Sample policy · Private clinic

Local anaesthetic safety and medical emergency policy (private clinic)

Statutory anchor: Regulation 12 (safe care and treatment), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). The primary clinical sources for local anaesthetic safety and medical-emergency response are the BNF (maximum safe doses) and Resuscitation Council UK (resuscitation and anaphylaxis standards), together with procedure-specific emergency guidance and the MHRA Yellow Card scheme. · 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))

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))

where equipment or medicines are supplied by the service provider, ensuring that there are sufficient quantities of these to ensure the safety of service users and to meet their needs, (Reg 12(2)(f) (sufficient equipment + medicines supply))

the proper and safe management of medicines, (Reg 12(2)(g) (medicines management))

The full text 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

This policy sets out how the Clinic assesses, administers, records and reviews local anaesthetic use and how Staff respond to medical emergencies.

It applies to outpatient cosmetic, dermatology, hair restoration and minor surgical procedures performed under local anaesthetic.

4. Scope

This policy applies to:

The Clinic does not provide sedation under this policy. If the Clinic offers sedation, it must adopt a separate sedation policy and verify it against current sedation guidance.

5. Local anaesthetic process

The Clinic follows a documented local anaesthetic process for every procedure.

5.1 Pre-procedure assessment

The clinician checks:

The clinician records the assessment before the local anaesthetic is given.

5.2 Dose calculation

The clinician calculates the maximum safe dose before administration.

The record includes:

The Clinic sets exact dose limits from current clinical source material. This template does not restate medicine-specific dose thresholds.

5.3 Administration and monitoring

The clinician administers local anaesthetic only within competence and scope.

Staff monitor the patient for:

The Clinic records observations where the procedure, patient risk or local procedure requires them.

6. Medical emergency response

The Clinic keeps a documented medical emergency procedure.

6.1 Immediate response

If a patient deteriorates, Staff:

Staff do not delay 999 escalation to complete internal paperwork.

6.2 Emergency medicines and equipment

The Clinic keeps emergency medicines and equipment appropriate to the procedures it provides.

The local emergency list covers:

The Clinic verifies the exact emergency medicines list against current Resuscitation Council UK, CQC and clinical source material before adoption.

6.3 Adverse drug reaction reporting

Where Staff suspect an adverse drug reaction, the Consultant considers MHRA Yellow Card reporting.

The decision record includes:

6.4 Suspected local anaesthetic systemic toxicity

If symptoms suggest local anaesthetic systemic toxicity, Staff must stop the procedure, call for senior clinical help, call 999 where required, monitor airway, breathing and circulation, follow the Clinic's emergency protocol, preserve drug, dose and time records, and complete the incident, duty-of-candour and medicines-safety review. The Clinic must verify whether lipid rescue is required or appropriate for its procedure scope, training and local emergency pathway before offering higher-risk local anaesthetic procedures. This template does not set lipid-rescue dosing; the Clinic verifies any dosing against current specialist guidance.

7. Post-procedure observation and discharge

The Clinic records post-procedure observation where local anaesthetic, procedure type or patient risk requires it.

Before discharge, the clinician confirms:

The Clinic does not discharge a patient who is clinically unstable.

8. Responsibilities

9. Recording requirements

The Clinic keeps the following records:

Records are kept in the clinical record and governance record according to local procedure.

10. Audit cadence

The Clinic uses the following Verivius default audit rhythm unless current source material requires a different rhythm:

Audit findings are recorded as improvement actions with an owner and review date.

11. Version control and review date

The Clinic keeps a controlled copy of this policy. The footer or document-control table records:

12. Related records

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

13. 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.

14. 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.

15. Document control

Version Date Author Changes
v1 2026-06-10 Verivius (sample) Conformed to the Verivius policy standard; anchored to Regulation 12 with verbatim quotes; original operational sections preserved and renumbered.

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.

Local anaesthetic in an outpatient cosmetic, dermatology, hair restoration or minor surgical clinic carries a particular shape of risk: the patient is awake, the procedure feels minor to them, and there is no anaesthetist and no resuscitation team down the corridor. Anaphylaxis usually declares itself within minutes of injection, and local anaesthetic systemic toxicity can arrive later still, sometimes once the clinical part feels finished and the room has quietened. That is precisely when a dose nobody worked out, or a defibrillator nobody has opened, becomes the whole event. The evidence trail here is really a competence trail: a maximum safe dose recorded with its named source shows the ceiling was known before the syringe was filled, and a live equipment log shows the emergency kit was ready rather than assumed ready. The scope boundary matters too, because this policy stops at local anaesthetic, and a clinic that starts offering sedation needs a separate policy and a different set of checks. People come to these clinics for elective treatment they have chosen and paid for, and they reasonably expect the safety net to be invisible and intact. Being able to show that trail to an inspector is the last and least of its uses.

  1. Emergency medicines and equipment are present, in-date and actually checked on a set rhythm, not assumed ready. What goes wrong in practice is a flat defibrillator battery or expired anaphylaxis medicine found only when a patient collapses.

    Strong evidence: Weekly Clinic Nurse check of emergency equipment and emergency-medicine expiry against the local list (oxygen, automated external defibrillator, bag-valve-mask, anaphylaxis medicine, hypoglycaemia treatment, pulse oximeter), recorded in the emergency equipment log and emergency medicine log (sections 6.2, 9, 10).

    Weak evidence: A log with a column of identical ticks and one signature, back-filled at the end of the month, that records a check happened but never what the check saw. There is no defibrillator battery or pad expiry reading against the manufacturer's stated replacement intervals, no earliest expiry date noted against the anaphylaxis medicine, and no entry showing what was replaced, so a flat battery or an out-of-date ampoule sits in the box until the day someone reaches for it. The duty is that equipment and medicines are safe, sufficient and properly managed; the weekly checking rhythm in this template is a Verivius default rather than a statutory interval.

    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) and reg 12(2)(g)

  2. The maximum safe local anaesthetic dose is calculated and recorded before administration against a named source, not reconstructed afterwards. The real-world failure is a total dose with no worked calculation or source behind it, so no one can show what ceiling the patient was kept inside.

    Strong evidence: Dose-calculation record holding drug name, concentration, volume planned, vasoconstrictor presence, the maximum-safe-dose source checked, patient weight where relevant, total dose administered, time administered and administering clinician (section 5.2).

    Weak evidence: A clinical note holding only a drug name and a volume, with no concentration, no vasoconstrictor status, no patient weight where dosing is weight-based and no named source for the maximum safe dose. The weakest version is a calculation written up after the patient reacted, so nobody can show what the ceiling was understood to be at the moment the syringe was filled.

    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 pre-procedure assessment, including allergies, previous anaesthetic reactions and weight where dosing is weight-based, is recorded before the anaesthetic is given. What goes wrong is an assessment written up after the event, or missing altogether, so the allergy and previous-reaction checks never actually preceded the anaesthetic.

    Strong evidence: Pre-procedure assessment record completed and documented before the local anaesthetic is administered (sections 5.1, 9).

    Weak evidence: The assessment sits inside the same block of text as the procedure note and is timed after the anaesthetic was given, so the record cannot show the checks came first. Allergy fields read "none known" with nothing to show previous anaesthetic reactions were specifically asked about, and the weight box is blank on weight-based dosing because the patient looked about average.

    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)(a) and reg 17(2)(c)

  4. Deterioration triggers an immediate airway-breathing-circulation and 999 sequence, and staff do not delay the 999 call for internal paperwork. The cost to the patient is time lost to forms while they are unstable.

    Strong evidence: 999 escalation record capturing time, symptoms, observations and actions, with the standing instruction that staff do not delay 999 escalation to complete internal paperwork (sections 6.1, 9).

    Weak evidence: A single retrospective line saying the ambulance was called and the patient was transferred, with no times, no observations and no sequence of what was assessed. The tell is a recorded 999 time that lands after the incident form was opened, or an unexplained gap between the patient deteriorating and the first recorded action, which is the delay the standing instruction not to hold up a 999 call for internal paperwork exists to prevent.

    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 suspected adverse drug reaction or local anaesthetic systemic toxicity produces the full trail, not just a clinical note. The failure that leaves the next patient exposed is a serious reaction with no reporting decision or safety review recorded.

    Strong evidence: On a suspected local anaesthetic systemic toxicity event, the adverse reaction record with the incident, medicines-safety review and post-event debrief. Two separate decisions sit alongside it and neither discharges the other: a Medicines and Healthcare products Regulatory Agency (MHRA) Yellow Card reporting decision, and a duty-of-candour assessment against the Regulation 20 threshold as it applies to a registered person who is not a health service body, which is owed to the patient and is not discharged by reporting to a regulator (sections 6.3, 6.4, 9).

    Weak evidence: One clinical entry saying the patient reacted and recovered, with no batch number, no recorded Yellow Card decision either way, and no medicines-safety review or post-event debrief. The candour question is often never put in writing at all, so there is nothing showing whether the event was assessed against the Regulation 20 notifiable safety incident threshold that applies to a registered person who is not a health service body, or what that assessment concluded. That assessment is owed to the patient and is a separate question from the Yellow Card decision, so answering one leaves the other still open. Reporting a suspected reaction to the Medicines and Healthcare products Regulatory Agency is a professional expectation rather than a statutory duty on the clinician, but this policy requires the decision itself to be recorded.

    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.

  6. Emergency readiness is rehearsed and role-appropriate resuscitation competence is current, not a one-off. The failure the patient meets is staff who have never run the emergency pathway, or whose life-support training has lapsed.

    Strong evidence: Quarterly medical-emergency simulation with recorded learning and a basic life support (BLS) training record for staff whose role requires it (sections 9, 10).

    Weak evidence: A training matrix carrying basic life support dates that lapsed last year, and a simulation folder holding one session run when the policy was written. Rehearsal records that name attendees and a date but capture no learning, no problems found and no improvement action leave the same delay in reaching the emergency medicines waiting to repeat itself in the real event. Life support currency for the roles that need it is a competence expectation in its own right; the quarterly simulation rhythm is a Verivius default, so a clinic may set a different rhythm and evidence why.

    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.

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Last verified 20 July 2026

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Last reviewed 10 June 2026