0 Personal protection and hygiene

7.0 Sharps injuries

Waste Policy page 10 of

10.0 Disposal of Waste

11.0 Waste Audits

12.0 Staff Training

13.0 Record keeping

16.0 Policy monitoring and Review

Appendix 1: Summary Table for the disposal of waste

Waste Policy page 11 of

1.1 1.1 Chief Executive’s Responsibility and Delegation

Whilst the Chief Executive accepts overall responsibility for the

1.2 Infection Control Management Team