All staff (clinical and non-clinical) must wear surgical face masks at all times, in all areas, unless working alone in an office.

No staff should be wearing face coverings.

Full guidance around wearing surgical face masks when you are in work is on our face masks FAQs page.

If you see anyone who is not adhering to these requirements, please don't be afraid to call it out. Have a conversation with the person to make sure they know what they should be doing.

This is about protecting everyone and it's important we are all comfortable with alerting people who may be inadvertently putting others at risk.

You should don level 3 PPE before undertaking an aerosol generated procedure. This includes during an emergency situation/cardiac arrest, when carrying out CPR. 

In the event of an emergency situation/cardiac arrest, staff must follow the resuscitation standard operating procedure (SOP) for all patients.

Level 3 PPE packs are available with the resuscitation equipment on each inpatient ward. Remember to dispose of the PPE appropriately after use. 

Following the incident, a Datix must be completed and should include information around the level of PPE worn by staff. 

All resuscitation policies and procedures can be found on StaffZone>Corporate-hub>policies-and-procedures

For any aerosol generating procedures (AGPs), full level 3 PPE must be worn including:

  • FFP3 mask
  • Gown
  • Visor
  • Gloves

Any staff who may be involved in AGPs must be fit tested with an FFP3 mask to ensure it provides suitable protection for them.

To arrange a fit test for an FFP3 mask, please email  

Continuous positive airway pressure (CPAP) is categorised as AGPs. As such, staff should wear an enhanced level of PPE when caring for patients who are undergoing any of these treatments, regardless of whether they have tested positive for Covid-19.

You can find a full list of all APGs on the Government website.

For more information about AGPs please see MBN 394 - Enhanced level 3 PPE for aerosol generating procedures.


A three-step procedure has been introduced which has been discussed with our trade union partners to ensure a fair and consistent approach when there is a PPE breach.

The process:

1)    First failure to comply with PPE requirements (first notification of concern)

Where it has been identified that a member of staff has failed to comply with PPE requirements, a meeting will take place with the staff member and line manager to issue a first notification. The manager will issue a letter as detailed in the procedure.

2)    Second failure to comply with PPE requirements (second notification of concern)

Where an individual has been issued with a first notification of concern, the second breach will be escalated to the Trust Chief Operating Officer/Deputy Chief Executive, given the significant risk posed by failing to adhere to PPE requirements.

3)    Third failure to comply with PPE requirements

Where an individual has failed to follow PPE requirements on a further occasion, this will be referred into the Trust’s Disciplinary Policy and Procedure. A formal investigation will be undertaken to ascertain the facts.

Further details about this process are outlined in the new three-step PPE procedure.