Sample policy · Reg 15

Premises and equipment policy template

Statutory anchor: Regulation 15 (premises and equipment), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 12 (safe care and treatment). · primary source

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Verivius pack version v1.2, 2026-07-21

1. What the regulation says

All premises and equipment used by the service provider must be ... clean, secure, suitable for the purpose for which they are being used, properly used, properly maintained, and appropriately located for the purpose for which they are being used. (Reg 15(1): the six criteria)

Regulation 12 adds the safe-care duties that this policy operationalises:

ensuring that the premises used by the service provider are safe to use for their intended purpose and are used in a safe way, (Reg 12(2)(d) (premises safety))

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 is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/15 and https://www.legislation.gov.uk/uksi/2014/2936/regulation/12. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

Premises and equipment must be clean, secure, suitable for purpose, properly used and maintained, and appropriately located. You have to maintain hygiene standards appropriate to the use. Equipment in the service user's own home that you did not supply and is unrelated to the care or treatment is out of scope. Care and treatment must also be provided in a safe way, which includes Regulation 12's areas a provider must address, including ensuring the premises are safe to use for their intended purpose and the equipment is safe for such use and used safely.

3. Purpose and scope

This policy sets out how the provider specifies, checks, maintains and audits the premises and equipment used for regulated activity, and how Staff remove unsafe equipment from use and record corrective action.

This policy applies to all premises operated under the control of and all equipment used in the delivery of any regulated activity. It covers clinical and clinical-adjacent rooms, shared services (reception, waiting areas, kitchen, laundry, waste), plant rooms, vehicles (where used for patient transport), portable equipment carried between sites, and equipment that the provider supplies into a service user's home (where this applies to the service).

(Tenant updates the angle-bracket placeholder.)

4. Roles and responsibilities

(Tenant updates the named role-holders.)

5. Procedure

The Reg 15 procedure operationalises the premises-and-equipment duty.

  1. Premises specification. Every site has a written premises specification: what regulated activity is delivered, what areas are clinical versus non-clinical, capacity per area, accessibility features (lifts, ramps, accessible toilets, hearing loops), shared services, vehicle parking where applicable. Reviewed annually.
  2. Equipment register. Every piece of clinical equipment is on the equipment register with: make, model, serial number, date of purchase or lease, location, last service date, next service date, last calibration where applicable, certification or compliance status. New equipment is added at purchase; retired equipment is marked decommissioned with the date.
  3. Cleaning specification. A cleaning specification names what is cleaned, by whom, at what frequency, with what product, to what standard. Per the IPC Code of Practice, the cleaning specification distinguishes clinical and non-clinical areas. Cleaning records are kept.
  4. Maintenance schedule. Building services (gas safety, electrical, lift, water hygiene legionella, fire-detection, escape lighting, fire extinguishers) are serviced on the relevant statutory or recommended cycle by competent contractors. Certificates are filed.
  5. Equipment servicing. Clinical equipment is serviced per the manufacturer's recommendation, the relevant Health Technical Memorandum (HTM) or British Standard (BS), or the contract terms. Critical equipment (resuscitation, anaesthetic, point-of-care testing, sterilisation, controlled-drugs storage) has additional pre-use checks recorded.
  6. Decontamination. Reusable medical devices are decontaminated per the relevant HTM (HTM 01-01 in general healthcare; HTM 01-05 for dental). Traceability links the decontamination cycle to the patient on whom the device was used.
  7. Fault reporting. Any equipment fault or premises hazard is reported the same shift on the incident reporting register. The equipment is taken out of use until repaired or replaced. Service users at risk are managed safely until normal service resumes.
  8. Pre-use check. Critical equipment is checked at the start of every clinical session (working order, calibration, stock, expiry). The check is recorded.
  9. Security. Premises are secure: external doors and gates lock, access-controlled clinical areas operate as designed, medication and controlled-drug storage is to BS 2881 spec for CDs, confidential records are stored securely. Visitor management runs through the visitor-log.
  10. Annual premises review. The Facilities Lead presents the annual premises review at the governance meeting: cleaning audit results, maintenance compliance, equipment service compliance, incident pattern, accessibility audit findings, any premises-change plans for the year ahead.

6. Training requirement

Training records held in the tenant's training matrix register.

7. Audit

Compliance with this policy is monitored by the Facilities Lead and the Registered Manager:

Audit findings recorded in the tenant's audit register; actions logged in the improvement-actions register.

8. Record-keeping

Premises and equipment records (equipment register entries, servicing certificates, maintenance schedules, cleaning records, statutory compliance certifications, premises audits) are held for a minimum of 8 years from the date of the last entry per the NHS Code of Practice on Records Management. Records linked to a specific patient (decontamination traceability for a sterilised device used on a named patient) follow the patient-record retention.

Statutory certifications that are routinely re-issued (annual gas safety, periodic electrical inspection, water hygiene, lift LOLER) are retained for the duration of validity plus the same NHS Code period; this means each certificate stays accessible across the audit window even after its replacement has been issued.

Verivius preserves the per-record audit trail indefinitely while the workspace is active.

9. Related policies in this pack

10. 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.

11. 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.

12. Document control

Version Date Author Changes
v1 2026-05-19 Verivius (sample) Initial sample template.
v1.1 2026-06-01 Verivius (sample) Filled out Sections 3 to 8 with concrete content. Section 4 names the Facilities Lead role. Section 5 expanded to a 10-step procedure covering premises specification, equipment register, cleaning specification, maintenance schedule, equipment servicing per HTM and BS, decontamination, fault reporting, pre-use checks, security, annual premises review. Section 6 names training tiers. Section 7 names the five audit cadences. Section 8 references the NHS Code of Practice. Section 9 cross-references IPC, fire safety, and RIDDOR.
v1, 2026-06-10 2026-06-10 Verivius (sample) Re-conformed to the current Verivius policy standard, preserving the original content. Added the current disclaimer, header block, policy owner / applies-to line, verbatim Regulation 15 and engaged Regulation 12 quotes with cite labels, the plain-English summary, Sources and further reading, and When to seek further advice. All original sections (scope, roles, procedure, training, audit, record-keeping, related policies) preserved and renumbered.
v1.2 2026-07-21 Verivius (sample) Made the operating purpose explicit alongside the policy scope.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the tenant'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.

Premises and equipment fail quietly. A sterilised instrument looks identical whether or not its cycle actually reached the validated point, a resuscitation trolley reads as ready until the moment a part is missing, and a warm-water outlet gives no sign that legionella is growing behind it. The danger unique to this policy is the gap between a thing that looks safe and a thing that has been proven safe, and the person using the service only discovers which one they met when something goes wrong, often irreversibly and often through no fault they could see coming. That is why the evidence here is the safety itself, not a record of it: the retained decontamination cycle, the periodic validation of the reprocessing equipment, the pre-use check signed by a named person, the current certificate with its remedial actions closed, and the fault taken out of use the same shift. Each one is the difference between assuming a device or a building system is fit for the person in front of you and being able to show it was, on the day they were treated in it.

  1. Every reusable medical device is decontaminated to the manufacturer's validated process and the relevant Health Technical Memorandum before it goes near the next patient, and each cycle is traceable to the patient the device was used on, so a device is proven clean rather than assumed clean (Reg 12(2)(e)).

    Strong evidence: The local decontamination policy naming the validated process, retained cycle records for the reprocessing equipment, the periodic testing and validation log for that equipment, and the traceability link from a sampled instrument set to the patient episode it was used in.

    Weak evidence: Cycle records with gaps, no periodic testing or validation of the reprocessing equipment on file, single-use items reprocessed against the manufacturer's marking, or traceability that stops at the batch so no one can say which patient met which set. A decontamination room whose workflow does not keep the dirty and the clean apart.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 12(2)(e)

  2. The resuscitation and emergency equipment is present, in date and ready to use the moment someone reaches for it, checked and recorded to the Resuscitation Council UK standard rather than signed off from memory.

    Strong evidence: The emergency-equipment check log showing the grab bag or trolley checked on the service's set cadence, with working order, stock and expiry confirmed and the checker named, plus the tamper-evident seal record.

    Weak evidence: A check sheet ticked in a single run of identical dates, gaps across days the service was open, or a sheet signed while an item was actually missing or out of date. Emergency oxygen or a defibrillator on the register but no record that anyone confirmed it works between one emergency and the next.

    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. Equipment that looks or reads as unsafe comes out of use the same shift and stays out until it is repaired or replaced, with the person who would have used it kept safe in the meantime, not left in service because removing it is inconvenient (Reg 15(1)(d)-(e)).

    Strong evidence: The fault reported on the incident register the same shift, the device labelled and quarantined out of use, the corrective action tracked through to repair or replacement, and a note of how any patient at risk was managed until normal service resumed.

    Weak evidence: A fault logged but the device still in the room and in use, a repair marked ongoing for weeks with no interim control, or a quarantined item with no label so a colleague could pick it up again. Faults that surface only in an incident after harm, never in a live fault log.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 15(1)(d)-(e)

  4. The building's safety-critical systems are maintained and independently certified on the cycle each statutory regime requires, and the remedial action each certificate flags is closed, so fire detection, gas, the fixed electrical installation, water hygiene and lift safety are proven current rather than assumed.

    Strong evidence: Current certificates from competent contractors for fire detection and escape lighting, gas safety, the fixed electrical installation, water hygiene (legionella) and lift examination, with the remedial actions each certificate flags tracked to closure in the improvement-actions register.

    Weak evidence: A folder of certificates with one or more lapsed and no renewal booked, a certificate carrying open remedial actions that no one has picked up, or a contractor whose competence for the regime is not evidenced. The certificate is filed but the fault it flagged is still live.

    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.

  5. Every piece of clinical equipment is on a live register and is serviced and calibrated on the manufacturer's recommended cycle, the relevant Health Technical Memorandum or British Standard, so a device in use is one whose next service is known rather than overdue and forgotten.

    Strong evidence: The equipment register carrying make, model, serial number, location, last and next service dates and calibration status, with servicing certificates on file and retired devices marked decommissioned with a date.

    Weak evidence: A register with blank next-service dates, devices in daily use whose service lapsed months ago, or calibration status left empty for equipment whose reading drives a clinical decision. A stock take that cannot say where a named device physically is.

    The instructions from the maker of a product, device, or medicine. Following them is how the item is used safely, and for medical devices it is effectively expected.

  6. Cleaning runs to a written specification that separates clinical from non-clinical areas and names who cleans what, how often and to what standard, with cleaning recorded, so a clinical surface is demonstrably clean rather than assumed to have been wiped.

    Strong evidence: The cleaning specification aligned to the infection prevention and control Code of Practice, the cleaning records for clinical areas, and the periodic cleaning audit with its findings turned into actions.

    Weak evidence: One generic cleaning rota covering the whole building with no distinction for clinical areas, cleaning records signed in advance for the week, or an audit that scored clean with no sample and no findings. Responsibility for a shared area that no role actually owns.

    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.

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Last verified 20 July 2026

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Last reviewed 21 July 2026