Policy Reference: 267 Personal Protective Equipment (PPE ...

Policy Reference: 267

Personal Protective Equipment (PPE) at Work Policy

Version: 3

Name and Designation of Policy Author(s)

Andre Haynes, Health and Safety Manager Jay Turner Gardner – Associate Director of IPC

Ratified By (Committee / Group)

Risk Management Committee

Date Ratified 30th May 2021

Date Published 7th June 2021

Review Date 7th June 2024

Target Audience All Wirral University Teaching Hospital NHS Staff

Other Associated Strategies, Policies, Procedures, etc

Trust Policy 118- Health and Safety Trust Policy 291 - Risk Management Policy Trust Policy 009 – Laser Safety in Diagnostics and Treatment Trust Policy 041a - Incident Reporting & Management Policy & Procedure Trust Policy 249- Control of Substances Hazardous to Health (COSHH) Policy Trust policy 181 – Standard precautions and isolation policy Trust Policy 008 – Standards of Dress, Uniform and Personal Appearance Policy Trust Policy 042 – Latex Allergy and Sensitisation Trust Policy 103 - Management of Inoculations Exposure to Bodily Fluid Trust Policy 296 - Managing Violent & Abusive Behaviour including Therapeutic Handling and Lone Working Trust Policy 253 – Noise At Work Trust Policy 266 – Radiation Safety Policy (Ionising Radiations) Trust Policy 252 – Working A Height Trust Policy 065 - Security Policy (inc wearing body cameras etc) Trust Policy 071- Safe Management of HealthCare Waste Trust Policy 347- Emergency Preparedness, Resilience & Response (EPRR) Trust Policy 190- Aseptic Policy Procedure Trust Policy 181- Standard Precautions and Isolation Trust Policy 182- Decontamination of Medical Devices Trust Policy 173 Clostridium difficile: prevention & management of infections Trust Policy 074 – Infection Prevention and Control Trust Policy 137- Methicillin-resistant staphylococcus aureus (mrsa) infection: control and prevention Trust Policy 191- Norovirus and Outbreak of Infection Policy Trust Policy 133 -Single room policy & procedure for isolating infected patients Trust Policy 230 -Tuberculosis – Prevention and Control of Infection in Wirral University Hospitals Trust Trust Policy 138 -Provision of cleaning services Trust wide risk assessments identifying PPE use Local Risk Assessments Identifying PPE Clinical Processes and National Guidance Relating To PPE

Key Points for Staff

A suitable risk assessment must be carried out initially to identify any risks from the task and to ensure adequate control measures have been taken prior to introducing PPE. The risk assessment must consider reducing risks by elimination, substitution, engineering controls, administrative controls and PPE as a last resort.

PPE should only be provided as a final control measure for a hazard when all other control measures have been explored - it is not a substitute for other risk prevention or reduction measures

PPE is needed when there are hazards present. Therefore if PPE is identified as a requirement in a risk assessment then it must be used.

PPE has the serious limitation that it does not eliminate the hazard at the source and may result in employees being exposed to the hazard if the equipment fails. Pre-use checks are vital every time it is donned.

PPE must be provided by the employer at no cost to the employee.

PPE must be suitable for the individual and may require fitting, training, and instruction. Only use PPE you are competent to use.

PPE must not interfere with the hazardous activity and must not introduce other hazards e.g. goggles/visors must not interfere with prescription glasses.

PPE must be stored safely, serviced, cleaned, inspected and maintained as per manufacturer’s instructions and staff must be aware of how to check for faults and how to report them

Staff using PPE must be provided with suitable and sufficient information, instruction and where necessary training on the safe use of any PPE required to be worn.

Staff must make full and proper use of any PPE required to be worn as identified by the risk assessment

Risk Assessment identifies a hazard in an environment or

work process.

Manager applies the first 4 stages in the Hierarchy of Controls to reduce the risk; 1. Elimination-physically remove the hazard 2. Substitution-swap to less hazardous 3. Engineering-isolate people from hazard 4. Admin Controls- provide training and information

If a risk still remains the manager applies 5. Introduce suitable PPE

Manager identifies if used already in the Trust for this activity. YES NO

Manager checks suitability of PPE considering nature of hazard, length of exposure and type of hazard. Ensure that;

products are CE marked

choose equipment that suits the user – consider the size, fit and weight of the PPE for the task (involve users)

If more than one item of PPE is worn at the same time, make sure they can be used together, eg wearing safety glasses may disturb the seal of a respirator, causing air leaks

Discuss with procurement and division prior to purchasing and

update risk assessment

Discuss with procurement, division then submit through the Trusts

Medical Products review process for approval of a “new” product. If

unapproved repeat earlier phases and discuss further with H&S team until suitable PPE is agreed by the

Trust.

Purchase, supply and train staff in correct use, storage, cleaning, maintenance, inspection and recognising/reporting defects

Manager to monitor use of PPE incl.

Check compliancy of staff use

Check competency

Check efficacy of PPE

Arrange Fit Testing for all RPE

Arrange refresher/induction training

Manage and monitor related incidents

Manage supply/demand

CONTENTS

Contents Page

1 Introduction .......................................................................................................................................... 1

2 Purpose and Scope ............................................................................................................................. 1

3 Risk Assessment ................................................................................................................................. 2

3.1 HIERARCHY OF HAZARD CONTROLS .................................................................................. 2

3.2 ADDITIONAL CONSIDERATIONS ........................................................................................... 3

4 Types of PPE ........................................................................................................................................ 3

4.1 Gloves ....................................................................................................................................... 3

4.2 Disposable Plastic Apron .......................................................................................................... 4

4.3 Fluid Repellent Gowns .............................................................................................................. 4

4.4 Facial Protection (Goggles and Visors) .................................................................................... 4

4.5 Surgical Masks and Respiratory Protective Equipment (RPE) ................................................. 5

4.6 Footwear ................................................................................................................................... 5

4.7 Headwear .................................................................................................................................. 5

5 Purchasing of PPE ............................................................................................................................... 5

6 Maintenance and Storage of PPE ....................................................................................................... 6

7 Decontamination of PPE ..................................................................................................................... 6

11 Duties and responsibilities ................................................................................................................. 8

11.1 Ward/Departmental Managers .................................................................................................. 9

11.2 Employees ................................................................................................................................ 9

11.3 Personal Protective Equipment (PPE) Oversight Group ........................................................ 10

11.4 Health & Safety Team ............................................................................................................. 10

11.5 Fit Testing Team (Lead) .......................................................................................................... 11

11.6 Infection Prevention and Control team (IPC) .......................................................................... 11

11.7 Occupational Health ................................................................................................................ 12

11.8 Procurement ............................................................................................................................ 12

11.9 Contractors or Third Parties .................................................................................................... 12

12 Diversity and Inclusion...................................................................................................................... 13

13 Additional resources- assessment forms, guidance documents etc. .......................................... 13

14 References .......................................................................................................................................... 13

Appendix A - Checklist for Inspecting PPE ................................................................................................. 15

Appendix B Examples of Different Types of RPE ....................................................................................... 16

Appendix C- Gloves Selection ...................................................................................................................... 17

Equality Analysis ............................................................................................................................................ 18

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Wirral University Teaching Hospital NHS Foundation Trust Page 1 of 21 Policy 267 PPE at Work Policy Date Published: 7

th June 2021 Review Date: 7

th June 2024

1 Introduction

Wirral University Teaching Hospital NHS Foundation Trust (the Trust) is committed to protecting the health, safety and welfare of its employees, so far as is reasonably practicable in accordance with the Health and Safety at Work Act 1974. The use of Personal Protective equipment (PPE) is regulated under Health and Safety legislation by the Personal Protective Equipment at Work Regulations 1992 (as amended). This document sets out the policy for the use of Personal Protective Equipment for Wirral University Teaching Hospital NHS Foundation Trust by which compliance with these regulations is to be achieved. PPE is equipment that will protect the user against health or safety risks at work. It can include items such as gloves, aprons, gowns, laboratory coats, eye protection, high-visibility clothing, safety footwear, safety helmets, and safety harnesses. It also includes respiratory protective equipment (RPE). Uniforms are not classed as personal protective equipment but rather as normal clothing and a means of corporate identity.

2 Purpose and Scope

As a result of the global COVID19 pandemic there has been a significant increase in the requirement for staff to wear PPE more frequently. This has resulted in increased demand of PPE in particular FFP3 and reusable RPE. IPC and the H&S Team with support from other key stakeholders have developed a range of processes to support staff and others to maintain safety during the COVID19 which are available on the IPC and H&S Sections of the Intranet which further support the contents of this policy. The purpose of this policy is to ensure that where residual risks remain after following the HSE hierarchy of control measures these risks are adequately controlled. Staff safety is a Trust priority therefore ensuring there are robust arrangements in place to identify and manage suitable PPE during work activities is of paramount importance. This policy also ensures that the Trust is compliant with its statutory obligations under the Health and Safety at Work (etc.) Act 1974, The Personal Protective Equipment Regulations 2002 and the Personal Protective Equipment at Work Regulations 1992 (as amended) give the main requirements. The PPE at Work Regulations do not apply where the following five sets of regulations require the provision and use of PPE against specific hazards. For example, gloves used to prevent dangerous chemicals penetrating the skin would be covered by the Control of Substances Hazardous to Health Regulations 2002 (as amended). The Regulations are:

The Control of Lead at Work Regulations 2002.

The Ionising Radiation Regulations 1999.

The Control of Asbestos Regulations 2012.

The Control of Substances Hazardous to Health Regulations 2002 (as amended).

The Control of Noise at Work Regulations 2005.



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In order to achieve both safety and compliance with existing legislation the Trust accepts that the implementation of an effective proactive approach to PPE is required. All staff must also comply with their duties under both the Health and Safety at Work Act and Personal Protective Equipment at Work Regulations 1992 as amended. This policy sets out the arrangements through which the Trust and employees will meet their obligations. This policy should be read in conjunction with Trust Policy 118 - Health and Safety Policy and other associated policies, clinical guidance documents and risk assessment guidance. Instruction from external bodies such as Public Health England (PHE), the Health and Safety Executive (HSE) and Environmental Health Officers (EHO) may also provide “best practice” and following this will be evidence of taking reasonably practicable measures and upholding the Trusts legislative duty.

3 Risk Assessment

PPE should only be provided as a final control measure when all other control measures have been explored - it is not a substitute for other risk prevention or reduction measures. A suitable risk assessment must be carried out initially to identify any risks from the task and to ensure adequate control measures have been taken prior to introducing PPE. There is a hierarchy of control measures that must be considered and PPE should always be regarded as the “last resort” to protect against risks to safety and health.

3.1 HIERARCHY OF HAZARD CONTROLS

1. Elimination, does the task need to be done, can the hazard be removed entirely. 2. Substitution, is there a safer alternative e.g. swapping to a safer cleaning chemical 3. Engineering Controls, i.e. local exhaust ventilation, positive pressure, barriers. 4. Administrative Controls e.g. labelling, reducing exposure time, training, vaccination etc. 5. Personal Protective Equipment e.g. gloves, aprons, respirators Having identified the need for PPE and what kind of PPE is required, a further assessment must be performed on the PPE itself considering the following:

Has the risk concerned been minimised by other control measures

That the type and specification of PPE is effective against the risk and is available

That the PPE itself does not constitute a risk e.g. does it fit correctly, use of non-latex gloves, ligature risks

Does the PPE interfere with the performance of the task e.g. bulky equipment interfering with movement, face masks obscuring the mouth when communicating

Is the PPE suitable for the person and the task, is it compatible with other PPE or essential equipment e.g. respirators allow safe use of visors or eyewear, can masks be face fit tested, does it have an adequate assigned protection value for example (APV)20.

Is the PPE suitable for the environment e.g. Thermal comfort, interaction with patients, waterproof, non-magnetic/ferrous in MRI areas

Is it recommended for the level of risk by specialist bodies eg Public Health England, HSE?



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3.2 ADDITIONAL CONSIDERATIONS

In order to ensure safety of staff and correct allocation of PPE/RPE there may be specific risks relating to an individual which need to be considered such as;

Medical conditions, long term health conditions or disabilities

Physical differences (eg. height, weight, facial profile)

Communication problems- hearing , sight, speech, smell may all be impeded by the use of some forms of PPE and may introduce further risk for users of all types

Role priority- in some instances it may be necessary to reallocate work duties requiring PPE use based on skill mix in the area, availability of PPE and individual risks. Where PPE is not issued/available/individual risks preclude its use the employee will be consulted and the division, manager and employee will review what reasonable adjustments can be made to ensure their safety and operational demands.

Religious/belief considerations- see Diversity and Inclusion

Persons in higher risk groups for the hazard- o New or expectant mother risk assessments (see New or Expectant Mothers

policy) o Black Asian and Minority Ethnic (BAME) group, risk determinants for BAME

employees have been noted in the 2020 Covid Pandemic and may become a factor when allocating risk scores to employees.

o Young Persons (17 and under) – legislation requires a young person’s risk assessment to identify potential higher levels of risk relating to physical and developmental maturity which may impact safe use, allocation of PPE or even exclusion from an area of work after appropriate HR involvement.

Gender identification- generally most PPE is gender neutral however if there are differences in PPE design which impacts upon their use by the individual based on gender identity or physical differences in body shape which introduces concerns or risks these should be addressed as part of the assessment process. See Diversity and Inclusion section of this policy.

The Health & Safety Team and the Infection Prevention and Control Team can provide specialist advice on the suitability of any new PPE that requires introducing within a department but are not responsible for identifying or purchasing said PPE. Latex free equipment is advised to protect the staff member and the patient from potentially harmful allergic reaction.

4 Types of PPE

4.1 Gloves

Gloves are an essential requisite of PPE and have two primary functions: I. protecting the operator II. protecting the patient Glove usage must be decided following a risk assessment of the planned task i.e. consideration of who is at risk (patient or staff); whether sterile or non-sterile gloves are required; the potential for exposure to blood and body fluids, secretions and excretions;



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the potential for contact with non-intact skin or mucous membranes during general care and invasive procedures. Gloves must be worn for invasive procedures, contact with sterile sites and broken skin or mucous membranes and all activities that have been assessed as carrying a risk of exposure to blood, body fluids, secretions or excretions, or sharp or contaminated instruments. Gloves must be changed between procedures on the same patient and between patients, and hands must be washed or decontaminated with an alcohol based hand rub before gloves are donned and when gloves have been removed. It is important for all healthcare staff to be made aware that sensitivities can also occur with gloves as there are many elements to the manufacturing process, e.g. chemical accelerators in nitrile gloves. Any sensitivity (e.g. redness, itching) should be reported to the Occupational Health Department. Any sensitivity noted on patients should be referred to medical team for review.

4.2 Disposable Plastic Apron

The purpose of wearing a disposable plastic apron is to protect either the patient who may be susceptible to infection, or the wearer from contamination as well as maintaining the uniform/clothes worn under the apron in a clean and dry state. They must be worn when there is a risk that clothing may be exposed to blood, body fluids, secretions or excretions, (with the exception of sweat). In addition aprons must be worn:

when coming into contact with used bed linen i.e. remaking beds, items contaminated with body fluids, and cleaning of nursing equipment

when undertaking activities using ANTT (Aseptic Non Touch Technique) principles Aprons must be removed promptly after use by gently breaking the plastic around the neck, allowing the top of the apron to drop down, breaking the ties around the waist and bringing the apron together the contaminated outside touching, and roll into a ball and then disposed of in accordance with the Trust waste policy, and hand hygiene performed immediately after removal and disposal of the PPE.

4.3 Fluid Repellent Gowns

Full body fluid repellent disposable gowns must be worn where there is a risk of extensive splashing of blood, body fluids, secretions or excretions with the exception of sweat onto the skin or clothing of staff, such as in high exuding/bleeding wounds, novel or emerging respiratory infections e.g. Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), and for aerosol generating procedures for patients with acute respiratory infections e.g. influenza.

4.4 Facial Protection (Goggles and Visors)

Protective eyewear and facial protection (goggles and visors) is to be used to control and minimise risk if the planned procedure is likely to cause splashing of blood, body fluids, secretions or excretions, or drugs (especially cytotoxic), fine particles from procedures that



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may cause aerosols, hazardous fluids or contaminated debris splashing into the eyes, mouth or face.

4.5 Surgical Masks and Respiratory Protective Equipment (RPE)

Respirators are designed to reduce the wearers exposure to airborne particles (prevent particles going from outside to in). Surgical masks prevent particles being expelled by the wearer into the environment (prevent particles going from inside to out). There are a variety of masks available and staff must ensure that they select the most appropriate mask for the level of protection required. Manufacturer’s instructions should be adhered to while donning face protection to ensure the most appropriate fit / protection. Specialist respirator masks such as FFP3 respirators which are used by staff when caring for patients with open pulmonary TB or whilst performing aerosolising procedures on patients with known or suspected respiratory infections i.e. COVID-19, influenza must always be fit tested before use to ensure the correct mask and model fit correctly and then ‘fit checked’ when donned. In accordance with the Health and Safety executive all staff should undergo a fit test with the Trust approved FFP3 respirators to ensure a good fit can be maintained. Please see Appendix B for further details

4.6 Footwear

When providing support/care, closed toed shoes must be worn to avoid contamination with blood and/or body fluids or potential injury from sharps. When designated footwear is assigned, i.e. theatre, local policies must be available for their use and care, including a clear cleaning schedule with responsibilities assigned. Specialist footwear may be required for some activities for example porters. Although the evidence is limited, the use of overshoes is not recommended by the Hospital Infection Society; they have not been shown to reduce floor colony counts and can lead to unnecessary hand contamination while putting on or removing.. Footwear worn must comply with the Trust Dress and Uniform Policy. Footwear for use in a dedicated area, e.g. theatres, must be removed when leaving that area and arrangements must be put in place to ensure footwear is appropriately cleaned.

4.7 Headwear

Headwear must be worn in theatre settings, clean rooms etc. They must be well fitting and completely cover the hair and they must be changed and disposed of between sessions or if they become contaminated with blood and/or body fluids. They must not be worn outside of the theatre complex.

5 Purchasing of PPE

Employees must not be charged for PPE which has been assessed as being required for their job. PPE should not be purchased without a risk assessment being performed on its requirement and suitability.



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PPE purchased by the Trust must conform to the British or European Standards relevant to the item(s) concerned. All such items should be ‘CE’ marked. Trust approved suppliers should be used where appropriate. Purchases must be in line with Trust Procurement processes. Staff are advised not purchase their own PPE for use for activities they are undertaking at work. New PPE cannot be introduced within the Trust without suitable and sufficient screening and assessment. Procurement will assist with the identification and review process. Health and Safety can advise with respect to compliance with the relevant legislation and its associated guidance notes. Where the PPE or RPE is used or required to manage an infection control risk then the Infection Prevention Control Team should be consulted for advice on the most effective use of PPE.

6 Maintenance and Storage of PPE

PPE provided to employees must be kept in good repair and appropriate storage facilities should be provided so the equipment is kept clean and cannot be damaged. Employees must check PPE before use in case it has become damaged/ contaminated and should request a replacement if it is not satisfactory. Damaged PPE must not be used (Checklist Appendix A) and must be reported via the online incident reporting form. Where the PPE is disposable or has a limited number of times it can be used, an adequate stock level must be maintained. Where PPE equipment requires a power supply this must be managed in line with Trust policy on Electrical Equipment and chargers or power adapters will be subject to PAT testing. If PPE needs to be maintained after use, suitable materials/tools must be provided. Damaged PPE should, if not repairable, be separated and removed from other stored PPE if it cannot be immediately disposed of. The risk assessment will identify the type and frequency of maintenance required for PPE including frequency of filter changes

7 Decontamination of PPE

If PPE needs to be decontaminated after use, suitable materials/tools must be provided. Where the decontamination process may result in exposure to risk the process must be risk assessed and staff given a safest standard operating procedure (SOP) to follow along with the necessary PPE and equipment It is important to note that all items must be adequately decontaminated between uses.



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The cleaning and decontamination of PPE may require the use of substances managed under the Control of Substances Hazardous to Health (COSHH) Trust Policy and reference to this and the chemical safety data sheet for the product must be made. Levels of decontamination include; cleaning, disinfection and sterilisation. The method of decontamination required will depend on the nature of the micro-organisms or other contaminant present, the infection risk associated with the PPE or procedure and whether or not the PPE is to be used sessionally or repeatedly on the same patient or on different patients. It is essential that the appropriate level of decontamination is selected and this will depend on:

The construction of the PPE/RPE and tolerance of materials used in the manufacture. For example electrical equipment, plastic, or grooves, lumens etc.

The current condition of the PPE/RPE with regards to maintenance, wear and tear.

The extent and nature of any contaminant present, especially heavy soiling, highly pathogenic micro-organisms or the presence of prion proteins.

How the PPE is to be used. For example, is the device to be used in an aerosol generating procedure, subjected to highly pathogenic organisms or used between different patients?

Please refer to Trust Policy; 181 Standard precautions and isolation, 182 Decontamination of Medical Devices or the IPC Team for further guidance on this important aspect of PPE/RPE use.

8 Training

Employees who are given PPE for their use must be provided with information, instruction and training so that they:

Understand the risk(s) associated with the task which requires PPE to be used;

Know why they need to use PPE and the protection offered by it

Where there are variations of the same PPE staff must know which type is suitable and or required for them.

Know that they must use the PPE provided and in the correct manner,

Know how to don and doff the PPE correctly.

Where applicable they must keep it in good order, properly stored after use, and report defects.

Where PPE is disposable they must know how to dispose of it correctly and into what waste stream the whole or part of the disposable PPE must go.

Know how to clean and decontaminate PPE as required by Infection Prevention and Control.

Know how to access replacement or additional PPE as required.

Employees should have made available to them, any manufacturer’s instructions detailing PPE use and care. This may include information as to the end of the guaranteed life of the product. All fit testers have been appropriately trained to undertake fit tests and this training is governed by a competency framework developed by the Trusts FIT Testing Lead.



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Training for the safe use of FFP3 and RPE is provided to all staff when they are fit tested by the respective fit testers. Instructions on how to don and dof FFP3’s and RPE safely is provided during these sessions with further information including videos on donning and doffing and posters available on the Trusts intranet. All staff requiring to wear PPE must undertake a local competency assessment to ensure correct techniques are used to don and doff to ensure the safety of the wearer and the patient.

9 Records

A copy of all risk assessments identifying the need for PPE should be retained in the Ward/Departmental Health and Safety File along with a corresponding risk assessment for each type of PPE. The risk assessments are working documents and do not evidence compliance on its own. Managers should record regular reviews of the risk assessment in relation to the use of the PPE. Reviews should be at least annually or immediately following any related incident, accident or should equipment, the work place or working process change in any way. The Trust uses risk assessments for determining the use, selection and allocation of certain types of PPE within the Trust and it is the responsibility of the manager to ensure that appropriate risk assessments to identify all hazards, risks and determining factors are performed before allocating, implementing, monitoring and supporting the use of PPE in their area. IPC and the H&S Team have carried out a range of risk assessments for the safe use of FFP3’s and RPE which are available on the intranet to support the risk assessment process locally. Staff records of all fit testing on FFP3’s and RPE they have passed OR failed on is recorded on the Trusts BI Portal.

10 Definitions

Personal Protective Equipment means all equipment (including clothing affording protection against the weather) which is intended to be worn or held by a person at work and which protects him/her against one or more risks to his/her health or safety and any addition or accessory designed to meet that objective. PPE= Personal Protective Equipment RPE=Respiratory Protective Equipment CE= CE marking is a certification mark that indicates conformity with health, safety, and environmental protection standards for products sold within the European Economic Area (EEA). BS=British Standards (BS) are the standards produced by the BSI Group which is incorporated under a royal charter (and which is formally designated as the national standards body (NSB) for the UK).

11 Duties and responsibilities

The Trust has overall responsibility for ensuring the health and safety of employees and other persons who may be affected by its operations.



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11.1 Ward/Departmental Managers

Responsible for;

Ensuring that appropriate risk assessments to identify all hazards, risks and determining factors are performed before allocating and supporting the use of PPE in their area.

Identifying the most suitable PPE for the type of work to be carried out

Purchasing the required PPE through procurement and ensuring it is compliant with relevant standards (i.e. British Standards and European equivalents)

Ensuring that sufficient stocks of all required PPE are readily available

Ensuring that all PPE is examined and inspected to ensure that it is in good working order before being issued to employees

Ensuring staff that are using PPE are adequately briefed/instructed and if necessary, trained in the use of PPE provided, to ensure their health and safety

Ensuring that adequate storage facilities are provided where possible so that PPE can be stored safety when not in use

Ensuring the necessary resources are available for the safe handling, transfer, donning/doffing and disposal of PPE.

Ensuring that safety signs are displayed to remind employees to wear PPE

Ensuring their employees make full and proper use of all the PPE provided for their safety.

Monitoring that PPE is effective for the purpose for which it is provided.

11.2 Employees

Employees are responsible for;

PPE must be worn and used in accordance with the instructions provided to them

Sessional PPE must not be used longer than directed or outside of the specified work area.

Contaminated PPE must be doffed in accordance with IPC and Trust guidance and disposed of in the correct manner and waste stream.

PPE should be returned to the appropriate storage unit (if applicable) after use, unless the employee takes their PPE home, for example footwear or clothing.

Reusable PPE must be visually examined before and after use.

Any loss or obvious defect must be immediately reported to their line manager

Employees must take reasonable care of any PPE provided to them and not carry out any maintenance unless informed, trained and authorised.

Employees must follow instruction on safe cleaning and sterilisation of PPE in accordance with the relevant risk assessment and SOP and as directed.

Employees required to wear fitted RPE are responsible for ensuring that they are fit tested on the RPE available prior to use.

Employees who have been fit tested but since this point may have lost or gained weight, had alterations in their facial shape/structure or believe their peruse fit test is not accurate must escalate and arrange re test.

Employees are responsible for informally peer checking colleagues PPE and highlighting issues when seen whether during donning, use or doffing

Incidents of PPE failure or exposure to risk because of failed or missing PPE must be reported as per Trust policy.

Employees must follow safety signs, signals or Trust instructions relating to PPE use



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Employees must ensure that their wearing of PPE conforms to the Standards of Dress Uniform and Personal Appearance Policy as far as is reasonably practicable but remember that safety comes before consideration of appearance. Please see Appendix B for Examples of Types of RPE.

11.3 Personal Protective Equipment (PPE) Oversight Group

The PPE Oversight group was set up during the Covid 19 Pandemic and is responsible for:

Ensuring that the Trust is acting in compliance with all relevant national

guidance, HSE rules and policy across all sites.

Ensuring that changes to national guidance are recognised and Trust guidance

and policy amended to reflect this as required.

Reviewing Trust operational policies around PPE and sign off any changes

required either due to a change in guidance or operational pressures.

Monitoring current stock of PPE, reusable gowns and scrubs across all Trust

sites identifying gaps or shortfalls where they are reported or occur.

Monitoring levels of demand for PPE and scrubs across all Trust sites, in line

with changing ward designations.

Monitoring effectiveness of distribution of PPE and scrubs across all Trust sites,

identifying gaps where they occur or are reported.

Monitoring effectiveness and availability of decontamination processes.

Seeking assurance that the procurement and distribution processes can meet

any anticipated increases in demand for PPE and scrubs.

Reviewing and signing off any Trust communications to staff regarding PPE.

Oversight of progress made with PPE Divisional Leads and the Fit testing teams

To direct, as required, Corporate or Operational teams to undertake any actions

as required to safely implement decisions taken by the group.

To review any emerging themes or trends around PPE reported via the Ulysses

System and ensure appropriate actions are being taken in response.

Reporting any ongoing risks and issues around PPE to the Silver Command and

to the Health and Safety Management Committee and ensuring risks are

appropriately recorded on the risk log. Where appropriate, the group will advise

the Silver Command of any potential impact on BAF risks.

Identify opportunities for learning and improvement and other relevant items as

identified.

The PPE oversight group will feed up through the Trusts Governance Structure in order to ensure that all levels of the structure are aware of relevant risks, concerns or issues relating to PPE.

11.4 Health & Safety Team

The H&S Team are responsible for:



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Assisting and advising management with respect to compliance with the relevant legislation and its associated guidance notes

Assisting departments with the development of risk assessments and SOPs relating to PPE.

Undertake specific duties in line with the Health & Safety Policy and in support of the legislation

Providing guidance on legislation and compliance

Liaising with the Health and Safety Executive (HSE)

Monitoring incidents relating to the use of PPE/RPE

Advising the Trust on risks identified through safety alerts, incidents or national guidance relating to the use of PPE / RPE

Actively participating in the PPE oversight group

Liaising with internal departments in relation to the safe use, supply and management of PPE/RPE e.g. Procurement, Infection Prevention and Control

11.5 Fit Testing Team (Lead)

The Fit Testing Team is responsible for;

Coordinating the face fit testing of Trust staff in relation to available RPE such as, FFP3s, half masks and FFP2s

Work in conjunction with the PPE group to manage and monitor the allocation of RPE hoods and half masks based on a risk assessed process.

Ensuring the accuracy of quantative testing using Porta-count fit test machines

Monitoring and recording the results of face fit testing on the Trusts Bi Portal system

Monitoring and reporting on the efficacy of face fit testing and issues arising from the process

Providing suitable instruction and training to staff on the donning and doffing of RPE being tested

Clearly informing staff on pass and fail results of face fit testing and giving clear instruction on what RPE should be used.

Giving clear instruction to staff about their allocated RPE in relation to storage, cleaning and decontamination

Identifying RPE concerns highlighted during the face fit testing process

Escalating concerns relating to the RPE face fit testing equipment, process or the issued RPE to the PPE Oversight Group.

Providing advice to managers and staff on RPE/face fit testing

11.6 Infection Prevention and Control team (IPC)

The IPC are responsible for:

Assisting and advising the Trust on the correct selection of PPE/RPE for the purposes of preventing and controlling the spread of infection within the Trust.

Supporting managers in the adoption of new PPE/RPE related IPC processes such as donning/doffing or identifying clinical circumstances when PPE/RPE may be needed

Monitoring the effectiveness of PPE/RPE in the management of IPC risks

Developing strategies, processes and guidance on the use of PPE/RPE relevant to IPC based on best practice and/or external instruction from Public Health England and other health bodies.



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Advising internal groups such as H&S, Fit Testing etc. on suitability of PPE sourced for the purpose of preventing infection and controlling disease transmission and any IPC issues identified.

Determining the level of decontamination required for PPE used in a clinical environment

11.7 Occupational Health

The Occupational Health Department are responsible for providing advice for staff who report they unable to wear specific PPE to due existing health concerns and to staff who become adversely affected by the wearing of PPE) eg dermatitis.

The Occupational Health Department will also advise managers on any reasonable adjustments and other control measures required if staff are unable to or are adversely affected by wearing PPE.

11.8 Procurement

The Procurement department are responsible for:

Ensuring that the supply of PPE/RPE is appropriately sourced, supplied and purchased in line with NHS procurement rules

Upon receiving instruction for new, specified PPE/RPE from a Trust Divisional Director Procurement will chose an appropriate procurement route to source the items in line with Trust Standing Financial Instructions (SFIs). The procurement route can be the utilisation of framework contracts (such as NHS Supply Chain), quotation exercise, local tender or OJEU tender.

Managing contracts and arrangements relating to the supply and delivery of PPE/RPE

Ensuring that key stakeholders / internal parties such as H&S, IPC, and the Fit Testing Lead with expertise relating to PPE are consulted as part of the procurement process.

Developing reports on the supply and demand issues surrounding PPE/RPE.

Liaising with NHS suppliers and national supply systems to ensure current and forecasted demand for PPE/RPE is communicated, addressed and met so far as is practicable.

Ensuring that WUTH’s financial transactions are carried out in accordance with law, government policy and best practice, in order to achieve probity, compliance and value for money.

11.9 Contractors or Third Parties

It is recognised that the Trust have many contractors who work on, enter, occupy or in other ways fall under the Trusts duty of care towards other persons (third parties). Where the use of suitable PPE is required to work in an area which requires PPE/RPE contractors will be notified clearly through local signage, instruction, induction or pre-visit communication of the necessary PPE. Contractors setting up IT services in an area of high risk for infection may be provided with the necessary PPE, carers accompanying a child in X- ray may be issued with lead lined aprons.



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Where contractors are required to use PPE as part of their role and have been contracted on that basis they will be expected to provide the PPE for their own role/activities e.g. builders will provide their own hard hats, scaffolders will provide their own arrest harness etc. Contractors and third parties must follow all Trust procedures whilst on site in relation the wearing of fluid replant surgical face masks and other control measures that are designed to reduce the risk of COVID 19 transmission.

12 Diversity and Inclusion

The Trust is committed to promoting diversity and inclusion in all areas of its activities. The Trust wants to ensure that everyone has equal access to its services and that there are equal opportunities in its employment practices. The Trust recognises the diversity of its employees and will take a sensitive approach when this affects the use and supply of PPE/RPE. Priority must be given to health and safety, security and infection prevention control requirements but only after individual representation has been made and listened to.

13 Additional resources- assessment forms, guidance documents etc.

The changing nature of Trust work processes, available PPE and professional recommendations for use of PPE/RPE is such that this policy cannot and should not stipulate specific advice for types of PPE available, specific decontamination processes and other professional guidance such as donning/doffing, PHE arrangements etc. For up to date advice, instruction and guidance please refer to;

Infection Prevention Control WUTH intranet

Current Pandemic arrangements WUTH intranet

Health & Safety Team WUTH Intranet

HR section of the intranet

Procurement Department

HSE website

Public Health England(PHE)

PPE manufacturers websites

14 References

1. The Health and Safety at Work etc. Act 1974 2. The Management of Health & Safety At Work Regulations 3. The Personal Protective Equipment at Work Regulations 1992 (as amended) 4. The Control of Substances Hazardous to Health Regulations 2002 (as amended). 5. The Ionising Radiations Regulations 2017. 6. The Control of Asbestos Regulations 2012. 7. The Control of Noise at Work Regulations 2005. 8. The Control of Lead at Work Regulations 2002. 9. Personal Protective Equipment at Work (Second edition). Personal Protective

Equipment at Work Regulations 1992 (as amended). Guidance on Regulations L25 (Second edition) HSE Books 2005 ISBN 978 0 7176 6139 8

10. Personal Protective Equipment (PPE) At Work, A brief guide Leaflet INDG 174: HSE books 2013



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11. Hazardous substances at work: A brief guide to COSHH Leaflet INDG136(rev5) HSE Books 2012

12. Noise at work: A brief guide to controlling the risks Leaflet INDG362(rev2) HSE Books 2012

13. Respiratory protective equipment at work: A practical guide HSG53 (Third edition) HSE Books 2005 ISBN 978 0 7176 2904 6



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Appendix A - Checklist for Inspecting PPE

Checklist for Inspecting PPE Protective clothing/equipment should only be used for the purpose intended. It should be properly maintained in a good condition and checked regularly for any defects prior to use. Uniform is not classed as PPE. Users should ensure:

It is in a good condition If mechanical, it is functioning correctly It is inspected for signs of damage, deterioration or distortion It is intact and is not showing signs of tears, holes, cuts or fraying Stitching checked for loose, worn or cut seams It is does not cause irritation to the user It is comfortable and fits appropriately Mask must not be worn on head when outside of the work area as this could

contaminate the mask. Where specialised fit testing is required the user carries out pre-use fit checks as

described by training. It does not hinder the work being carried out. It is cleaned thoroughly and disinfected where necessary It is discarded if it is worn, contaminated, deteriorated or has exceeded

manufacturers recommended guidelines for usage or storage. Ensure that all PPE is appropriately stored when not in use and it is kept free from contamination, loss or damage.



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Appendix B Examples of Different Types of RPE

*During the COVID 19 Pandemic it will be necessary to wear a mask for sessional use which will exceed an hour of use. To prevent dermatitis and other skin conditions developing please ensure you keep well hydrated and use barrier creams. For further information on skin care please see link - https://www.wuth.nhs.uk/media/14408/c0129_preventing-skin-damage-under-ppe_9-april.pdf



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Appendix C- Gloves Selection



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Equality Analysis

The Equality Analysis (EA) form should be completed in the following circumstances:

All new policies All policies subject to renewal Business cases submitted for approval to hospital management impacting on service

users or staff Papers submitted to hospital management detailing service redesign/reviews

impacting on service users or staff Papers submitted to Board of Directors for approval that have any impact on service

users or staff

Title Personal Protective Equipment (PPE) at Work Policy

Policy Reference 267

Lead Assessor Andre Haynes

Date Completed 11.12.2020

What groups have you consulted with? Include details of involvement in the EA process

Staff in area concerned Staff side colleagues

Service users HR

Other Other

Please Give Details IPC team, Procurement, Fit Testing Team

What is being assessed? Please provide a brief description and overview of the aims and objectives

Accuracy of responsibilities and processes has been checked

Who will be affected (Staff, patients, wider community?)

All persons affected by the Trust activities who may be required to wear PPE or who may be protected by person wearing the correct PPE

Please note the results of this Equality Analysis will be published on the Trust website in accordance with the Equality Act 2010 duties for public sector organisations Section 1 should be completed to analyse whether any aspect of your proposal/document has any impact (positive, negative or neutral) on groups from any of the protected characteristics listed overleaf. When considering any potential impact you should use available data to inform your analysis such as PALS/Complaints data, Patient or Staff satisfaction surveys, local consultations or direct engagement activity. You should also consult available published research to support your analysis. For further support with this, please refer to the Library and Knowledge Service accessible via the Trust’s intranet site or switchboard.



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Section 1 – Initial analysis

What is the impact on the equality groups below?

Positive:

Advance equality of opportunity

Foster good relations between different groups

Address explicit needs of equality target groups

Negative:

Unlawful discrimination, harassment and victimisation

Failure to address explicit needs of equality target groups

Neutral:

It is quite acceptable for the assessment to come out as Neutral impact

Be sure you can justify this decision with clear reasons and evidence if you are challenged

Equality Group

Any potential impact?

Positive, negative or neutral

Comments / Evidence (For any positive or negative impact please

provide a short commentary on how you have reached this conclusion)

Disability (inc physical and mental impairments)

Positive Policy specifically instructs the Trust to consider type and use of PPE in light of any disability or long term health condition to ensure the same level of protection and support equality in the workplace.

Age

Positive Young Persons and the levels of risk determinants present in those aged 17 or under are covered by this policy as a legal requirement.

Race (all ethnic groups)

Positive The policy actively instructs managers to assess the risk presented to persons who may have ethnicity based risk determinants.

Religion or belief

Positive The policy recognises the impact that religion or belief may have upon the wearing of PPE and instructs managers to review and discuss this with persons who may be impacted by this.

Sexual Orientation

Neutral No additional considerations required

Pregnancy & Maternity

Positive Reference to risk assessing for New and Expectant Mothers as required by law

Gender

Positive Reference to considering any risk determinants raised by persons relating to gender and identification.

Gender Re-assignment

Positive Reference to considering any risk determinants raised by persons relating to gender and identification.

Human Rights

Positive Policy supports the right to life, health and safety

Other e.g. Carers

Positive Risks and use of PPE relating to third persons is addressed in the policy.

If you have identified any negative impact you should consider whether you can make any changes immediately to minimise any risk. This should be clearly documented on your paper cover



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sheet/policy document detailing what the negative impact is and what has changes have been made. If you have identified any negative impact that has a high risk of adversely affecting any groups defined as having a protected characteristic then please continue to section 2. In all cases - you should submit this document with your paper and / or policy in accordance with the governance structure with copies to [email protected] for monitoring purposes.

Section 2 – Full analysis If you have identified that there are potentially detrimental effects on certain protected groups, you need to consult with staff, representative bodies, local interest groups and customers that belong to these groups to analyse the effect of this impact and how it can be negated or minimised. There may also be published information available which will help with your analysis.

Who and how have you engaged to gather evidence to complete your full analysis? (List)

Name & Job Title Name & Job Title

What are the main outcomes of your engagement activity?

What is your overall analysis based on your engagement activity?

Section 3 – Action Plan You should detail any actions arising from your full analysis in the following table; all actions should be added to the risk register for monitoring.

Action required Lead name Target date for completion

How will you measure outcomes

Following completion of the full analysis you should submit this document with your paper and or policy in accordance with the governance structure.

mailto:[email protected]



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You should also send a copy of this document to [email protected] for monitoring purposes.

Consultation, Communication and Implementation

Consultation Required Authorised By Date Authorised Comments

Equality Analysis Andre Haynes 11/12/2020 Full assessment not required

Policy Author Checklist Andre Haynes 11/12/2020 Checked for workforce / development, medicines, finance or wider corporate implications.

Other Stakeholders / Groups Consulted as Part of Development

Health and Safety Partnership Team

Trust Staff Consultation via Intranet

15th December 2020 to 30

th December 2020

Date notice posted in the News Bulletin.

N/A Date notice posted on the intranet

7th June 2021

Describe the Implementation Plan for the Policy / Procedure (Considerations include; launch event, awareness sessions, communication / training via DMTs and other management structures, etc)

By Whom will this be Delivered?

New staff will be made aware of this policy at local induction. Existing staff will be informed through email notifications and it will be made available on the Intranet.

Ward/Department managers

Version History

Date Ver Author Name and Designation Summary of Main Changes

August 2014

1 Andre Haynes, Health and Safety Manager

New policy

September 2017

2 Andre Haynes, Health and Safety Manager

Minor changes to clarify process, additional examples of PPE, policy updated to reflect PPE regulations 2002

May 2021 3 Andre Haynes , Health & Safety Manager / Jay Turner Gardner Associate Director of IPC

Minor changes to further clarify process, additional appendixes included, included duties section for Occupational Health, included reference to COVID-19, Reference to IPC organism management policies, included a new section 4 within the policy describing PPE types Minor changes to clarify processes following RMC meeting and further review of the policy by IPC and H&S, additional appendix C added relating to gloves

mailto:[email protected]

Monitoring Compliance with the Policy

Describe Key Performance Indicators (KPIs) Target How will the KPI be Monitored? Which Committee will Monitor this KPI?

Frequency of Review

Lead

All departments will have relevant risk assessments in place relating to this policy

85% Health and Safety Management Audit

Health and Safety Management Committee

Annually Health and Safety Manager

Performance Management of the Policy

Who is Responsible for Producing Action Plans if KPIs are Not Met? Which Committee Will Monitor These Action Plans? Frequency of Review (To be agreed by Committee)

Health & Safety Manager Health & Safety Management Committee and the Divisional and Directorate H&S Committees

Annually

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