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 a CQC inspector checks

The same requirement seen through an ex-CQC-inspector's eyes: what they actually ask to see, and the gap they are testing for.

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

    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).

  2. The maximum safe local anaesthetic dose is calculated and recorded before administration against a named source, not reconstructed afterwards. The failure tested is a total dose with no worked calculation or source behind it.

    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).

  3. The pre-procedure assessment, including allergies, previous anaesthetic reactions and weight where dosing is weight-based, is recorded before the anaesthetic is given. The failure tested is an assessment written up after the event or missing.

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

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

    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).

  5. A suspected adverse drug reaction or local anaesthetic systemic toxicity produces the full trail, not just a clinical note. The failure tested is a serious reaction with no reporting decision or safety review recorded.

    Evidence: Adverse reaction record and a Medicines and Healthcare products Regulatory Agency (MHRA) Yellow Card reporting decision, with the incident, medicines-safety review and post-event debrief, and a duty-of-candour assessment against the Regulation 20 threshold on a suspected local anaesthetic systemic toxicity event (sections 6.3, 6.4, 9).

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

    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).

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Last reviewed 10 June 2026