Code of Practice

1        Introduction

This Code of Practice (COP) describes where staff and visitors should be wearing Personal Protective Equipment (PPE) around The Griffin Institute and to ensure enhanced hand sanitisation is practised.  This COP is intended to be used as a constant reference whereby, you agree to abide and uphold these rules.

  1. This CoP has been updated on the 21st September 2020 to reflect new government advice.

2        Working Principles

  • All staff, visitors and contractors working in the BSU, surrounding theatres and labs adhere to these instructions to protect yourselves, colleagues, and animals. Any PPE/RPE that is worn, must fit and be worn correctly
  • Only the minimum number of personnel will be asked to attend training courses/ carry out experiments. This is to ensure we can control social distancing
  • Hand hygiene performed correctly at the appropriate time remains the most important intervention in the prevention and control of the spread of infections
  • The Griffin Institute will provide PPE that meets the current standards set out by the Health and Safety Laboratory
  • Staff and visitors do not need to wear a mask in the office area as long as social distancing is adopted, but if they would like to then masks will be available
  • For coughs and sneezes, Catch it, Bin it, Kill it. Use a tissue to catch a cough and/or sneeze, and dispose of immediately before washing and sanitising your hands

3        Personnel

3.1       All Personnel

  • Any personnel with a cough, cold or flu like symptoms will not be permitted on site
  • All training course attendees that have to cancel their attendance due to COVID-19 symptoms, will be offered to rebook on to the next available course
  • Whilst the threat of COVID-19 is present only visitors and contractors that have business to be on site, will be granted access. In light of government advice for Labs and Research facilities, The Griffin Institute will continue to insist that only those who have a direct need to be onsite, will be permitted access.
  • Surgical masks and visors are available for all, please ask if you would like one when you arrive

3.2       Visitors from Overseas

Any company or individual wanting to attend the institute from a country that has not been classified as in a travel corridor with the UK must quarantine for 14 days unless they qualify for a travel exemption. Overseas visitors may be asked to provide the Griffin Institute with proof of the date that they arrived in the UK.

The full list of jobs that qualify can be found here:

This guidance lists the jobs that qualify for an exemption and tells people:

  • if they need to self-isolate
  • if they need to complete a passenger locator form
  • any conditions they will need to meet or evidence they will need to show

If you do one of these jobs, you still need to follow the same health guidance as people who live in the UK. Check the guidance for staying safe in England here:

Travellers exempt from quarantine on arrival MUST obtain a negative COVID-19 test that can be presented to The Griffin Institute at least 24hrs before they are due on site.

All individuals from overseas MUST wear a face covering at all times when on site and the only exception is to eat or drink.

If visitors cannot wear a face mask for medical reasons, they will not be permitted on site.

3.3       Respiratory Protective Equipment (RPE)

The Griffin Institute do not have an RPE policy. Visitors that require respiratory protection must bring with them, their own supply of P3 masks, half-mask or powered respirator.

3.4       Best Practice

3.4.1         SURGICAL MASKS

  • Wash hands before and after donning and removing a mask
  • Masks are single use and once removed must be replaced by a new one
  • If the mask becomes moist or damaged it must be changed
  • Do not touch or play with the mask

3.4.2         GLOVES

  • Wash hands before putting on gloves and after taking off
  • Do not touch your face with your gloved hands
  • Remove gloves without touching your skin, pull them inside out as you remove them and dispose of via the clinical waste stream
  • Never reuse gloves

4        Hand Hygiene

It is the responsibility of the individual to ensure that hand washing/ sanitisation is carried out frequently and adequately. Personnel can do this by using a 70% alcohol hand gel or rub, liquid soap and water and/or anti-microbial soaps. When washing hands with soap and water, wash for at least 20 seconds.

  • Jewellery is be discouraged as it can harbour germs on and under it
  • False nails should be avoided and nail length kept short to avoid bacteria and micro-organisms getting trapped under them
  • If you suffer with a skin condition such as eczema or dermatitis please bring an emollient to maintain skin health

5        Entering Level 2 Laboratories

  • Access to the laboratories is gained from entering the main stairwell from the Level 3 concourse
  • COVID-19 UPDATE: Do not ride the elevators. Elevators must only be used to put in equipment and consumables that need to travel to each floor. Personnel must not travel in the lifts in case the lifts break down and we cannot get a service engineer to attend in good time, place your goods in the elevator then go to the alternate floor and summon it
  • Outdoor clothes and shoes are permitted, but must be covered with a lab coat and overshoes
  • Gloves must be worn, changed regularly and be disposed of via the clinical waste stream
  • Masks are provided for if you are sharing lab space or for those who wish to wear them
  • A 2 metre distance must be kept between all personnel where possible. If closer proximity is needed, then a mask/visor must be adopted
  • Use back-to-back or side-to-side working (rather than face-to-face) whenever possible

5.1       Leaving the Level 2 Laboratories

  • Discard overshoes, mob caps, masks and gloves
  • Leave the labs via the same route as entering

6        Entering the BSU

  • All personnel that are not entering the facility transiently, must change into scrub suits, located in the changing rooms on Level 3
  • Access to the BSU is gained from entering the main stairwell from the Level 3 concourse
  • Upon entering the BSU, you must wear gloves, a mob cap and overshoes (if not wearing institute clogs)

7        Entering the Theatres

  • Change into clean theatre scrub suits and leave outdoor clothing in a locker, keeping your own shoes on
  • Put on overshoes at the entrance to the theatres and animal facility and don a mob cap, gloves, mask and eye wear/visor/ gown if required

If personnel are wearing the full quota of PPE, masks, gloves, mob caps and scrubs, the risk of transmission is minimal.

It is understood that when performing surgical work, a 2 metre distance is not practicable, therefore you work as you need to, keeping in mind to always distance as much as is possible.

7.1       Access and Gowning Procedure for Theatre Work

  • Theatre suites are accessed via the male and female changing rooms on level 3
  • Change out of outdoor clothes into theatre scrub suits
  • Leave your shoes on or wear theatre clogs
  • Exit changing rooms via the back door and descend the stairs
  • At the foot of the stairs, if wearing outside shoes, put on overshoes
  • For THEATRE 1: Enter the theatre corridor and turn right until you reach the scrub room
  • For THEATRE 2: Enter the theatre corridor and turn right until you reach the main concourse. Follow the corridor on the right to the very end, to the prep/scrub room
  • Put on a mob cap and face-mask
  • Wash hands and arms with approved soap
  • Wear gloves

7.2       CT Room

  • Enter the theatres as detailed in Section 7
  • Lead aprons must be worn over PPE when operating the CT scanner
  • Further details can be found by reading the local rules document for working in the CT room and SOP 1:2:32

8        Leaving the BSU, Theatres and Laboratories

  • Discard overshoes, mob caps, masks, gloves and disposable gowns (if worn) at either entrance of the theatres
  • Place all launderable PPE in the laundry bins within the changing rooms before getting dressed into your outdoor clothes

8.1       The Griffin Institute Clean Down of Theatres

TGI staff shall establish mandatory routine disinfection of the theatre area on a daily basis. The theatre area shall go through increased disinfection procedures before all surgeries and courses, this includes:

  • Chairs
  • Tables
  • Trolleys
  • Operating table
  • Operating lamp
  • Anaesthetic machine
  • All doors and handles leading to the training area
  • Any other equipment that may have been used during the course
  • The hand washing area should be thoroughly cleaned
  • All clinical waste bags sealed and properly disposed of
  • Topping up of all PPE and maintaining hand washing facilities


9        Maximum capacity of personnel for communal areas

This table is based on 2m² per person and has been rounded up for the areas in blue due to limited movement of personnel in these areas.

  Area (m²) Max persons
Break Room 47.9 12
Conference Room 1 29.8 8
Conference Room 2 23.8 6
Theatre 1 47.3 11
Theatre 2 28.0 7
CT Room 39.6 9