Infection control and PPE

Last updated 20 June 2022

Personal Protective Equipment changes from 16 May 2022

Changes to personal protective equipment in the Trust come into place from Monday 16th May 2022. Please note, masks must continue to be worn at all times in both community and inpatient environments, and lateral flow device testing should continue to be performed twice weekly before working face to face with colleagues or service users.

For a reminder on the PPE needed when working with service users please download and print this poster to display in your workplace: PPE-update-poster-13May2022

Changes to the use of eye protection in all service user facing settings (including community bases and visits in the homes)

The Infection Prevention and Control (IPC) team has reviewed the need for routine wearing of eye protection for staff who work with service users, and for both inpatient and community settings eye protection needs to be worn only in the following circumstances:

  • when providing care for a person who has tested positive for covid-19 (or other respiratory infection as advised by the IPC team), until their period of isolation is complete
  • when working in an outbreak area
  • when caring for a service user without infection, where a risk assessment identifies risk of blood/bodily fluid splash or exposure
  • when sharing a car with other staff or service users (unless you are the driver)

Remember, when caring for a service user who is isolating in both inpatient and community settings:

  • Try to maintain 2 m distancing when not delivering direct care
  • Ventilate the room by opening windows as much as possible
  • Keep the area clear and uncluttered to cleaning easier
  • Thoroughly clean any shared equipment e.g., ECG machine, between patient use and additionally after using in an area where a service user is isolating, and
  • Carefully doff all PPE on exiting an isolation room following the donning and doffing guidance. Clean hands and apply PPE appropriate to the setting.
Changes to mask wearing in some areas of the Trust from Monday 16th May 2022

In line with the national Living with Covid guidance, the Trust is making changes to how masks are used in areas of the Trust where there is no face-to-face contact with service users.

If you are working on a Trust site in an office or an area that patients cannot access, the new guidance below applies to you.

  • Undertake twice weekly later flow testing and ensure you have a negative result before coming onto site
  • Do not come to work on a Trust site if you feel unwell
  • You must wear a mask on entering, leaving, and moving about the workplace, but once you are seated this can be removed
  • You should be familiar with local procedures for the building such as ventilation, the number of staff allowed and the clean desk policy etc.
  • You should practice regular hand hygiene with soap and water or hand sanitiser. Hand sanitiser will remain available on site for you to use

If you wish to continue to use full PPE whilst at work, the Trust fully supports this and will ensure adequate stock is available. You can raise any concerns you may have about this change in guidance with your line manager and with the IPC team at

The impact of these changes will be monitored by the IPC team and may be reviewed as necessary e.g. in the event of escalation of the pandemic, increase in infection on Trust sites, or where there is evidence that the steps above are not being consistently followed. Please continue to consider the wellbeing of your colleagues at all times.

The above guidance is effective from Monday 16 May 2022. It supersedes some of the other guidance published on this page below.

Self-isolation for NHS staff (posted 1 April 2022)

Updated UKHSA guidance

The UK Health Security Agency (UKHSA) has announced an update on the self-isolation period and the implications for the NHS. The letter is now published and states that starting Monday 17 January, staff who have received a positive Covid-19 test result can end their isolation period after five full days following two negative lateral flow tests on days five and six. This must be followed by daily lateral flow testing up to and including day 10 after the positive test.

It is important that colleagues continue to contact the Infection Prevention Control Team to inform them of a positive test and to receive further advice on safe return to their place of work. Please also ensure that results of all lateral flow tests must be uploaded to our SmartSurvey or alternatively on the GOV.UK website.

The Trust will now operate under this national guidance which requires a minimum isolation period of five days following the day of test. We hope this will allow our colleagues to return to work sooner and in a safe and managed way.

Any member of staff who has been in contact with a positive case or has a household member who is positive does not need to isolate or complete a PCR test. They will just require their twice-weekly lateral flow tests unless they become symptomatic – at this point they should contact the IPC team.

We know that infection rates are high and we have a duty to protect our service users, fellow colleagues and loved ones so please:

  • remain vigilant and wear the correct personal protective equipment (PPE) at all times whilst at work
  • raise concerns with colleagues if observed not being compliant with PPE
  • test twice weekly using the lateral flow tests – visit our testing web page for details
  • turn off the Track and Trace app whilst at work
  • remember to keep yourself safe whilst away from work (you may want to continue wearing a mask on public transport and when using taxis)
  • remember the same infection prevention principles outside of work in relation to space and frequent handwashing
  • try to avoid crowded gatherings with little ventilation.
Frequently asked questions from our Infection Control Team - updated June 2022
What should I do if I feel unwell at home and think I might have COVID-19?

If you develop any of the symptoms of COVID-19, however mild, you must:

  • Stay at home, take a lateral flow test and follow the guidance as described on the GOV.UK website.
  • Inform your line manager
  • Contact the Infection Prevention and Control Team on 0113 855 5957 or email at who will begin a risk assessment

If you need medical advice you should use the NHS111 online service or call NHS111 and seek medical review. In an emergency call 999

What should I do if I feel unwell at work, and I think that I might have COVID-19?

If you develop symptoms of COVID-19 at work, you must:

  • Isolate yourself away from colleagues and/or patients, ensuring you are wearing the correct level of PPE for your area of work
  • Alert your line manager or the person in charge
  • Take a lateral flow test if you have one available. If this is not available you should go directly home to test.
  • Continue to wear a mask or face covering during your journey and maintain strict social distancing
  • If the test is positive, visit the GOV.UK website and inform the IPC Team.
  • If the test is negative, you may return to work if you are clinically well enough to do so and do not have a high temperature. Discuss this with your line manager and also the IPC Team if you need further advice.

If you need medical advice, you should use the NHS111 online service or call NHS111 and seek medical review. In an emergency call 999.

What should I do if I receive a positive lateral flow device test?
  • Do not come to work. Follow the guidance on the GOV.UK website.
  • Inform your line manager.
  • Record your result on our SmartSurvey or alternatively on the GOV.UK website.
  • Contact the Infection Prevention and Control Team on 0113 855 5957 or email who will begin a risk assessment.
  • Continue to follow guidance and the instructions from the Infection Prevention and Control Team.

Household contacts should follow the national stay at home guidance.

What should I do if I am told to self-isolate by a health professional or by the NHS Covid app?

You should immediately follow the instructions provided and contact the IPC Team to complete a risk assessment and receive further advice.

What should I do if a member of my household is self-isolating at home with COVID-19?

Any member of staff who has been in contact with a positive case or has a household member who is positive does not need to isolate or complete a PCR test. They will just require their twice-weekly lateral flow tests unless they become symptomatic – at this point they should contact the IPC Team.

How long do I need to isolate for?

Positive with or without symptoms: If you test positive on a lateral flow device (LFD) or PCR, you must isolate for at least five full days following the day of test (known as day 0). You may only return to work if you complete LFD tests on day 5 and 6 (the results to both are negative), and daily LFD tests up to and including day 10 remain negative. You must also have received a risk assessment completed by a member of the IPC Team to return to work.

When is day 1 of isolation?

The day of the test or the day of symptom onset (if this was before the test) is day zero.

I previously tested positive for COVID-19 and made a full recovery. However, I’m experiencing symptoms of COVID-19 again. What should I do?

You must isolate and complete a test. Due to the high levels of reinfection it is important that everyone follows the same guidance.

What should I do if I have been in close contact with a patient or colleague who has COVID-19 without wearing the recommended PPE, or if I have had a breach in my PPE whilst caring for the patient?

Talk to your line manager and seek advice from the Infection Prevention and Control Team. You can do this via

I’ve been working alongside a colleague who has tested positive for COVID-19.  What should I do?

The IPC Team is usually informed of positive staff cases and will complete a risk assessment to ensure we identify any other colleague who may be at risk.  If you are concerned that you are at risk and have not been contacted, please get in touch via

Guidance on the use of PPE

PPE guidance change

A minor change to PPE guidance comes into effect from Monday 21 February. Routine apron use has been discontinued. The wearing of aprons has been reviewed and risk assessed by our Infection Control Team, and we have also considered your feedback about impact on the environment.

It remains absolutely vital that you wear the correct PPE to stop the spread of Coronavirus – PPE compliance and good hand hygiene both make a difference.

All other PPE remains in place. This is in line with other local acute and mental health trusts.


As a reminder for all our clinical settings:

Wear all appropriate PPE, change PPE regularly and please remind each other

  • you should always wear a mask and eye protection (a visor or goggles)
  • you should wear an apron and gloves where you may come into contact with blood or body fluids or the service user e.g., when delivering personal care or if a service user has a confirmed or suspected infection. It is important to remember to remove gloves and apron after this direct contact and clean your hands before moving onto your next task.

As you know our Infection Prevention and Control team is working tirelessly with clinical teams across the Trust to manage infections and outbreaks.

They are better placed than any of us to link PPE adherence to successful infection containment and what they are seeing in a few areas is that PPE compliance is starting to wane, and links to outbreaks amongst staff and service users are then emerging.

We appreciate that our IPC team live and breathe this every day, and those working long shifts on wards and in other settings are juggling a lot of other responsibilities.

However, we all have a duty of care to our vulnerable service users. And, with around 20% of our entire workforce currently unavailable for work (through sickness and leave combined), it’s something we cannot afford to relax.

In non-clinical areas you should follow these seven steps:

  • Wear a mask at all times
  • Maintain 2 metre spacing
  • If someone stops to talk with you, politely ask them to maintain a 2-metre distance
  • You can briefly pass within 1 metre of a person when wearing a mask without needing to wear eye protection
  • If you are within 2 metres of someone for more than 1 minute, then both mask and eye protection are required
  • You do not need to wear a mask if in a room by yourself, but you must have a mask on if sharing the room. Be ready to put a mask on if someone enters.
  • When eating and drinking in a designated area – you must maintain 2-metre spacing between yourself and others

Download and display new posters in changing areas and ward / office doors:

PPE Compliance A4 Posters.230222 – 3 posters – PPE for inpatient and community and when to change PPE

PPE Compliance Ward Poster.220222 – please remind colleagues to wear correct PPE

Is PPE being worn safely in your area?

We all have a collective responsibility to inform, remind and reinforce the message.

So, we are asking for the following renewed efforts:

    – please wear all the appropriate PPE for your area in line with the updated     guidance
    – don and doff carefully, cleaning hands following doing so
    – remind others and welcome being reminded yourself
    – knowing if you are positive before a shift and not coming in could save us from an outbreak

If you notice that PPE is not being used correctly by an individual, we are encouraging you to politely discuss this with them in the first instance. In many cases it will be a simple mistake and they will be grateful for the reminder.

If this approach doesn’t work, or there are repeated breaches, please discuss this with your line manager and complete a Datix submission.

Other useful documents

More information

For any queries about infection control and PPE please contact the Trust’s IPC Team on 0113 855 5957 or email

How to put on and remove PPE (donning and doffing)

The following guides are from the Public Health England website:

Our changing facilities

Changing facilities at each inpatient site

Fit checking

We are asking staff to ensure they are familiar with how to fit check their mask, using the guidance given during fit testing. This should be carried out each time you put on a new FFP3 mask.

By training you to fit check, you will have the expertise to know when a mask is fitted properly.

If you need to arrange fit testing for you or your team, please contact the Infection Control and Prevention Team on 0113 855 5957.

The Health and Safety Executive have also provided a poster and a video to help you fit check face masks:

Here’s a video guide to conducting a qualitative fit test before using a respirator:


Ordering PPE and scrubs
Ordering PPE

Your PPE stocks should include:

  • Standard masks / FFP3 masks
  • Aprons / gowns
  • Standard gloves (medium/large)
  • Powder free gloves (small/medium/large)
  • Alcohol wipes
  • Yellow waste bags
  • Offensive waste bags

Please order replenishments directly via our Logistics Team at

For all other items, please continue to order these through your usual processes.

Additional personal protective equipment is also stored in the following locations:

  • 136 cupboard at the 136 Suite at the Becklin Centre
  • The Newsam Centre, Room 12
  • Clifton House
  • The Mount, Ward 2
Car sharing - infection control guidance

It’s vital you adhere to our infection control guidance and wear your PPE, including safety glasses.

This is important if you are sharing a car with another member of staff to travel to or from work or during visits to service users. If you are car-sharing please remember:

  • There can be maximum two people per car – one driver and one passenger
  • The driver must wear a mask, and the passenger must wear a mask and eye protection
  • The passenger should sit diagonally behind the driver to allow for maximum distancing and to minimise risk of infection
  • Touch points should be cleaned with a disinfectant wipe and hands should be sanitised before and after the journey.
Working across sites and split shifts
Infection prevention guidance when moving to different sites

Under usual circumstances, there is no additional risk working across sites providing every effort is made to reduce the risk of cross contamination in accordance with the Trust’s infection prevention policy.

Where there is an outbreak of respiratory infection, the wards will receive advice from the Infection Prevention and Control Team on how to reduce the risk of infection in relation to staff working across different sites. Please ask your manager or the shift coordinator if there is any special instruction to follow.

Split shifts
  • At the end of your first shift: Ensure you have doffed your PPE safely and cleaned your hands, including forearms up to the elbows. Put your uniform into a plastic bag and change into new uniform before starting your next shift.
  • At the end of your second shift: Put both uniforms into a plastic bag and change into your personal clothes before leaving.
  • Once you arrive home: Wash both uniforms at 60 degrees.
Public Health England advice and hand hygiene

It is important that hand hygiene guidance is followed at all times to help prevent the spread of infection.  Washing hands in soap and water or alcohol sanitising gel is recommended.

The advice from Public Health England is focused on how people can protect themselves and others from spreading the infection through good hygiene and social distancing measures.

Please display posters in your staff and public areas about good hand washing technique and social distancing advice – these can be found in the resources section.

Advice for everyone can be found at

  • wash your hands with soap and water often – do this for at least 20 seconds
  • always wash your hands when you get home or into work
  • use hand sanitiser gel if soap and water are not available
  • cover your mouth and nose with a tissue or your sleeve (not your hands) when you cough or sneeze
  • put used tissues in the bin immediately and wash your hands afterwards
  • avoid close contact with people who have symptoms of coronavirus
  • touch your eyes, nose or mouth if your hands are not clean
Policy on uniforms
A short clarifying statement for those working in ALL WARDS

Please arrive at work in your own clothes and change into your uniform in the sites where we have changing facilities. You must double bag your uniform when taking it home and wash it on a 60 degree wash as soon as you are home. Take a shower and wash your hands on arrival at home.

If you don’t have a uniform please follow the same principles as described above and ensure you wear clean laundered clothes each time you come to work. This will help to maintain effective infection prevention principles.

A printable leaflet for inpatients explaining the use of PPE is available: Inpatient Leaflet on PPE

Waste management and the disposal of PPE

In the majority of circumstances where PPE is deemed essential then once used it should be routinely treated as Non-Infectious, Offensive Waste and disposed of into the appropriately labelled internal waste bin for Offensive waste.

The only exceptions to this are where a clinician determines a high risk of infection, as a result of known or suspected cases of COVID-19 or other infectious diseases. Under these circumstances PPE waste should be treated with the same precautions as other Infectious waste and disposed of in an Infectious waste bin.

Offensive Waste Segregation

Internal bins provided at Face Mask and Hand Wash Stations will, in the vast majority of cases be designated and labelled for Offensive Waste, (excluding COVID-Secure Wards). These should be lined with a single Tiger-Striped (Black & Yellow) liner.

Unless an infection risk is known or suspected then all used PPE should be disposed of into the Offensive Waste Stream.

Offensive waste must be segregated in the relevantly labelled internal bin designated specifically for Offensive waste. Do not mix Offensive and Infectious waste items.

For more information, please download the Standard Operating Procedure on COVID – 19 and PPE Waste.