MD Standard Operating Procedures

Standard Operating Procedures Please note, this is a live document which is subject to change in line with updates from the appropriate regulators.

Table of Contents Version Control Introduction Goals Background Keeping staff safe Staff risk assessment Staff support and wellbeing Time Frames Definition of Dental Treatment Preparation for reopening Getting back to practice Principle task Waiting room set-up and policies Posters Preparation for surgeries Training for the team Fit testing of respirator masks Patient Communication Reopening letter to patients Social media posts Diary Management Personal Protective Equipment Non-AGP For all AGPs PPE for Reception Staff PPE for team members greeting patients and undertaking screening PPE for patients and visitors PPE Use Guidelines The New Patient Journey Patients’ perspective 16 Staff perspective 2

Table of Contents cont Patient Screening Testing Clinical protocols Containment Subject to change 22 Handling Lab Work Hygiene Appointments Decontamination Hand hygiene Management of the surgery Cleaning protocols On completion of environmental cleaning and disposal of waste Patient departure Staying up to date Medication prescription & delivery Non-clinical cleaning protocols What you need to know Cleaning and disinfection Staff room protocols Laundry Waste ANNEXES ANNEX 1 Return from Furlough meeting ANNEX 2 Manager checklist ANNEX 3 Reception Checklist ANNEX 4 Surgery door poster ANNEX 5 Front door poster ANNEX 6 Waiting room poster ANNEX 7 Toilet door poster ANNEX 8 Poster to be displayed above the toilet ANNEX 9 Poster to be displayed above the sink ANNEX 10 Staff room door poster 3

Table of Contents cont ANNEX 11 Sign for waiting room chairs ANNEX 12 Waiting room poster ANNEX 13 Surgery door poster ANNEX 14 Return to work Team meeting agenda ANNEX 15 Reopening letter to patients ANNEX 16 PPE requirement summary ANNEX 17 Putting on (donning) PPE for AGPs ANNEX 18 Putting on (donning) PPE for AGPs ANNEX 19 Taking off (doffing) PPE for AGPs ANNEX 20 Taking off (doffing) PPE for AGPs ANNEX 21 A guide to putting on standard PPE ANNEX 22 A guide to putting on (donning) PPE for non-AGPs ANNEX 23 A guide to taking off (doffing) PPE for non-AGPs ANNEX 24 Triage questions prior to appointment booking ANNEX 25 Patient Screening Form ANNEX 26 Chairside checklist ANNEX 27 Patient journey leaflet ANNEX 28 Hand hygiene techniques ANNEX 29 Hand hygiene techniques ANNEX 30 Custom Screen Instructions ANNEX 31 Key Equipment checklist ANNEX 32 Team member risk assessment ANNEX 33 Water Safety Instructions 4

Version Control Revision New Summary of changes date version number 20.5.20 V1 ● Initial Version current stage = Phase 1 26.5.20 V2 ● Move to Phase 2, definition of essential treatment ● ● ● 5

STANDARD OPERATING PROCEDURES Introduction This document offers guidance and information to all members of our dental teams in how to safely and effectively care for our patients in the new reality after the Covid-19 pandemic. It includes procedures to manage the possible contact with Covid-19 and how to reduce exposure and cross infection. It also offers information on how we need to adapt the patient journey, whilst we are enduring this current pandemic. All procedures have been modified to ensure the safety of our patients and staff and in line with current guidance from PHE, CDO and NHS England. We have also studied what is being done in other countries to ensure that we are adopting best-in-class protocols. A Selection of Other Relevant Documents Other relevant documents to be read in conjunction with this SOP are: 1. Briars COVID-19 risk assessment 2. BDA Risk Assessment 3. NHS COVID-19 guidance and standard operating procedure 4. SCDEP guidance - Management of Acute Dental Problems during COVID-19 5. SCDEP guidance - drugs for the management of dental problems during COVID-19 6. Video consultations - process and logins document 7. GDC - GDC guidance on remote prescribing 8. Public Health England -PHE COVID-19 Infection Control Guidance These documents are all also stored in the ‘Mayhew Dental’ SOP Shared Folder’. Goals o To keep patients, staff and clinicians safe o To effectively meet the oral health needs of our patients o To give our patients confidence in our procedures and in seeking care at our practices o To give our clinicians and staff confidence in our procedures and in delivering care at our practices At Mayhew Dental, our aim is to ensure the safety of our staff and patients at all times, by training and supporting the team to keep up to date with current guidance and procedures. 6

Background What is Covid-19? Coronavirus disease (Covid-19) is caused by an infectious agent of viral pneumonia, recognised as a novel coronavirus (SARS-CoV-2). Coronaviruses are enveloped RNA viruses that belong to the Coronaviridae family. What are the symptoms? Common: o Fever o New continuous cough o Loss or change to sense of smell or taste Some patients: Aches, pains, runny nose, nasal congestion, sore throat, diarrhoea. Severe cases: pneumonia, severe acute respiratory syndrome, sometimes death. N.B. Some patients have no symptoms How is Covid-19 transmitted? Primary transmission between people: respiratory droplets and contact routes; direct contact with infected people; indirect contact with surfaces in the immediate environment, objects used by an infected person. The disease can be transmitted directly or indirectly through saliva. Airborne transmission may be possible in specific circumstances through procedures that generate aerosols known as AGPs. Our aim is to avoid these where possible, or where this is impossible, to mitigate (reduce) the dispersion and effect of them by additional measures, such as aspiration, rubber dam, air exchange, PPE and cleaning. Keeping staff safe It is essential that both patients and team members are confident to return to our practices and feel safe. A significant factor in return to work will be patient and dental team confidence and reassurance. Whilst advised measures may change with emerging evidence, we will ensure that our measures are up to date and hence effective. 1. As well as the safeguards laid out in this document, all staff will return to work in advance of reopening to receive full training with the rest of the team. 2. Every team member will have a one-to-one. Please refer to ANNEX 1. 3. Mayhew Dental will provide all staff with the required PPE to keep them safe. 4. Receptionist position has been redesigned to ensure a 2m safeguarding distance between receptionist and patient, and we will be limiting patients from using reception or the waiting area. Should reception become used more frequently reception shields will be fitted at reception….. There will be disinfectant dispensers at the point of entry. 5. At each practice, on a daily basis, all staff should be risk assessed on an ongoing basis to protect them and keep possible cases, household contacts, staff who should be shielded, or those at increased risk, away from work. If the screening highlights any Covdi-19 risk factors, the employee should contact the principles and go home following government advice: https://www.gov.uk/government/publications/covid-19-stay-at-home-guidance 7

6. Covid-19 guidance around social distancing and good hygiene practice should be promoted as far as possible in the workplace. 7. If staff become unwell with symptoms of Covid-19 while at work, they should stop work immediately, inform the principle and go home. Full decontamination should be carried out as for a patient with symptoms of Covid-19. No additional precautions need be taken for patient and staff contacts unless they develop relevant symptoms. 8. Patients and staff in contact or exposed to someone with symptoms of Covid-19 in a health care setting do not need to stay at home unless they also develop symptoms. 9. Patients and staff in contact or exposed to someone that tests positive for Covid-19 in a health care setting do not need to stay at home unless they develop symptoms. 10. The government has issued guidance about stringent social distancing and shielding for vulnerable groups at particular risk of severe complications from Covid-19. Staff who fall into these categories should not see patients face to face, regardless of whether a patient has symptoms of Covid-19 or not. Remote working should be prioritised for these staff where possible. Staff risk assessment Before any each team member starts work, they must complete the Team Member Risk Assessment form show in ANNEX 32. If they are working an afternoon session, their temperature should be taken after lunch and recorded on the risk assessment form completed that morning. Practice Managers are asked to store these risk assessments in the same way they would store confidential documents in a locked, fireproof cabinet. If the screening highlights any Covdi-19 risk factors, the employee should contact the principle and go home following government advice: https://www.gov.uk/government/publications/covid-19-stay-at-home-guidance Staff support and wellbeing We recognise the impact that the Covid-19 response is having and will continue to have on the mental wellbeing of dental teams, and that it is important to support them as much as possible during their continued commitment to patient care. All members of the team will be given a return to work, one-to-one meeting with the principle (ANNEX 1) where they will have the opportunity to raise any concerns and to discuss how they are feeling about returning to practice. We want each and every one of you to feel supported by us. What is in place for staff wellbeing? The following learning resource is available to staff: Health Education England e-Learning for Healthcare has created an e-learning programme in response to the Covid-19 pandemic that is free to access for the entire UK health and care workforce. This can be accessed at: https://www.elfh.org.uk/programmes/coronavirus/ We will ensure that our infection protection and staff protection guidelines are available and understood by all staff. Training for additional measures and regular staff meetings will be performed. 8

Time Frames The following Standard Operating Procedure (SOP) details the planning and operating of The Mahyhew Dental during the COVID-19 Pandemic. It covers: o PHASE 1 - the protocols employed during remote triage system o PHASE 2 - the protocols employed when face to face non-AGP urgent care is provided o PHASE 3 - the protocols to be employed when AGPs are to be provided o PHASE 4 - the protocols to be employed when routine and elective dental care recommences The COVID-19 Lead is Rupal Gupta PHASE 1 – Mayhew Dental is currently operating a remote triage system with referral to UDCCs. It is anticipated that The BDC will move to: PHASE 2 on 8th June May 2020 PHASE 3 when PPE/FIT TESTING is available if required/been completed OR the risk level reduces such that lower level of PPE is permitted for AGP treatment. To include the introduction of essential treatment in addition to urgent and emergency care. PHASE 4 elective care is anticipated to recommence according to the Government directions in respect of the risk level. Definitions of Treatment Dental Treatments Emergency (directed to A&E): Life threatening emergencies, e.g. airway restriction or breathing/ swallowing difficulties due to facial swelling Uncontrollable dental haemorrhage following extractions that cannot possibly be dealt with within the Urgent Dental Care Hub; Rapidly increasing swelling around the throat or eye which causes immediate threat to life; Trauma to head and neck to include dental arches that requires maxillofacial services. Urgent (may require Face to Face treatment): Trauma such as dento-alveolar injuries or avulsion of a permanent tooth Oro-facial swelling that is significant and worsening but does not present realistic threat to life Post extraction haemorrhage that the patient cannot control by local measures but does not present realistic threat to life 9

Dental conditions that have resulted in acute and severe systemic illness Severe dental and facial pain: that is pain that cannot be controlled by the patient following self- help advice or the use of appropriate antimicrobials. Fractured teeth or tooth with pulpal exposure Dental and soft tissue infections without systemic involvement/effect. Oro-dental conditions that are likely to exacerbate systemic medical conditions Suspected oral cancer. Essential: Any treatment that ought to be provided to prevent deterioration of a patient’s dental health. Not Urgent (delay): Mild or moderate pain: that is, pain not associated with an urgent care condition and that responds to over the counter medications. Minor dental trauma. Post extraction bleeding that the patient is able to control using self-help measures. Loose or displaced crowns, bridges or veneers. Fractured or loose-fitting dentures and other appliances including orthodontics; o If the ulceration is due to part of an orthodontic appliance, patients should be advised to contact their orthodontist for advice. Further information for dentists and patients may be accessed via the BOS website https://www.bos.org.uk o If the ulceration is due to a fractured tooth or filling, advice includes purchase of a temp filling kit when someone next visits a pharmacy. Fractured posts; fractured, loose or displaced fillings. Treatments normally associated with routine dental care bleeding gums. Dental Aerosol Procedures include: Use of high-speed handpieces for routine restorative procedures Use of Cavitron, Piezosonic or other mechanised scalers Polishing teeth High pressure 3:1 air syringe. NB Risk of aerosols could be reduced when using a 3:1 if only the irrigation function is used, followed by low pressure air flow from the 3:1 and all performed with directed high-volume suction. Dry guards, cotton wool or gauze can also help with drying and moisture control. 10

Preparation for reopening Getting back to practice o Emergency drugs to be checked o Check servicing folders to ensure everything is in date to allow us to open o Some of the reception and nursing team to return to work o One-to-one meetings as needed o Reception & waiting rooms prepared including removal of all unnecessary items; establishment of Covid-19 station; marking out of social distancing measures o Surgeries prepared and waterlines to be tested/cleaned o Equipment testing o Stock check and orders placed o Diary zoning o The whole team come in for training day o One-to-one meetings as needed o Record all PPE o Mask fit testing and fit checking training (day may vary subject to availability) o Patient reopening policy emailed to patients, posted on the website and social media o Start contacting patients by phone, according to priority o Practice meeting to address any concerns or further training needs may be via zoom if needed. o Final checks to be completed Principle tasks Please refer to the checklist in ANNEX 2 and the key equipment checklist in ANNEX 31. Waiting room set-up and policies Reconfigure reception and there should be wall-mounted hand gel dispensers at the point of entry. A screening station should be established to allow patients’ temperature to be taken and the screening questions posed to the patients again. All magazines and all non-essential material should be removed, including drinks dispensers. There should only be chairs in the waiting room and if these cannot be spaced 2m apart we would suggest using laminated signs to indicate which chairs they can sit on still observing social distancing rules. Social distancing markings should also be made on the floor, 11

Posters that are framed or laminated can be retained on the walls but all items on the wall and surfaces should be capable of being cleaned with surface wipes. Waiting area should be scheduled for regular cleaning throughout the day including chairs and floor. Video consultations/phone calls may be set up for another time should further discussion be required or further appointment requires. Please refer to ANNEX 3 for the checklist. Posters The following posters should be displayed: o Front door – ANNEX 5 o Reception and waiting rooms – ANNEX 6, ANNEX 11, ANNEX 12 o Surgeries – ANNEX 4, ANNEX 13 o Staff room – ANNEX 10 o Toilets- ANNEX 7, ANNEX 8, ANNEX 9 Preparation for surgeries As per HTM105, all items not immediately required in a clinical room should be removed, a very minimalist approach should be considered sensible. This is more important now than ever Surfaces should be wiped clean and uncluttered Single use items should be used wherever possible We need to maximise aspiration to reduce the dispersion of aerosols. Ensure aspirator working optimally serviced, emptied and cleaned according to manufacturer’s guidance. o Check the fluid collection capability of your suction (aspirator) unit by measuring out one (1) litre of water and suctioning this up with a suitable aspirator tip attached. If the fluid is completely collected within one (1) minute, the unit is working optimally. o Use the correct aspirator tip for the suction unit: diameter/design, as some are better than others. Those with a lip seem to collect fluid better than a square end bore and close support (good four-handed dentistry support from the assistant). o Regularly clean through the suction pipework, ideally after each AGP. Need to set-up to enable avoidance of AGPs. This will include slow speed handpiece. Surgeries will be equipped with surface approved surface disinfectants in the decontamination process. The Water Safety instructions must be carried out in full as laid out in ANNEX 33. 12

Training for the team All team members will be fully trained in all of aspects of our new procedures. This will include: o Patient triage and screening o Revised patient journey o Use of PPE including fit testing and fit checking for respirator masks o Diary management and zoning o Decontamination process Please refer to ANNEX 14 for the training day agenda. MAKE SURE ON APPENDIX 14 We will also be doing some in-house, role specific webinars. The clinical team will join Andy Fenn for subjects like reducing aerosols, effective use of rubber damn and decontamination procedures. The Manager and Reception Teams will join Sarah Carney for topics such as diary management and the new patient journey. These will be an opportunity for you to ask us any questions you may have. Fit testing of respirator masks All team members will need to undergo fit testing for each type of FFP2/3 mask that they are going to use. These tests must be undertaken by each team member prior to their use of any respirator mask and for each change in manufacturer, model or size of mask available. Background Tight-fitting respirators (such as disposable FFP3 masks and FFP2 masks) rely on having a good seal with the wearer’s face. A face fit test should be carried out to ensure the respiratory protective equipment (RPE) can protect the wearer. What is a respirator fit test? A fit test is a test protocol conducted to verify that a respirator is both comfortable and correctly fits the user. Fit testing uses a test agent, either qualitatively detected by the wearer’s sense of taste, smell, or involuntary cough (irritant smoke) or quantitatively measured by an instrument, to verify the respirator’s fit. Why is fit testing necessary? Fit testing each model of respirator the team member is to use in the clinical setting before their use is important to assure the expected level of protection is provided by minimizing the total amount of potential contaminant leakage into the facepiece. The benefits of this testing include better protection for the team member and verification that the team member is wearing a correctly-fitting model and size of respirator. Higher than expected exposures to a potential contaminate may occur if users have poor face seals with the respirator, which can result in excessive leakage. The size or shape of some team members’ face may mean that they fail the fit test with certain masks and they should NOT therefore use these masks and will need to be provided with a respirator for which they do pass the fit test. 13

How often must fit testing be done? Because each brand, model, and size of particulate facepiece respirators will fit slightly differently, a user should engage in a fit test every time a new model, manufacture type/brand, or size is worn. Also, if weight fluctuates or facial/dental alterations occur, a fit test should be done again to ensure the respirator remains effective. Otherwise, fit testing should be completed at least annually to ensure continued adequate fit Once I am fit tested can I use any brand/make/model respirator as long as it is the same size? No. A fit test only qualifies the user to don (put on) the specific brand/make/model of respirator with which an acceptable fit testing result was achieved. Users should only wear the specific brand, model, and size respirators that he or she wore during successful fit tests. What is a respirator user seal check? It is a procedure conducted by the respirator wearer to determine if the respirator is properly seated to the face. The user seal check can be either a positive pressure or negative pressure check, which are generally performed as follows: The positive pressure user seal check is where the person wearing the respirator exhales gently while blocking the paths for exhaled breath to exit the facepiece. A successful check is when the facepiece is slightly pressurized before increased pressure causes outward leakage. The negative pressure user seal check is where the person wearing the respirator inhales sharply while blocking the paths for inhaled breath to enter the facepiece. A successful check is when the facepiece collapses slightly under the negative pressure that is created with this procedure. A user seal check is sometimes referred to as a fit check. A user seal check should be completed every time the respirator is donned (put on). It is only applicable when a respirator has already been successfully fit tested on the individual. When should a user seal check be done? Once a fit test has been done to determine the best model and size of respirator for a particular user, a user seal check should be done by the user every time the respirator is to be worn to ensure an adequate seal is achieved. Facial hair You should be clean-shaven around the face seal to achieve an effective fit when using disposable respirators. Beards and stubble will stop the disposable respirator sealing to your face and protecting you properly. Other pre-use checks Make sure the disposable respirator is clean and undamaged before you use it. 14

Patient Communication The importance of communicating with patients at this time cannot be underestimated, and a consistent message should be used at all times and be understood by all team members: o What the clinic is doing to prevent virus transmission and protect the patients o An understanding of Covid-19 to avoid misinformation o Increasing adoption of Telemedicine, remote consultation and online channels to pre- screen and review patients. These measures are likely to remain as standard practice in the long term. Reopening letter to patients Please refer to ANNEX 15 for a copy of the patient letter informing them of our reopening, Social media posts In addition to the letters sent out, we will have messages posted on their social media platforms. Diary Management Good diary management is going to be essential to protect patients and staff, and to maximise the treatment that we can provide for our patients. Diary management must be implemented to facilitate: 1. First appointments of the day to be prioritised for vulnerable patients (i.e. had organ or bone marrow transplant; having cancer treatment including chemotherapy, antibody or immunotherapy, or radiotherapy; have a severe lung condition; have a disease which makes them at very high risk of getting infections, e.g. SCID or sickle cell; taking medicines that make them much more likely to get infections, e.g. high doses of steroids; have a serious heart disease AND are pregnant). 2. Block sessions for non-aerosol generating appointments. 3. Aerosol-generating procedures to be planned prior to breaks in the diary, e.g. before morning break, before lunch, before afternoon break and at the end of the day. 4. Next appointment not to be booked for 30 minutes after the end of an AGP appointment. This period may be reduced. 5. Where a spare surgery is available, this may be used by a clinician to reduce idle time after completing an AGP. 15

6. Hygiene appointments will remain at the same duration and interval as historically, with treatment being performed with hand scaling only to avoid AGP. 7. Bespoke approach for each clinic to suit available staff and planned working patterns 8. Staggered appointment times: minimise congestion in the practice and maximise social distancing 9. End of the day: cleaning time, additional PPE, aspirator removal or control using high volume external aspirator. Staff with additional protective items 10. Splitting dental team/ shift pattern: extend work hours reducing number of patients at one time, reduce whole team risk exposure. 11. Time should be made available for emergency appointments. 16

Personal Protective Equipment During periods of widespread community transmission of Covid-19, while we are making every effort to avoid Covid-19 patients from coming to the practice, we will provide dentists with the PPE appropriate to the type of care they are providing with an assumption that all patients present a risk of transmission of the virus: PPE summary for staff Good hand hygiene Waiting room Surgery – non Surgery – AGP Steri’ room Yes AGPs procedures Yes Disposable gloves No* Yes Yes No Disposable apron Yes No Yes Yes Fluid resistant Yes gown Yes Yes No No Fluid resistant Yes surgical mask No No Yes FFP2/FFP3 masks Yes Yes Yes, over Eye protection respirator masks (visor) No No FFP2/FFP3 Yes Yes Yes *Heavy duty should be used in the decontamination room as normal, as per HTM105. This summary is also shown in ANNEX 16 in case you would like to print and laminate it. Non-AGP treatment of all patients involves compliance with standard infection control procedures. This will ensure there is no contact or droplet transmission of Covid-19. Eye protection, disposable fluid- resistant surgical mask (Type IIR FRSM), disposable apron and gloves should be worn. No home clothes should be worn. For all AGPs, to prevent aerosol transmission, fluid-repellent gown/long sleeve apron, gloves, eye protection (with visors being preferred) and an FFP3 respirator should be worn by those undertaking or assisting in the procedure. No home clothes should be worn. HSE advises that if FFP3 is not available FFP2 is permissible but requires to be fit-tested. In all cases, FFP3 masks must be: o Fit-tested may be required on all healthcare staff who may be required to wear an FFP3 mask to ensure an adequate seal/fit according to the manufacturers’ guidance as deemed. to our risk assessment. o Fit-checked (according to the manufacturers’ guidance) by staff every time an FFP mask is donned to ensure an adequate seal has been achieved o Compatible with other facial protection used – i.e. protective eyewear – so that this does not interfere with the seal of the respiratory protection; regular prescription glasses are not considered adequate eye protection o Disposed of and replaced if breathing becomes difficult, the mask is damaged or distorted, the respirator becomes obviously contaminated by respiratory secretions or other body fluids, or if a proper face fit cannot be maintained; o Shielded from ‘splatter’ in situations where FFPs are used for a ‘session’ with a fluid resistant surgical mask or visor to protect the respirator from droplets; a session ends when the healthcare worker leaves the care setting/exposure environment; sessional use should always be risk assessed; PPE should be disposed of after each session or earlier if damaged, soiled, or uncomfortable. 17

PPE for Reception Staff Reception staff are not required to wear PPE. Please see below for PPE to be worn should they leave the protected reception desk area. PPE for team members greeting patients and undertaking screening These team members should wear surgical masks, a disposable apron, gloves and visors. PPE for patients and visitors PPE summary for patients/visitors Good hand hygiene Visitors e.g. Patients in Patients for non Patients for AGP delivery waiting area AGP appointments Disposable gloves men/women only appointments Yes Disposable apron No Yes Yes Yes No Fluid resistant gown No No No No Fluid resistant surgical mask No No No No FFP2/FFP3 masks No No No No No Eye protection No Yes No No No No No No No N.B. Wherever possible, those who accompany patients to their appointments should wait in the waiting room and not go into the surgery when the patient is being treated. If this is unavoidable, the person accompanying them must wear the same PPE as the team members. In the interest of time, it is important to establish if someone will be accompanying the patient prior to their appointment. Adult patients will be asked to attend alone unless with a carer and children with one adult only. All other family will need to wait outside/in the car. This summary is also shown in ANNEX 16 in case you would like to print and laminate it. PPE Use Guidelines Guidance on use of the PPE including putting it on (donning) and taking it off (doffing), must be followed carefully. This guidance can be found in: o Requirements - please refer to ANNEX 16 o Putting on (donning) - please refer to ANNEXES 17, 18, 21, 22. o Taking off (doffing) - please refer to ANNEXES 19, 20, 23. o Laundry – please click here o Mask fit-checking – please refer to ANNEX 30 18

The New Patient Journey Patients’ perspective We have given consideration to the design of the patient journey including remote diagnostics and pre-visit triage measures and protocols to ensure our team and patients are kept safe at all times. o Patients will be contacted 3 days prior to their appointment ideally to send them the medical questionnaire and Covid-19 questions. They will also be asked to prepay for treatment by BACS or card over the phone. o If your Dentist/therapist/hygienist would like patients to be triaged before booking an appointment please see questions in ANNEX 24. o If the need for an appointment is determined, before booking it, the screening questions as per ANNEX 25 must be put to the patient to determine whether they have symptoms of Covid-19 or whether they may be at particularly high risk of infection. Patients will be warned not to be early or late for their appointment. The questions have already been added to your custom screens on SOE as shown below. o If patients need to cancel due to illness, remember we are encouraging only those patients who are well and free from possible virus infection to attend for their appointment. To protect you and other members of society, we will typically not be imposing any last-minute cancellation fees. It is important that patients if unwell, do not attend for their appointment but, they should be advised to let us know. o On the day of the appointment, patients will only be allowed into the practice when the practice is ready to accept the patient. Patients will be called to let them know that they can enter the practice. • Where possible if they have anyone accompanying the patient they should remain outside of the practice (if they must come in they will need to be screened in the same way as the patient). o Patients will have their temperature taken at the front door before being allowed in. If their temperature is over 37.8 degrees C their temperature should be taken a second time. If the second reading indicates a temperature over 37.8 degrees then the patient must be asked to rebook at least 7 days later. o If the patients’ temperature is below 37.8 degrees they should be asked to use sanitising hand gel. • They will then be directed to a screening station where they will be asked the screening questions as per ANNEX 25 and have their temperature recorded. Any patient exhibiting symptoms of Covid-19 will be asked to go home and their appointment rescheduled. o Any forms such as medical histories should be signed by the receptionist with a note ‘signed on behalf of the patient due to Covid-19’. We have checked with the BDA that this is acceptable. o When the patient is called into the surgery, they should be asked to put their belongings, such as coats and bags, into the clear plastic boxes provided. o Treatment: This will have been decided on the basis of the pre-treatment screening. Such that AGP or non-AGP will be planned for rather than reactive. Please refer to ANNEX 26 for the chairside checklist to be used in surgery. o Prior to treatment, the patient may be asked to gargle and rinse their mouth with a hydrogen peroxide (1.5%) mouthwash. 19

o After treatment, patients should be asked to wash their hands and then asked to take their belongings from the storage box before being directed out of the practice and only taken to Reception if absolutely necessary. Consider confidentiality due to 2m distancing rules. Patients will be encouraged to pay prior to attending. Where possible use contactless technology for all interactions. Where this is not possible, ensure that the pen, keypad etc. must be disinfected after each use. If we do not have a ready supply of disposable pens, then patients should be asked to bring their own. o Patients will be advised that they will be contacted by phone or email to make their next appointment. The patient journey is show in ANNEX 27 which will be personalised for each of your practices using your own logo and colours. Diagram appendix annex 27 Screening questionnaire have been added to SOE custom screens – please refer to ANNEX 30 for instruction See picture 20

Staff perspective As soon as a patient books an appointment, send them Medical history form and Covid Questions. Ask them to return it immediately if possible. Covid questionnaire will need to checked again during screening process. We will also take prepayment for the appointment which should be taken when booking, BACS or over the phone. Call the patient if waiting in the car park or to confirm where they are if travelling by public transport. If they are going to be late, this may mean they cannot be seen, and the appointment will have to be rescheduled. Confirm the patient details. The member of staff should be wearing the correct PPE (FRSM, gloves and eye protection) and open the door to the patient. They should confirm the patient’s identity and then take their temperature using the infrared thermometer. If the reading is over 37.8 degrees C, then you should take a second reading. If the second reading is over 37.8 degrees C, then the patient must be rebooked at least 7 days later. 3. If their temperature is below 37.8 degrees C you ask them to sanitise their hands using gel. They should then ask the Covid screening questions (ANNEX 25) and record their temperature reading obtained at the door in clinical notes. If the patient is accompanied by a parent/carer/translator, they will have to be Covid screened and have their temperatures taken also. Where possible other family members or those accompanying a patient should remain outside of the practice. If they have to come in they should be provided with the same PPE and asked to sit in the waiting room (the chairs will be set at 2 metres apart) and to keep their PPE on. The clinical team will call the patient/accompanying person (if necessary) into the surgery and they should be wearing the same PPE as the Dental team. Access to the clinical areas should be restricted to clinical personnel only and access should be controlled by cleansable signage (surgery in use). Patient is called in to the surgery and they should be asked to put their belongings in to the clear plastic boxes provided before washing their hands. All clinical staff to be wearing appropriate PPE depending on planned procedure. 1. Confirm patient D.O.B and consent to continue with exam/care 2. MH changes? 3. We may ask the patient to gargle and rinse for one minute with a pre-treatment mouthwash (hydrogen peroxide). 4. Confirm what is being provided based on pre-treatment screening (clinical staff should be prepared for AGP if this is required and hence be wearing correct PPE). Treatment planning discussions should be carried out and verbal consent gained. Treatment plans can be emailed to patients to avoid paper copies. 5. Avoid where possible any clutter in the surgery. Clear and clean surfaces essential. Avoid use of paper where possible. 21

6. If radiographs required, is it possible to carry out extra-oral imagery to avoid causing any coughing/gagging? If not try and limit radiographs taken unless essential at this stage. 7. Consider all opportunities to mitigate aerosol if planned, such as use of high-volume aspiration, placement of rubber dam, avoidance of obvious aerosol generation such as ultrasonic scalers and where possible turbines. If you have access to a speed increasing handpiece, use this in preference. 8. Try where possible to provide all care in one session (if possible) with patient consent. 9. Complete treatment and advise patient of any post-treatment requirements. 10. The patient can then be directed out of the practice and told further appoints will be made by email/phone. Remove PPE except mask and carry out appropriate hand hygiene according to donning/doffing guide (ANNEXES 17-23 for PPE and ANNEXES 28 and 29 for hand hygiene). Vacate the surgery wearing your mask. Ensure mandatory down time is allowed (20 minutes mandatory and possibly more) before decontamination is carried out using correct protocols. Patient Screening It is important that we are reducing the risk to ourselves and our patients by treating those who are apparently free of virus. 1. Identify yourself, the dentist’s/clinicians name and ask to speak with the patient or the patient’s parent or legal guardian. 2. After explaining the purpose for the call, such as an appointment reminder, proceed with the Patient Screening Form questions (Covid-19). Positive responses to any of these would indicate a deeper discussion with the dentist before proceeding with agreeing to any elective dental treatment. Please see ANNEX 25 which have been added to your SOE custom screens. These questions are: o Have you tested positive for Covid-19? o Have you a raised temperature or fever? (feel hot to touch on your chest/ back) o Do you have a new continuous cough? (1hr recurrently or 4+ episodes/24hr) o Do you have partial/total loss of your sense of smell or taste? o Have you been in isolating with symptoms in the past 14 days? o Have you been in contact or does your household exhibit any flu like symptoms? o If response is NO for all answers above, then presumed Covid-19 negative may be documented in the patient’s clinical records. o If response is YES for COVID symptoms, then presumed Covid-19 positive may be recorded. If the patient needs urgent or emergency treatment, they should be referred to a local Urgent Dental Centre for treatment. 22

3. Inform patients that these questions (Covid-19) will be repeated and their temperature will be taken when they arrive at the practice in order to ensure nothing has changed since the phone conversation. Remind patients/guardians to limit extra companions on their trip to your practice to only essential people in order to reduce the number of people. Adults will be asked to attend alone unless with a carer and children with one adult only. If patients/parents/guardians seem reluctant in any way, reassure them that although this may seem strange, it is all being done out of an abundance of concern for their health, as well as that of the other patients being seen in the practice, the dentist and the staff, and any public with whom they might come in to contact. If you need to leave a voicemail or are sending a text message, ask the patient to call the practice prior to their appointment for preliminary screening. The completed document should be scanned and saved as part of the patient notes. Please remember to confirm the patient’s details, in particular their email address and phone number which will be more important now than before. Testing In-practice Covid-19 testing (or self-testing) (3-5 days prior to appointment / same day / next day) may become the norm in future. Testing of patients for the presence of antibodies will become available and will form part of the prescreening process with time. We will advise you of this when it becomes available. Ideally, staff treating patients in the clinic should be tested. We will adopt these measures as and when they are advised. 23

Clinical protocols In performing treatment, clinicians should focus on avoiding aerosol generation when possible and limiting the dispersion of any aerosol produced. For example: When patient is in surgery Clinical protocols Rubber dam Mouth rinse access to surgery should be controlled (sign on door “surgery occupied”) 4 Handed Dentistry Radiographs use should be considered as important in reducing field of exposure, Impressions aerosol load in the air and viral load of aerosol Lab work Patients may be asked to rinse with povidone-iodine or hydrogen peroxide for 60 seconds prior to the commencement of treatment Work 4-handed to ensure maximal support and avoidance of poor aspiration technique. Extra oral radiography should be considered as an alternative to intra-oral where appropriate Where available, digital scanning should be adopted to reduce bacterial, fungal and viral contamination. Where analogue impressions are taken, these must be appropriately rinsed and disinfected and labelled before sending to the technician On receipt of laboratory items, these must be disinfected before try- in/fitting in the patient’s mouth. The clinic should re- disinfect prosthetic work before insertion into the patient’s mouth. Non-aerosol procedures can include: 1. Examination, including BPE and taking radiographs (avoid the latter with gaggers and those prone to coughing). If possible, use extra-oral radiographs. Do not use High pressure 3:1 air syringe. However Risk of aerosols could be reduced when using a 3:1 if only the irrigation function is used, followed by low pressure air flow from the 3:1 and all performed with directed high-volume suction. Dry guards, cotton wool or gauze can also help with drying and moisture control. 2. Hand scaling a patient (EFP guidance recognises that hand scaling is as effective than ultrasonic scaling alone), irrigating pockets and carrying out a DPC (6PPC), combined with oral hygiene advice/home care. 3. Removal of caries carried out using a slow speed handpiece and hand instruments, adopting the ART approach. If high speed cutting is required apply rubber dam and use high volume aspiration. Where you have to resort to this, ensure that this is carried out as quickly as possible. Restoration of the cavity should ideally be carried out with rubber dam in place regardless of the materials used. 4. Restoration of a fractured tooth. Where the fracture does not require gross removal of hard tissues, consider using a soflex disc or equivalent to generate a bevel etc. can be carried out. If greater reduction is required (as above), apply rubber dam and use high volume aspiration. 5. RCT cases. These should always be carried out under rubber dam. Cut an initial access cavity with a suitable slow speed bur if possible. If this is not possible, access through enamel may be achieved using a high-speed handpiece under rubber dam with high volume aspiration. If a tooth is out of alignment with its neighbour teeth, consider quadrant isolation to ensure the access cavity alignment does not increase the risk of perforation. Post/core placement again ideally under rubber dam, should use a placement technique to minimise the need to overly prep the core for a crown. 24

6. Build up cases using composite. These should be completed under rubber dam and should not involve the need to use a high-speed handpiece. Where composite restorations are placed use the ‘addition’ technique or record an ‘occlusal stamp’ prior to any preparation to avoid the need for excessive and prolonged adjustment. Again, these should be provided under rubber dam 7. Orthodontic cases. At the bond up stage will there be a risk of some aerosol, but this can be minimised by using the 3:1 as water only, dabbing and air drying before bonding, with high volume aspiration before bonding. As with all dentistry, the support from a well organised and effective assistant is essential. Removal of composite at de-bonding can be achieved with some newly available instruments as well as the use of discs, with care and good aspiration. 8. Prosthodontics: removable. There is a low risk of aerosol when taking impressions, bite registration, try in or fit, but care should be taken to avoid stimulating coughing or gagging. Any adjustments with a straight handpiece should be after disinfection with a suitable virucidal agent and this would also go for the disinfection of impressions, try-ins and inserts. If a digital scanner is used, the correct disinfection procedures are performed post scanning using a suitable agent (that has virucidal action). 9. Oral surgery: We generally avoid high speed handpieces as they are likely to cause surgical emphysema. However, slow speed drilling can be associated with some aerosol generation. Implant placement may be carried out with the current protocols on non-vulnerable patients. The restoration of implants should be accomplished without significant aerosol generation. Hand scaling around cemented fixtures should be acceptable to ensure no excess cement is left. Cutting a crown preparation is the one process that is probably not advised during this period and simply because this has to be carried out for a vital tooth with copious irrigation from the built-in water ports of the handpiece and results in an obvious aerosol. As the process is typically extended by its very nature, the aerosol risk is probably the highest for any procedure other than ultra-sonic scaling and therefore conventional crown preparations, unless cut under rubber dam are not advised, and even if you could place rubber dam, the length of time that an aerosol is generated would increase the risk. If you have access to a speed increasing handpiece on a micromotor, you will reduce the degree of aerosol, but some irrigation will still be needed to avoid thermal injury to the pulp. 25

Containment ???? Subject to change -IS THIS TALKING ABOUT EXTERNAL ASPIRATORS ONLY. High volume external aspirator units should be given serious consideration. If the aerosol generated by the patient is “contained”, the risk of infection is very significantly reduced. Collection of the aerosol leads to a very significant reduction in air and surface contamination. (It also reassures the patient- a “step up” measure in infection management). We should: o Ensure aspirator is working optimally serviced, emptied and cleaned according to manufacturer’s guidance. o Check the fluid collection capability of your suction (aspirator) unit by measuring out one (1) litre of water and suctioning this up with a suitable aspirator tip attached. If the fluid is completely collected within one (1) minute, the unit is working optimally. o Use the correct aspirator tip for the suction unit: diameter/design, as some are better than others. Those with a lip seem to collect fluid better than a square end bore. Good four handed dentistry should be practised. o The suction should be flushed cleaned after every AGP. Any procedures should be carried out with a single patient and only staff who are needed to undertake the procedure present in the room with the doors shut. There have been some suggestions that aerosol is increased with rubber dam in place, however, the nature of the aerosol changes as saliva, blood, GCF (assuming dam well fitted) is excluded. Handling Lab Work Where analogue impressions are taken, these must be appropriately rinsed and disinfected and labelled before sending to the technician. On receipt of laboratory items, these must be disinfected before try-in/fitting in the patient’s mouth. The clinic should re-disinfect prosthetic work before insertion into the patient’s mouth. Hygiene Appointments The Standard Operating Procedures described previously for Non-AGPs and AGPs should be followed, as appropriate. o Hygienists will not be asked to see confirmed COVID-19 patients. o Down-time between appointments should not be necessary if no AGP is performed. o Hygienists, in the initial return to work phase, should have a dedicated nurse to help with high- power suction, PPE and decontamination. This will also help with a smooth patient journey. o Patient’s personal items should be placed in a sealed, lidded box if stored in the surgery. o Patients may be asked to rinse with an H2O2 mouthwash (e.g. Peroxyl™) for 60 seconds before any examination or treatment. o Oral hygiene instruction should be prioritised with the use of models although intra-oral demonstration is permitted, if necessary. 26

o The use of Non-AGP treatment should be prioritised in the initial phase. USS should be avoided, although their use has been shown to have a low chance of disease transmission. o Evidence proves that hand scaling is as effective as ultrasonic scaling alone. This should be carefully explained to patients who are used to USS, AirFLow™ or Prophy-Jets. o Thorough infection-control procedures will be provided by the dedicated dental nurse. o Polishing with prophy paste and slow handpieces (with cups or brushes) are considered “Splatter Generating” procedures rather than AGPs but we may consider not providing intially. o Irrigation of pockets with CHX gel or mouthwash is allowed with the use of appropriate suction. o Post-operative advice should be delivered as usual. At the end of the appointment the patient should be directed immediately out of the practice until protocols change. 27

Decontamination Decontamination following treatment should follow HTM01-05. In addition, when an AGP has been used, it is recommended that the room is left vacant with the door closed for 20 minutes performing a terminal clean (meaning an period of 30 minutes between appointments). The gap between AGP appointments is subject to change. Windows to the outside in neutral pressure rooms can be opened. If the room needs to be put back into use urgently, then it is recommended that the room is cleaned as in the guidance below. We are also exploring the potential of using hypochlorous acid either in a misting spray on in a fogging machine to further reduce the time required to eliminate any virus particles. Hand hygiene Hand hygiene, washing thoroughly with soap and water, is essential to reduce the transmission of infection. All dental staff and patients/carers should decontaminate their hands with alcohol-based hand rub when entering and leaving the practice. Hand hygiene must be performed immediately before every episode of direct patient care and after any activity or contact that potentially results in hands becoming contaminated, including the removal of PPE, equipment decontamination and waste handling. APPENDIX 28: Best practice – how to hand wash APPENDIX 29: Best practice – how to hand rub Management of the surgery As per HTM105, all items not immediately required in a clinical room should be removed, a very minimalist approach should be considered sensible. This is more important now than ever. Surfaces should be wipe clean and un-cluttered. Clinic rooms can be cluttered with papers and other items, all these items should be removed. Single use items should be used wherever possible. All team members should wash hands at regular intervals and in accordance with guidelines Cleaning protocols should be clear, with training of staff and monitored, to ensure safety All surfaces should be wiped between each appointment. Surgery floor should be cleaned at the beginning of the session, middle of the day and at the end of the day, using the agreed agents. High and low volume aspiration units attached to dental unit should be cleaned using a cleaning fluid between patients when the equipment has been used. Waste management to be considered with an increase in disposable products. We are also exploring the potential of using hypochlorous acid either in a misting spray on in a fogging machine to further reduce the time required to eliminate any virus particles. 28

Cleaning protocols The responsible person undertaking the cleaning with detergent and disinfectant should be familiar with these processes and procedures: Collect all cleaning equipment and clinical waste bags before entering the room. PPE must be worn for cleaning and disinfection of the room. Before entering the room, perform hand hygiene then put on PPE in correct order as per ANNEXES 17, 18, 21, 22 and 28 and 29. Cleaning and disinfection require the use of both detergent and disinfectant. This can be achieved in either a one stage clean process or in a two-stage clean process if a combined detergent and disinfectant wipe is not available. It is important to establish the type of wipe you are using prior to cleaning and disinfection. WHAT ARE WE GOING TO USE?? One Stage Clean Process Combined detergent Cleans and disinfects The dual detergent/disinfectant wipe specified by HPSC at and disinfectant wipe in one stage clean present for single stage cleaning and disinfection is a Detergent wipes process combined detergent disinfectant wipe equal to 1000 parts Disinfectant wipes per million (ppm) of available chlorine (av.cl.) (0.1% A neutral purpose solution). detergent followed by separate disinfection Two Stage cleaning process with wipes (1000 ppm av.cl.) (0.1% Used to clean only To be followed by disinfectant wipes or solution solution) Part 1 of 2 stage process Used to disinfect Require prior cleaning with detergent solution or only Part 2 of 2 detergent wipe stage process Two stage clean process with solution After cleaning with neutral detergent, a chlorine-based disinfectant should be used, in the form of a solution at a minimum strength of 1,000ppm (0.1% solution) available chlorine. Follow manufacturer’s instructions for dilution, application and contact times for all detergents and disinfectants – If using 50 ml Milton (note this is a 2% solution) & 950 mls water (1000 ppm available chlorine 0.1% solution) On completion of environmental cleaning and disposal of waste o Any cloths and mop heads must be disinfected or disposed of as single use items (TELL KATHRYN- WASHING MACHINE WEEKLY- HAVE ENOUGH) o Clean, dry and store re-usable parts of cleaning equipment, such as mop handle o Perform hand hygiene immediately after removing gloves o Waste should be disposed of as clinical waste and the bag sealed for disposal o Remove and discard PPE. Follow the order of removal of PPE as outlined in ANNEXES 19, 20 and 23. Please see ANNEX 26 for a chairside checklist. 29

Patient departure When patients have finished their treatment initially they will be asked to leave the practice and not stop via reception. This protocol will change over time. We will call them regarding the next appointment. We will aim to take prepayment. Should they need to stop at reception, minimise contact and you must maintain the 2m rule. Things like treatment plans should ideally be emailed to the patient to avoid unnecessary paperwork. Staying up to date Prepare to receive communications in the following ways: 1. Email 2. Phone Calls 3. Zoom meetings 4. Face to face with social distancing as much as reasonably possible. We will use a variety of additional methods to keep you informed of the emerging situation, alongside Royal Colleges, regulators and professional bodies. Medication prescription & delivery Dentists should note that given the current Covid-19 situation, community pharmacies are busier than usual. Therefore, it is advised that all emails are followed up by a phone call to avoid a delay to patients getting their prescription items. Practices should liaise with their local pharmacies to continue the arrangements in place during the shutdown are continued in lieu of electronic prescribing. Medication prescription & delivery Delivery of prescription items Shielded patients Pharmacies are required to act as a ‘backstop’ for delivery of medicines for shielded patients and therefore, the following can be advised to them: o Where patients currently have prescriptions delivered to them, or collected for them by a nominated carer, friend or volunteer, they should continue to do this. There are also online pharmacies that provide delivery. o If the patient does not currently have their prescriptions collected or delivered, they can arrange this by asking someone who can pick up their prescription from the local pharmacy this includes asking a volunteer (this is the best option, if possible) Non-shielded patients Pharmacies are not required to act as a ‘backstop’ for delivery of medicines to non-shielded patients including those self-isolating with possible COVID-19. Normal arrangements apply, where patients make their own arrangements, which includes in some cases the pharmacy delivering to them. Preparation for incident management for unwell patients with possible/confirmed COVID19. 30

Service providers may wish to draw on their existing protocols for dealing with medical emergencies in practice, as the incident management principles are the same: o Develop and rehearse the service provider’s COVID-19 triage protocols and isolation procedures: o agree practice approach for each stage of the potential scenarios o confirm role and responsibilities for each staff member o appoint an incident manager o confirm lead for discussions with patients/NHS 111 o prepare an aide-memoire for staff o rehearse practice response. o Review the coronavirus infection prevention and control protocols here. o Anticipate impacts on service schedule. Practices are advised to review the likelihood of disruption to services and prioritise the most urgent clinical work on the day. Non-clinical cleaning protocols Experience of new coronaviruses (SARS-CoV and MERS-CoV) has been used to inform this guidance. The risk of infection depends on many factors, including: o the type of surfaces contaminated o the amount of virus shed from the individual o the time the individual spent in the setting o the time since the individual was last in the setting The infection risk from coronavirus (Covid-19) following contamination of the environment decreases over time. It is not yet clear at what point there is no risk. However, studies of other viruses in the same family suggest that, in most circumstances, the risk is likely to be reduced significantly after 72 hours. What you need to know Cleaning an area with normal household disinfectant after someone with suspected coronavirus (Covid- 19) has left will reduce the risk of passing the infection on to other people Wear disposable gloves and aprons for cleaning. These should be double-bagged, then stored securely for 72 hours then thrown away in the regular rubbish after cleaning is finished Using a disposable cloth, first clean hard surfaces with warm soapy water. Then disinfect these surfaces with the cleaning products you normally use. Pay particular attention to frequently touched areas and surfaces, such as bathrooms, grab-rails in corridors and stairwells and door handles If an area has been heavily contaminated, such as with visible bodily fluids, from a person with coronavirus (Covid-19), use protection for the eyes, mouth and nose, as well as wearing gloves and an apron Wash hands regularly with soap and water for at least 20 seconds, and after removing gloves, aprons and other protection used while cleaning Public areas should be cleaned regularly during the day with especial attention being paid to high-touch areas such as door handles 31

If a risk assessment of the setting indicates that a higher level of virus may be present, for example, where there is visible contamination with body fluids, then the need for additional PPE to protect the cleaner’s eyes, mouth and nose might be necessary. The local Public Health England (PHE) Health Protection Team (HPT) can advise on this. Non-healthcare workers should be trained in the correct use of a surgical mask, to protect them against other people’s potentially infectious respiratory droplets when within 2 metres, and the mask use and supply of masks would need to be equivalent to that in healthcare environments. Cleaning and disinfection Public areas where a symptomatic individual has passed through and spent minimal time, such as corridors, but which are not visibly contaminated with body fluids can be cleaned thoroughly as normal. All surfaces that the symptomatic person has come into contact with must be cleaned and disinfected, including: o objects which are visibly contaminated with body fluids o all potentially contaminated high-contact areas such as bathrooms, door handles, telephones, grab-rails in corridors and stairwells. Use disposable cloths or paper roll and disposable mop heads, to clean all hard surfaces, floors, chairs, door handles and sanitary fittings, following one of the options below: o use either a combined detergent disinfectant solution at a dilution of 1,000 parts per million available chlorine or o a household detergent followed by disinfection (1000 ppm av.cl.). Follow manufacturer’s instructions for dilution, application and contact times for all detergents and disinfectants or o If an alternative disinfectant is used within the organisation, this should be checked and ensure that it is effective against enveloped viruses Avoid creating splashes and spray when cleaning. Any cloths and mop heads used must be disposed of and should be put into waste bags as outlined below. When items cannot be cleaned using detergents or laundered, for example, upholstered furniture and mattresses, steam cleaning may be needed. Any items that are heavily contaminated with body fluids and cannot be cleaned by washing should be disposed of. 32

Staff room protocols 1. You may need to stagger changing into uniforms. Once you have changed please leave the room immediately so it can be used in an efficient manner. 2. Social distancing should be observed as much possible. 3. Where possible, team members should use their own cups, plates and cutlery. 4. Each team member must wash their cups, plates and cutlery immediately after use. 5. Food kept in the fridge should be kept in sealed containers. 6. Windows should be left open if possible. Please see ANNEX 10 for a poster you can print, laminate and display in the staff room. Laundry Uniforms and reusable gowns should be removed and placed into a clean pillowcase. The laundry can be taken home and placed straight into the washing machine. They should be washed as normal at 40 degrees or higher and must be washed separately to other clothes. Waste Waste from possible cases and cleaning of areas where possible cases have been (including disposable cloths and tissues): 1. Should be put in a plastic rubbish bag and tied when full. 2. The plastic bag should then be placed in a second bin bag and tied. 3. It should be put in a suitable and secure place and marked for storage until the individual’s test results are known. Waste should be stored safely and kept away from children. 33

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