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Personal protective equipment (PPE) policy

1 Document summary

Personal protective equipment (PPE) is safety equipment or clothing worn to minimise exposure to hazards that could cause serious workplace injuries and illnesses. These injuries and illnesses may result from contact with biological, chemical, radiological, physical, electrical, mechanical, or other workplace hazards.

This policy details the trust’s arrangements for the selection, storage and use of personal protective equipment. It ensures compliance with the Personal Protective Equipment at Work Regulations 1992 (as amended 2022).

The policy sets out:

  • the types of personal protective equipment available
  • what should be considered when selecting personal protective equipment
  • use of personal protective equipment limitations
  • how personal protective equipment should be stored
  • the process for use of personal protective equipment

The use of personal protective equipment should be considered as the least preferable option for protection against risks as it only protects the individual wearing it. If it is not possible to eliminate the hazard then it is preferable to support the use of personal protective equipment with other controls, such as safe working procedures.

1.1 Responsibilities

Managers must identify suitable personal protective equipment for work tasks, ensure adequate supplies are available, provide suitable storage and provide information about how to use the personal protective equipment correctly. Regular checks should be made to ensure that personal protective equipment is worn where indicated by risk assessment.

Employees must co-operate by wearing relevant personal protective equipment, report any damaged or expired equipment and sign to indicate that they have received personal protective equipment (appendix A).

Where an employee’s role requires the use of an FFP3 face mask, they should co-operate with the requirement to be face fit tested for a suitable face mask.

2 Introduction and aim

There is a statutory requirement under the Personal Protective Equipment at Work Regulations 1992 (as amended 2022) for personal protective equipment to be supplied and used at work wherever there are risks to health and safety that cannot be adequately controlled in other ways. Personal protective equipment (PPE) must be considered in addition to all other control measures and should not be relied on as the only means of protection. Personal protective equipment is:

“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 individuals against one or more risks to their health or safety.” (regulation 2, Personal Protective Equipment Regulations).

In addition, core standard 65 of NHS England core standards for emergency planning, resilience and response (EPRR) requires organisations to:

“Have access to and be trained to use FFP3 mask protection (or equivalent)”

For:

“Staff who may come into contact with confirmed infectious respiratory viruses.”

The arrangements in the policy detail the trust arrangements to comply with this requirement. FFP3 masks are face masks or respiratory protective equipment (RPE) that protect the user by preventing the inhalation of hazardous substances including liquid aerosols.

The policy applies to all employees and workers employed by the trust, including apprentices, bank employees and volunteers. It should be noted that some personal protective equipment is not covered by the Personal Protective Equipment Regulations; Ear protection is covered under the Control of Noise at Work Regulations (2005) and respiratory protection is covered under the Control of Substances Hazardous to Health (COSHH) Regulations (2002) and Confined Spaces Regulations (1997). However, the advice given in this policy is still applicable, as the general principles of selecting and maintaining suitable personal protective equipment and training employees in its use are common to all regulations that refer to personal protective equipment.

The trust has a number of clinical policies that deal with personal protective equipment selection and use from an infection prevention and control perspective. These can be found in the infection prevention and control (IPC) manual. Some of the precautions associated with these other policies overlap with this policy. The primary objective of this policy is to ensure that the legal requirements for the provision of personal protective equipment are outlined in more general terms.

3 Procedure

Personal protective equipment (PPE) is a control measure designed to reduce the wearers exposure to hazardous agents whether that is chemical (such as cleaning products), physical (such as noise) or biological (such as bodily fluids). Use of specified items of personal protective equipment is usually identified when a task risk assessment or control of substances hazardous to health (COSHH) assessment is carried out.

This policy is fundamentally about the selection of the correct personal protective equipment and what must be considered during this process.

Where a risk assessment identifies the need for personal protective equipment, it must be suitable, fit for the purpose it was designed for, effective at controlling the risks identified and be a good fit for the individual.

Although a risk assessment may identify personal protective equipment as being necessary, other means of control should be given preference, and wherever possible, personal protective equipment must not be relied upon as the sole means of protection. Personal protective equipment should be regarded as a “last line of defence” in terms of protecting against risks to health and safety.

3.1 What types of personal protective equipment are available?

Personal protective equipment (PPE) includes the following when they are worn for the protection of health and safety.

Protective clothing, such as:

  • aprons
  • clothing for adverse weather conditions like coats and waterproof trousers
  • gloves, see appendix B
  • safety footwear for example with protective toe caps
  • safety helmets
  • high visibility vests

Protective equipment, such as:

  • eye protection like goggles or safety glasses
  • respiratory protective equipment (RPE), ranging from dust masks to breathing apparatus
  • hearing protection: ear plugs or muffs
  • safety harnesses
  • lone working devices

There may be various types of hazards identified in the risk assessment indicating why personal protective equipment is required to be worn, such as:

  • impact, fixed objects, ejection hazards, sharp objects, puncture and penetration hazards
  • falls from height, falling and flying objects
  • chemical, radiation and contamination hazards
  • noise, vibration and electrical hazards
  • visibility, extreme temperatures, weather hazards and oxygen deficient hazards

3.2 Personal protective equipment selection

Personal protective equipment (PPE) should be used if the risk assessment identifies it as an appropriate means of controlling exposure to risks, or if local rules stipulate its use. It must be suitable for its intended use.

The selection process must take into account:

  • the hazard it is intended to protect against
  • the task to be undertaken, for example, whether the length of time or physical effort whilst wearing the personal protective equipment will be an issue
  • fit requirements for the individual worker
  • its compatibility with any other item of personal protective equipment to be worn at the same time
  • the health of the person who will be wearing it
  • whether wearing personal protective equipment increases the risk or creates new risks like making communication more difficult

All personal protective equipment must conform to an approved standard. Compliance with the standard is identified in the UK by marking items with the CE kite mark or UKCA mark (UK Conformity Assessed). Only equipment that is marked in this way is approved for use by colleagues.

When assessing whether personal protective equipment is suitable, risk assessors will need to specify what type of personal protective equipment should be worn. For example, nitrile rubber gloves “BS EN ISO 374”, eye protection to “EN 166 34B”, not just gloves and goggles.

3.2.1 Personal protective equipment and disability

It is recognised that many deaf and hearing-impaired people rely on lip reading and facial expressions for clear communication, something that is not possible when opaque face masks are being worn.
If colleagues are required to wear masks due to national, NHS or trust guidance a clear face mask may be worn if treating a deaf patient. However, use of a clear mask must be considered on a case-by-case basis, carefully considering the risks and ensuring that the mask provides the same level of protection as a type IIR surgical face mask.

3.3. Personal protective equipment limitations

  • Effective protection is only achieved by using personal protective equipment that is suitable for the hazard which it is supposed to protect against. It must be correctly fitted, maintained and properly used.
  • Personal protective equipment protects only the person wearing it, whereas measures controlling the risks at source can protect everyone in the workplace.
  • Personal protective equipment may restrict the wearer to some extent by limiting mobility, visibility or by requiring additional weight to be carried.
  • Some items of personal protective equipment have limited life spans such as personal protective equipment and hard hats and therefore these should be recorded as part of the personal protective equipment inspection. Expired personal protective equipment must be replaced. Information on life spans can be obtained from the manufacturer’s guidance which accompanies the personal protective equipment.
  • Close fitting face masks need a tight seal with the user’s face. This is not generally possible where colleagues have facial hair or stubble so FFP3 type masks may not work effectively in this group of employees.

3.3.1 Health impacts

Any skin allergies related to personal protective equipment resulting in dermatitis, such as from latex, should be reported using the trust’s Radar incident reporting system and reported to the Health and Safety Executive (HSE) under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR). Occupational dermatitis is a reportable disease under RIDDOR. Colleagues reporting skin reactions should be referred to occupational health.

Latex is a natural product obtained from the rubber tree (hevea brasiliensis) that is used in the manufacture of many medical products commonly used in healthcare settings, including gloves. It is recognised as a sensitiser and a substance hazardous to health as defined by the Control of Substances Hazardous to Health (COSHH) Regulations.

Associated health problems include:

  • type 1 latex allergy, an immediate hypersensitivity reaction characterised by rash, conjunctivitis, rhinitis, asthma and occasionally difficulty in breathing and life-threatening anaphylaxis
  • type 4 latex allergy, rash often developing hours after exposure, it may be due to latex proteins or chemical residues added in latex processing; this reaction predisposes individuals to developing type 1 allergy

As a result of knowledge and developments connected with the use of latex gloves and in consultation with the trust’s infection prevention and control team into the type and range of trust activities where glove use occurs a decision was made to cease the use of latex gloves in the trust. Purchasing and purchase ledger have placed a block to prevent the ordering of any supplies of latex gloves. A range of gloves made from alternative materials is available, some of which are unsuitable for use in clinical environments. See appendix B for details.

3.4 Personal protective equipment storage

Personal protective equipment must be stored in a location that does not put the equipment at risk of being damaged or contaminated by damp, sunlight or harmful substances such as solvents.

If personal protective equipment becomes contaminated it should be stored separately from ordinary clothing and where necessary be labelled. It should be cleaned if it can be cleaned without affecting the level of protection it offers to the user. If this is not possible it should be disposed of.

4 Responsibilities

4.1 Employees

All trust colleagues should wear and use personal protection equipment (PPE) correctly, check it for damage before use, report any defects, maintain and clean where necessary and store where it cannot be damaged or contaminated. Colleagues should request a replacement for damaged or expired equipment.

Employees must co-operate with managers in any personal protection equipment selection process and sign for any personal protection equipment issued to them (see appendix A).

Where an employee’s role requires the use of an FFP3 face mask, they should co-operate with the requirement to be face fit tested for a suitable face mask.

If there is any adverse reaction or sensitivity to personal protection equipment, employees should inform their manager and complete a Radar incident report. This will allow occupation health or GP advice to be sought.

4.2 Managers

Managers are required to conduct risk assessments to identify all workplace hazards which are of significant risk and review the possibilities of reducing the risks by means other than personal protection equipment usage. However, in some circumstances personal protection equipment may be identified as a risk reduction measure. Where this is the case suitable personal protection equipment must be provided. If required, advice may be sought from a suitably competent person to ensure any requirements related to personal protection equipment are implemented and that users are involved in any decisions about the choice of personal protection equipment.

Managers must:

  • provide a suitable quantity of personal protection equipment and maintain an appropriate stock level
  • provide all colleagues with instruction and training in correct usage, identification of wear and tear, and any known faults together with any maintenance that may be required
  • provide suitable storage facilities for personal protection equipment
  • audit and inspect personal protection equipment on a periodic basis and record the findings
  • maintain records of issue and receipt for personal protection equipment and use personal protection equipment personal equipment signature (PES) form for the colleague to sign for the receipt of any issued personal protection equipment (see appendix A)
  • as appropriate, ensure signage is posted in those areas where the wearing of personal protection equipment is compulsory, for example, noise zones
  • ensure colleagues are aware of the hazards of latex sensitisation based on the information contained within this policy and glove use see section 3.4 personal protection equipment storage)
  • in clinical services, where it has been identified that colleagues may have a requirement to wear FFP3 respirator, ensure that fit testing has been undertaken and recorded appropriately in the individual colleagues’ records; further details about aerosol generating procedures (AGPs) can be found in the infection prevention and control manual

4.3 Health and Safety team

The Health and Safety team will:

  • provide information and advice on personal protection equipment
  • follow up on any reported personal protection equipment and ill health related incidents
  • report on any hazards, associated with any particular personal protection equipment, coming to light during use

4.4 Procurement and purchase ledger

The department is responsible for putting a block on any orders for latex gloves and for notifying the relevant department of any orders which have been raised for latex gloves.

4.5 Care group directors

There should be sufficient resources to ensure that any personal protection equipment needed is available and that there is a regime for face fit testing where there is an identified need, such as where there is a risk of exposure to a respirable infection, such as measles. This includes identifying groups of employees who need face fit testing for FFP3 face masks and nominating an individual to co-ordinate face fit testing arrangements who will ensure that relevant new employees are fit tested and that existing employees are re-tested every 3 years. A number of employees should be identified to be trained as face fit testers. Records of trained face fit testers and employees fitted with a mask should be kept and maintained.

5 Training

5.1 Face fit tester and Portacount training for fitting FFP3 face masks

  • Employee groups requiring training: nominated face fit testers.
  • Frequency: every three years.
  • Length of the training: 6 hours.
  • Delivery method: face to face.
  • Deliver by: external provider.

Users of personal protective equipment should be provided with information about how to use this correctly. This is available from personal protective equipment suppliers.

6 Monitoring arrangements

6.1 Correct use of personal protective equipment

  • Who by: local managers.
  • Reported to: care group and directorate leadership.
  • Frequency: random.

6.2 Personal protective equipment risk assessment

  • How: inspection.
  • Who by: Health and Safety team.
  • Reported to: directorate leadership and health, safety and security.
  • Forum frequency: annual.

7 Related documents

8 Appendices

8.1 Appendix A personal protective equipment personal equipment signature (PES) form

Refer to appendix A: personal protective equipment personal equipment signature (PES) form (staff access only).

11.2 Appendix B glove materials and selection

All examination gloves are single use only and as such must be discarded after use. Examination gloves must not be washed between use as damage may go undetected.

Some gloves, usually used outside clinical settings, are designed to be re-used. For example, more robust rubber gloves used for domestic or catering activities or leather or textile gloves used in maintenance or gardening activities. Rubber gloves should be checked before use for discolouration, cracking or damage and disposed of if damaged or contaminated on the inside. These types of rubber gloves should be washed after use to remove decontamination. Alcohol hand gel or rub must not be used to decontaminate rubber or gloves

All gloves have a use by date, and this must be checked prior to the use of gloves. Gloves that have gone beyond their use by date must be disposed of and not used.

The glove of first choice in the trust will be non-latex.

11.2.1 Synthetic rubber

The most commonly used type is nitrile. Nitrile is the accepted material choice for gloves used in healthcare due to the strength barrier properties. A concern for many years has been the risk of impaired dexterity due to muscle fatigue where gloves are worn for a prolonged period of time, but the stretch ability of these gloves has continued to be improved by manufacturers. Residual accelerants in nitrile or other synthetic rubbers may also cause Type IV allergic response in some wearers, although accelerator free gloves are now available. Accelerators are the chemicals used in the glove manufacturing process to help make gloves more durable and elastic. Unfortunately, chemical accelerators are also some of the most common causes of allergic reactions.

Latex: only to be used in the trust in exceptional circumstances.

Natural rubber latex (NRL) provides excellent protection against blood-borne viruses which for many years has made it the material of choice for gloves when dealing with blood and blood stained body fluids.
The use of latex gloves in healthcare and therefore employees’ exposure to natural rubber latex has increased since the mid 1980’s. Although allergy to natural rubber latex remains rare it can produce reactions ranging from non-allergenic irritation to allergy which is a key disadvantage.

There will be areas of healthcare where it continues to be appropriate to use natural rubber latex gloves, mainly where invasive surgery takes place. In such circumstances a risk assessment would be required to indicate the choice of glove.

11.2.2 Vinyl

Vinyl gloves are looser fitting than either Nitrile or natural rubber latex but due to degradation with use they have a higher leakage rate and therefore a greater risk of skin contamination. It should also be noted disposal of vinyl gloves by incineration can lead to pollution through release of toxins.

11.2.3 Polythene

Only used in catering.

11.2.4 Glove selection

Glove selection is to be decided based on a risk assessment of the activities to be undertaken. Five areas should be considered (HSE, 2018):

  • substances being handled
  • other hand hazards, for example, risk of puncture wounds or cuts.
  • type and duration of contact, for example, worn for long periods or intermittently?
  • the wearer in terms of size and comfort
  • the task and how robust the glove needs to be

Manufacturers should be able to provide guidance on the best glove for use with a particular hazard.

Glove selection in general clinical settings:

  • vinyl examination gloves should not be used in a clinical setting
  • non-sterile synthetic rubber, for example nitrile gloves should be worn for procedures where there is risk of exposure to blood or body fluids
  • sterile synthetic rubber, for example, nitrile gloves should be used for procedures where a sterile field and high barrier protection is required

11.3 Appendix C filtering facepiece disposable respirators

Filtering facepiece respirators (FFPs) are a form of respiratory protective equipment that provide a higher level of respiratory protection than surgical face masks. They are available in three protection levels:

  • FFP1
  • FFP2
  • FFP3

The higher the number, the more efficiently the mask filters particles such as dust or airborne liquid particles from the air. For this reason, FFP3 respiratory masks may be used against more harmful substances and at higher concentrations than FFP1 and FFP2 masks.

Disposable FFP3 masks are used in the trust and must be worn by employees carrying out aerosol generating processes (AGPs) or where a patient is known or suspected to have an infection spread via the aerosol route. Examples of aerosol generating procedures (AGPs) include tracheostomy procedures (insertion or removal) and respiratory tract suctioning beyond the oro-pharynx. The trust infection prevention and control manual provides more examples.

FFP3 or FFP2 masks may also be used by Estates colleagues to protect against moderate (FFP2) or higher level (FFP3) fine dusts, such as wood, or oil and water-based mists.

11.3.1 Face fit testing

Each model of FFP3 respirator is slightly different in its fit and one type of mask may not fit everyone due to individual face dimensions. In order to protect the user masks must be a tight fit around the user’s face so that contaminated air cannot enter and be breathed in, potentially causing illness or harm. A face fit test will identify whether a mask is suitable for use by a particular wearer or advise if alternative masks need to be tried. Each user must be fit tested for each type of mask used.

In order to ensure resilience should there be a shortage or discontinuation of a particular model of masks, the user must be tested so that they are able to use at least two models of mask. Fit testing should be carried out every 3 years or whenever there is a change in the circumstances of the wearer that could alter the fit of the mask, for example, facial changes, such as weight loss or gain, piercing, rhinoplasty, fillers (cheeks and lips). Additionally, users should check that there is a good fit every time a respirator is used.

Facial hair, such as a beard or stubble does not allow a tight seal around the face, so individuals must be clean shaven or alternative protection such as a hood must be used.

Fit testing must be carried out by a competent person who has been trained to carry out testing.

11.3.2 Trust arrangements and procedure

The trust uses a variety of makes of mask:

  • Kolmi and Medicom, small and medium
  • Drager 1730
  • Handany HY9330
  • GVS F31000
  • Alpha Solway HX3

Minimum stocks of these are kept on receptions at Tickhill Road, Great Oaks and Swallownest Court and by the Patient Flow team. The masks are disposable and for single use.

There are a number of suitably trained employees in each care group able to carry out face fit testing.

All new employees who may be required to carry out aerosol generating procedures (AGPs) should be identified by their line manager and undergo face fit testing. This must be recorded on electronic staff record (ESR) and refreshed every 3 years unless there is a change in circumstances of the individual as mentioned in the previous section.

The process for donning and doffing a face mask is detailed in appendix D. Masks should be put on with clean hands to avoid contamination of the mask and disposed of as clinical waste after use. Once a mask has been put on it is important that the user carries out a pre-use check to ensure there is a good seal between the face and the mask. This should be done each time a fit-tested facepiece is worn and before entering the hazardous environment. Note, however, that a pre-use wearer-seal check is not a substitute for fit testing.

To carry out a pre-use check the user should breathe out sharply after placing their hands around the mask. If air is felt, then there is not an adequate seal. Tighten the headbands if there is airflow around the edges of the mask or adjust the nose piece if air is leaking here. If there is no leakage, then there is a good seal. If a seal cannot be achieved refit the mask and repeat the process to achieve a good seal. If a seal cannot be obtained, then the hazardous area should not be entered as the user may be exposed to contaminated air.

Provided the seal remains intact, masks can be worn comfortably for at least two hours but are effective for longer unless compromised, for example, splashed with body fluids or damp with respiration. Ensure that respiratory masks are changed after an aerosol generating procedure or after a session.

11.4 Appendix D how to put on and fit check a filtering facepiece level 3 (FFP3) respirator poster

Refer to appendix D: how to put on and fit check a filtering facepiece level 3 (FFP3) respirator poster (staff access only).

Document control

  • Version: 8.
  • Unique reference number: 220.
  • Approved by: Risk Management Group.
  • Date approved: 7 April 2026.
  • Document author: health and safety Lead.
  • Title of accountable director: chief nurse.
  • Date issued: 17 April 2026.
  • Review by date: April 2029.

Page last reviewed: April 17, 2026
Next review due: April 17, 2027

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