IR(ME)R local rules (dental)

1. What the regulation says

The Ionising Radiation (Medical Exposure) Regulations 2017 are the primary law for medical radiation exposures and are not held in the Verivius regulation manifest, so the verbatim quotes below are from the engaged CQC regulation, Regulation 12 (safe care and treatment). Read them alongside the IR(ME)R 2017 text at the primary source URL.

Care and treatment must be provided in a safe way for service users. (Reg 12(1) (the headline duty))

assessing the risks to the health and safety of service users of receiving the care or treatment, (Reg 12(2)(a) (risk assessment))

doing all that is reasonably practicable to mitigate any such risks, (Reg 12(2)(b) (risk mitigation))

ensuring that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely, (Reg 12(2)(c) (staff competence))

ensuring that the equipment used by the service provider for providing care or treatment to a service user is safe for such use and is used in a safe way, (Reg 12(2)(e) (equipment safety))

The full text of the engaged CQC regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/12 and the full text of IR(ME)R 2017 is at https://www.legislation.gov.uk/uksi/2017/1322/contents. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

Care and treatment must be provided in a safe way. The regulation lists the areas a provider must address, including risk assessment, risk mitigation, staff competence, safe premises, safe equipment, sufficient equipment and medicines, medicines safety, infection prevention and shared-care planning. Regulation 12 is central to CQC's safety expectations. For dental radiography, the IR(ME)R 2017 framework sets the detailed duties on top of this safe-care baseline.

3. Purpose and scope

These local rules set out how the Practice manages dental radiography under the Ionising Radiation (Medical Exposure) Regulations 2017 and related guidance.

The Practice must verify these rules against the current IR(ME)R 2017 legislation, the 2024 amendment guidance and its appointed radiation protection advisers before adoption.

They apply to every dental radiographic exposure carried out by or on behalf of the Practice, every location and item of imaging equipment, all referrers, practitioners and operators entitled under the employer's procedures, and staff who maintain records, equipment or the quality assurance system.

Before adoption, the Practice must record the legal employer, entitled duty holders, equipment and locations, adviser contacts, local diagnostic reference arrangements, notification decision route and the exact employer's procedures in force.

4. Sources to verify before adoption

• Ionising Radiation (Medical Exposure) Regulations 2017: https://www.legislation.gov.uk/uksi/2017/1322/contents
• GOV.UK guidance to IR(ME)R 2017, updated 4 September 2024: https://www.gov.uk/government/publications/the-ionising-radiation-medical-exposure-regulations-2000
• CQC IR(ME)R notification criteria: https://www.cqc.org.uk/guidance-providers/ionising-radiation/ionising-radiation-medical-exposure-regulations-irmer/criteria-making-notification
• GDC Standards for the Dental Team, Principle 7 and relevant record-keeping standards: https://standards.gdc-uk.org/
• HCPC standards of proficiency for radiographers, where a radiographer-linked role is involved: https://www.hcpc-uk.org/standards/standards-of-proficiency/radiographers/
• HSE ionising radiation legal base for staff and public exposure context: https://www.hse.gov.uk/radiation/ionising/legalbase.htm

5. Equipment inventory

The Practice keeps a current inventory of radiography equipment. The inventory includes:

• intra-oral X-ray units
• panoramic equipment, including OPG where used
• cephalometric equipment where used
• CBCT equipment where used
• handheld X-ray equipment where used
• image receptors, sensors and processing equipment
• software used for image capture, storage and reporting

For each item, the inventory records:

• manufacturer and model
• serial number
• location
• date installed
• date of last service
• date of last quality assurance check
• radiation protection adviser or medical physics expert contact where applicable
• local procedure linked to that equipment

6. Duty holders

The Practice records named people or role holders for each IR(ME)R duty holder.

• Employer: the legal person or organisation responsible for the radiography service. The employer ensures employer's procedures, protocols, quality assurance programmes and training arrangements are in place.
• Referrer: the person entitled under the employer's procedures to refer a patient for a dental radiographic exposure.
• Practitioner: the person entitled under the employer's procedures to justify the exposure.
• Operator: the person entitled under the employer's procedures to carry out practical aspects of the exposure.
• Medical physics expert: the person or service providing expert advice where the current IR(ME)R framework requires it.
• Radiation protection adviser: the adviser for workplace radiation protection arrangements under the wider ionising radiation framework.

The same person may hold more than one role only where the current IR(ME)R source and employer's procedures allow it.

Operational roles and responsibilities

• Legal employer: approves and maintains the employer's procedures, entitlement framework, protocols, quality assurance programme, training controls and investigation arrangements required by the current law.
• Registered Manager: checks that the local system is operating, keeps evidence available for CQC and governance review, and makes sure incidents, risks and actions are followed through. This role does not replace the legal employer or an IR(ME)R duty holder.
• Radiation lead: keeps the inventory, entitlement records, adviser contacts, audit schedule and local documents current, and escalates gaps to the employer and Registered Manager.
• Practitioner and operator: act only within recorded entitlement, complete their own legal functions and stop when the referral, justification, patient, equipment or exposure instruction is unclear.
• Radiation protection adviser and medical physics expert: provide advice within their appointed scope. The Practice records advice received and the decision taken rather than treating advice as an undocumented conversation.

7. Justification process

No dental radiographic exposure is made until it has been justified and authorised according to the employer's procedures.

Before justification, the practitioner considers:

• the clinical question
• the patient's history and previous imaging where available
• whether a non-radiographic option can answer the question
• the expected benefit to the patient
• the radiation risk, including patient age and pregnancy status where relevant
• the equipment and exposure setting proposed

The Practice does not use standing wording from this template as a substitute for the current IR(ME)R justification requirements. The employer's procedure must cite the current source.

Step-by-step exposure procedure

1. Receive a valid referral. Confirm the referrer is entitled and the referral identifies the patient, clinical question and examination requested.
2. Identify the patient and check relevant information. Use the local identifier standard, review previous imaging where available and apply pregnancy-enquiry procedures where relevant.
3. Justify and authorise. An entitled practitioner weighs the expected benefit and radiation risk and records the decision before exposure.
4. Select and optimise the exposure. An entitled operator chooses the approved protocol and patient-specific settings, then checks positioning and equipment readiness.
5. Carry out and record the exposure. Record the operator, equipment, exposure details, image quality and any deviation or repeat.
6. Evaluate and report. Make sure the image receives the required clinical evaluation and the outcome reaches the patient record and responsible clinician.
7. Escalate an exception. Stop and follow the accidental or unintended exposure process for a wrong patient, wrong examination, equipment fault, significant dose concern or other suspected failure.

8. Optimisation

The Practice keeps exposures as low as reasonably practicable while still achieving an image that answers the clinical question.

The local optimisation procedure covers:

• selection of equipment and exposure setting
• patient positioning
• collimation and beam alignment
• use of rectangular collimation where adopted by the Practice
• repeat-image reduction
• image-quality grading and review
• child-specific and pregnancy-specific considerations
• CBCT-specific protocols where CBCT is used

The Practice reviews repeat images as part of clinical audit.

9. Dose recording and image records

The Practice records radiographic exposure information in the patient record or linked radiography record according to the local procedure.

Records include:

• reason for the exposure
• date
• equipment used
• operator
• practitioner or authoriser
• exposure type
• dose information where the equipment provides it
• image-quality assessment
• report or clinical interpretation
• repeat exposure reason where applicable

Radiographs, consent forms and related recordings form part of the patient record under GDC record-keeping standards. The Practice verifies the detail against GDC Principle 4 before adoption.

10. Accidental or unintended exposure

The Practice has a written process for suspected accidental or unintended exposure.

The process includes:

• immediate clinical review
• securing relevant equipment and records
• informing the Registered Manager and radiation lead
• recording the event in the Practice incident register
• seeking advice from the radiation protection adviser or medical physics expert as applicable
• assessing whether CQC notification criteria are met
• informing the patient where required by duty of candour or local procedure
• documenting corrective action and learning

Staff do not decide notification thresholds from memory. The Practice checks the current CQC IR(ME)R notification criteria and current IR(ME)R guidance before making a notification decision.

11. Quality assurance, audit and monitoring cadence

The Practice keeps a radiography quality assurance schedule for each equipment type.

The schedule covers:

• routine image-quality review
• reject and repeat analysis
• equipment performance checks
• service and maintenance
• staff competency review
• clinical audit
• local procedure review

The Practice must set the exact frequency and check type from the current IR(ME)R guidance, equipment manufacturer's instructions and adviser recommendations. This template does not restate regulatory test intervals.

12. Training requirements

Staff only act as referrer, practitioner or operator where the employer's procedures entitle them to do so and their training record supports the role.

The training record includes:

• GDC registration role where relevant
• HCPC registration role where relevant
• IR(ME)R training completed
• equipment-specific training
• CBCT-specific training where relevant
• date of competency sign-off
• refresher review date
• scope limits, such as intra-oral only or CBCT excluded

The Practice checks current GDC and IR(ME)R expectations before approving role entitlement.

13. Review and document control

The Registered Manager reviews these local rules:

• annually
• after equipment change
• after role-holder change
• after a reportable or potentially reportable exposure incident
• after source-material change

Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.

14. Related policies in this pack

• Consent for treatment policy
• Incident reporting, investigation and learning policy
• Record keeping and documentation standards policy
• Training, competency and mandatory training policy
• Safe care and treatment policy

15. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

• Ionising Radiation (Medical Exposure) Regulations 2017 (https://www.legislation.gov.uk/uksi/2017/1322/contents)
• Ionising Radiations Regulations 2017 (IRR17)
• CQC Regulation 12: Safe care and treatment (https://www.legislation.gov.uk/uksi/2014/2936/regulation/12)
• CQC dental radiation expectations and IR(ME)R notification criteria
• Radiation protection adviser (RPA) and medical physics expert (MPE) advice
• CQC Fundamental Standards
• GDC Standards for the Dental Team
• HCPC standards of proficiency for radiographers, where a radiographer-linked role is involved

16. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

17. Document control

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the provider's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.