Sample policy · Dermatology

Minor skin surgery and specimen handling policy (dermatology)

Statutory anchor: Regulation 12 (safe care and treatment), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). · primary source

1. What the regulation says

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))

where responsibility for the care and treatment of service users is shared with, or transferred to, other persons, working with such other persons, service users and other appropriate persons to ensure that timely care planning takes place to ensure the health, safety and welfare of the service users. (Reg 12(2)(i) (shared / transferred responsibility))

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/12. 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.

3. Purpose

A dermatology service removes and biopsies skin lesions. Two things must not go wrong: the right lesion must be removed from the right patient, and the specimen must reach the laboratory, be matched to the patient, and the result acted on. A lesion excised but never sent, or a malignant result never seen, is a serious harm. This policy sets out how the Service carries out minor skin surgery safely and handles specimens and results so none is lost.

The Service must verify this policy against current British Association of Dermatologists and Royal College of Pathologists guidance before adoption.

4. Sources to verify before adoption

5. Scope

This policy applies to:

6. Roles and responsibilities

7. Right patient, right lesion, right site

8. Consent and the procedure

9. Specimen handling

Every specimen is handled so it reaches the laboratory correctly matched to the patient:

A lesion that may be cancer is never simply discarded; it is sent for histology, or referred for the patient to be diagnosed by a service that will.

10. Acting on results: the fail-safe

The single most important step after surgery is that the result is seen and acted on:

11. Required procedure and specimen record

The record includes:

The specimen log and clinical record must reconcile. A blank field, conflicting site or missing responsible clinician is corrected before the specimen leaves the service wherever possible.

12. Wound care and follow-up

The patient is given clear aftercare advice, including wound care, the signs of infection, when stitches come out, and how to get help. The follow-up needed to give the result and any further treatment is arranged and recorded.

13. When something goes wrong

A wrong-lesion excision, a labelling mismatch, a lost specimen, or a missed or delayed result is treated as a patient-safety incident and logged in the incident register on the day it is identified. The Service investigates the event, considers the duty of candour threshold and changes the system to prevent a repeat.

Repeated delays, an unresolved laboratory-interface risk or a backlog that could affect patients is also entered in the risk register. Every investigation or audit action has an owner, due date and closure evidence in the improvement action plan. Closing the incident does not close the action automatically.

14. Training

Clinicians performing minor skin surgery are trained and competent for the procedures they do, and staff who handle specimens and results are trained in labelling, tracking and the fail-safe. The Service records who is competent and the next refresher date.

15. Audit cadence

The clinical lead checks the outstanding-specimen log every working week. Each month, they audit 10 completed procedures or all procedures if fewer than 10 occurred, and confirm that:

The Registered Manager and the clinical lead review the results each month and record the improvement actions that follow. Any unaccounted-for specimen, unreviewed result or overdue urgent action is escalated on the day it is found rather than waiting for the meeting.

16. Related policies in this pack

17. 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.

18. 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.

19. Document control

Version Date Author Changes
v1.1 2026-07-19 Verivius (sample) Added named roles, specimen evidence fields, register links, related policies and a measurable audit cadence.
v1 2026-06-10 Verivius (sample) Initial sample template, conformed to the Verivius policy standard.

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.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

Minor skin surgery is short, routine and usually uneventful, which is what makes it deceptive. The harm rarely happens in the treatment room. It happens weeks later, when a report naming a melanoma or an incompletely excised basal cell carcinoma sits unread in a tray and nobody is waiting for it. A patient with several similar lesions on their back cannot check the clinician's choice for themselves, so the mark they look at and agree to before the skin is cleaned is often the only independent confirmation that the right lesion is coming off. Two specimens from one patient, or two patients on one list, are the classic points where a pot and a person come apart, and a mislabelled skin specimen cannot be put right: the tissue has already gone and it cannot be taken again. The practical test is whether the service can say, on any given morning, which specimen belongs to whom, who owns each result and which results are still outstanding. A service that can answer that has something true to tell an anxious patient who rings on a Friday afternoon, and it has it long before anyone comes to look.

  1. Every specimen sent is tracked until its result is back and an overdue result is chased, so the system does not rely on the result simply turning up.

    Strong evidence: The specimen log reconciled against the clinical record, the named clinician responsible for the result, and the clinical lead's weekly check of the outstanding-specimen log (sections 10 and 11, audit cadence section 15).

    Weak evidence: A specimen log that records only what was sent, with no expected result date and no date the result came back, so nothing can be shown to be outstanding and nobody can say how many results are in flight today. The clearest tell is an overdue histology result that surfaces because the patient rang to ask, rather than because the log was reconciled against the clinical record.

    What the regulator expects to see. Not a law in itself, but CQC judges you against it, so an inspector will look for it and expect a reason where you depart from it.

  2. Staff confirm the correct patient and the correct lesion and mark the site before surgery, using at least three identifiers, rather than assuming it from the notes.

    Strong evidence: The record of the three identifiers and the identity of the staff who completed the check, plus the site-mark confirmation the patient agreed (sections 7 and 11, monthly audit).

    Weak evidence: A consent form and an operation note that both name the lesion, but nothing showing who confirmed the patient's identity, which identifiers were used, or that the patient saw and agreed the site mark before the skin was cleaned. Where a patient has several lesions, an entry reading "lesion excised, back" with no side, no exact anatomical site and nothing tying it to the lesion that was described and marked leaves nothing to demonstrate the correct one was taken.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  3. The specimen pot carries the patient's identifiers and the exact site, labelled at the patient's side before the next case, with each lesion in its own pot, so nothing is confused on the way to the laboratory.

    Strong evidence: The specimen-pot identifier, anatomical site and time-placed fields, matched patient-to-laboratory in the monthly audit (sections 9 and 11, audit cadence).

    Weak evidence: Pots labelled at the reception desk or written up at the end of the list from a pile of forms, with the anatomical site left blank or recorded as "x2" for two lesions travelling in one container. If the time the specimen was placed in the pot is never filled in, there is no evidence the label was applied at the patient's side before the next case began.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  4. A lesion that may be cancer is never discarded: it is sent for histology, or the patient referred to a service that will diagnose it.

    Strong evidence: The specimen record of what was sent and when, and the request form giving the pathologist the clinical suspicion (sections 9 and 11).

    Weak evidence: A curettage or shave recorded as "lesion removed, benign appearance" with no specimen number and no entry in the log, so the decision not to send tissue was never made explicitly by a named clinician or reviewed by anyone. Equally thin is a referral mentioned in the notes with no copy of the letter, no acknowledgement from the receiving service, and nothing showing the patient actually got there.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  5. A malignant or unexpected result triggers prompt action, and the patient is told, with the record showing how and when, including where contact attempts failed.

    Strong evidence: The result interpretation and action field, and the record of how and when the patient was told with any unsuccessful contact attempts and safety-netting (sections 10 and 11).

    Weak evidence: A malignant or unexpected result filed with an initial, a date and the word "seen", but no record of what the clinician concluded, how urgent it was, or what was arranged as a result. Where the patient could not be reached, the weak version is silence: no note of the numbers tried, the times, the letter sent, or what the service will do next if there is still no answer. How many attempts are made and how they escalate is a Verivius default, not a prescribed sequence.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  6. A wrong-lesion excision, labelling mismatch, lost specimen or missed result is logged in the incident register on the day it is identified, and the Regulation 20 duty of candour, which is owed to the person and is not a notification, is considered against the notifiable safety incident threshold that applies to this provider type.

    Strong evidence: The incident-register entry dated the day of identification, the investigation, and the duty-of-candour consideration where the Regulation 20 harm threshold is met (section 13).

    Weak evidence: Wrong-lesion, mislabelling and lost-specimen events handled as laboratory administration and settled by phone or email, never entered in the incident register at all, or entered weeks later dated to the meeting that discussed them (same-day entry is a Verivius default, not a statutory deadline). A duty-of-candour field marked "not applicable" with no reasoning against the notifiable safety incident threshold that applies to this provider type, or an apology described as a conversation with no written account of what happened and what further enquiries will be made.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

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Last verified 20 July 2026

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Last reviewed 10 June 2026