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General Policy
Health & Safety
Health and Safety Manager
Health & Safety Manager
Director of Property & Asset Management
01 March 2007
01 March 2023
01 March 2025

General Note

NHS Fife acknowledges and agrees with the importance of regular and timely review of policy statements and aims to review policies within the timescales set out. New policies will be subject to a review date of no more than 1 year from the date of first issue.

Reviewed policies will have a review date set that is relevant to the content (advised by the author) but will be no longer than 3 years.

If a policy is past its review date, then the content will remain extant until such time as the policy review is complete and the new version published, or if national policy or legislative changes are made


1.1. This policy and any associated guidance, protocols and documentation have been developed to allow NHS Fife to comply with the requirements of the Personal Protective Equipment at Work (Amendment) Regulations 2022. Under PPER 2022, the types of duties and responsibilities on employers and employees under PPER 1992 remain unchanged but are extended to limb (b) workers: a worker now has a duty to use the PPE in accordance with their training and instruction, and ensure it is returned to the storage area provided by their employer. The Policy will also assist in compliance with other regulations which address the use of Personal Protective Equipment (PPE).


2.1 Location

2.1.1 The policy applies across all areas of NHS Fife and the Fife Health and Social Care Partnership including domiciliary settings.

2.2 Scope

2.2.1 The policy applies to all NHS Fife and Fife Health and Social Care Partnership staff including agency and contracted personnel, and any other person who is not an NHS Fife employee, but who is working under the supervision and direction of an NHS Fife employee. The policy also applies to members of the public who may be present in areas where risks need to be controlled through the provision of PPE. This policy does not apply to ordinary working clothes and uniforms which do not specifically protect the health and safety of the wearer nor does the policy apply to sportswear.


3.1 Senior and Line Managers

3.1.1 Senior and line managers are responsible for ensuring that risks are controlled as far as reasonably practicable, without the requirement to use PPE. Only where risks cannot be adequately controlled by other means should appropriate PPE be made available to staff.

3.1.2 Where it is necessary to provide PPE, senior and line managers must ensure that an assessment of the PPE is carried out to ensure that it is suitable for the risks being controlled. In this context “suitable” means that it will both reduce risks to staff and fits the wearer.

3.1.3 Senior and Line Managers must also ensure that reusable PPE can be adequately cleaned after use and can be stored safely when not in use and is readily accessible.

3.1.4 Senior and Line Managers should also ensure that reusable PPE is maintained and replaced as necessary.

3.1.5 Senior and Line Managers must also ensure that suitable and sufficient information, training and instruction for all employees’ using PPE is provided to enable staff to make proper use of PPE and be aware of its limitations.

3.2 Employees

3.2.1 Employees using PPE are responsible for ensuring that PPE is used in accordance with training and instruction provided

3.2.2 Employees must immediately report any loss or defect with PPE to their line manager.

3.2.3 Employees also have a responsibility to return PPE to its place of storage after cleaning, or to dispose of appropriately.


4.1 PPE is defined in the Personal Protective Equipment at Work Regulations 1992 as “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 the person against one or more risks to that person’s health or safety, and any addition or accessory designed to meet that objective.”

4.2 In relation to Infection Prevention and Control, PPE is one of the nine elements of standard infection control precautions (SICPs) which are particularly concerned with the spread of organisms that might be present in blood or other body fluids.

4.3 PPE should only be used as a “last resort” or as a short-term emergency measure while other control measures are assessed. Engineering controls and safe systems of work should be considered first.
Hierarchy of Controls
• Elimination – physically remove the hazard
• Substitution – replace the hazard
• Engineering controls – isolate people from the hazard
• Administrative controls – change the way people work
• PPE – protect the worker with personal protective equipment

4.4 PPE should only be used for occasional work of short duration when there is no other alternative.

4.5 Suitable PPE must always be worn where there is a risk of contact/ contamination with blood or body fluids.

4.6 Provision of Suitable and Appropriate PPE

4.6.1 The PPE provided must be appropriate for the risks involved and the conditions where it will be used. The PPE must take account of ergonomic requirements and the state of health of the person who is required to wear it.

4.6.2 Departments must choose PPE that gives:
• adequate control of risks without itself, adding to the risk
• compatibility with other items of PPE (e.g. ear defenders worn with a safety helmet must still provide the necessary degree of attenuation);
• minimum discomfort to the wearer

4.6.3 Departments must provide PPE free of charge to employees when risks to health and safety cannot be adequately controlled by other means.

4.6.4 If individuals feel that, on medical grounds, they have difficulty in using the PPE provided; they should advise their line manager and be referred without delay to the Occupational Health department for an early assessment of the problem.

4.7 Standard of PPE provided

4.7.1 All PPE selected must conform to an appropriate British (BS) or European (EN) Standard. It must be “CE” marked and user information must be provided by the manufacturer / supplier.

4.8 Assessment of Suitability of PPE

4.8.1 This should be carried out on all items of PPE before it is provided to staff. The Head of Department or Line Manager must keep a record of this. The H&S Team will assist in assessments of PPE suitability.

4.9 Storage, Maintenance, Replacement, and disposal of PPE

4.9.1 All PPE, but particularly reusable PPE must be stored in an assigned and suitable area with easy access

4.9.2 Reusable PPE must be maintained and replaced in accordance with the manufacturer’s advice. A record of maintenance must be retained locally by the manager.

4.9.3 Departments must devise written procedures for any necessary maintenance of PPE including cleaning, disinfecting, examination, repair, replacement, and testing. These procedures must detail the extent and frequency of maintenance, and the names of responsible individuals.

4.9.4 The use of disposable or single use PPE avoids the need to devise and carry out such procedures, but manufacturer instruction must be passed on to users so that they can recognise when to discard and replace equipment.

4.9.5 Disposable PPE or reusable PPE which is broken or damaged must be disposed of in accordance with waste management guidance. Any PPE believed or known to be contaminated with biological agents, blood or body fluids must be disposed of in accordance with the Infection Control Manual.

4.10 Provision of information, training, and instructions

4.10.1 Users must be provided with sufficient information, instruction, and training to use PPE effectively. It should include both theoretical and practical aspects as to why the PPE is being used, its limitations, how to fit, wear or store it, and will vary with the complexity of the equipment. Training records must be kept wherever more than very simple instruction is required.


5.1 This procedure is a part of NHS Fife’s system for managing risk as described in the NHS Fife Risk Register and Risk Assessment Policy (GP/R7) & NHS Fife Adverse Events Policy (GP/I9).


6.1 GP/R7 Risk Register and Risk Assessment

6.2 GP/E8–5 Safe Handling of Laundry Procedure

6.3 GP/G1–1Glove Selection Procedure

6.4 GP/N1 Noise at Work Procedure

6.5  Appendix 1 - Types of Protective Equipment


7.1 Personal Protective Equipment at Work Regulations 2022; Guidance on Regulations, L25, HSE Publications

7.2 The Control of Substances Hazardous to Health Regulations 2002; Approved Code of Practice and guidance, L5 HSE Publications

7.3 The Electricity at Work Regulations 1989

7.4 National Infection Prevention and Control Manual

7.5 Respiratory Protective Equipment, 4th edition, 2013. HSG53 HSE Publications

7.6 The Control of Noise at Work Regulations 2005, Guidance on the regulations; L108, 3rd edition, HSE Publications