Sample policy · Private clinic

Minor surgical procedure and infection prevention policy (private clinic)

1. Purpose

This policy sets out how the Clinic prepares for, performs, records and reviews minor surgical procedures and infection prevention.

It applies to outpatient procedures such as skin lesion excision, mole removal, biopsy, wound closure, hair restoration steps and other minor procedures within the Clinic's registration and competence.

2. Sources to verify before adoption

3. Scope

This policy applies to:

The Clinic provides only procedures within its CQC registration, clinician competence and local equipment capability.

4. Procedure safety process

The Clinic follows a documented process for every minor surgical procedure.

4.1 Pre-procedure checks

Before the procedure, Staff confirm:

The Clinic adapts the WHO Surgical Safety Checklist for outpatient minor surgery and verifies the adapted checklist before adoption.

4.2 Procedure-room readiness

Staff prepare the procedure room before the patient enters or before the sterile field is created.

The check covers:

Staff do not proceed where missing equipment, failed cleaning or uncertain sterility affects safety.

4.3 Instrument tracking

The Clinic records instrument tracking for reusable instruments.

The record includes:

The Clinic follows its decontamination procedure and verifies it against current infection prevention and device source material.

5. Infection prevention and wound care

The Clinic keeps an infection prevention process for minor surgery.

5.1 Aseptic technique and sterile field

Staff use aseptic technique for procedures that require it.

The local procedure covers:

The clinician records any break in aseptic technique as an incident or near miss.

5.2 Surgical site infection prevention

The Clinic gives written and verbal wound-care advice after relevant procedures.

Advice covers:

If the Clinic identifies a possible surgical site infection, the Consultant reviews the patient, records the finding and decides whether external reporting or duty of candour consideration is needed.

5.3 Sharps and needlestick management

Staff manage sharps safely throughout the procedure.

If a sharps injury or needlestick occurs, Staff:

6. Specimens, histology and unexpected findings

Where a procedure produces a specimen, the Clinic follows its specimen-handling process.

The process covers:

The Clinic records any lost specimen, wrong-label incident or abnormal result not acted on as an incident.

7. Responsibilities

8. Recording requirements

The Clinic keeps the following records:

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

9. 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.

10. Version control and review date

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

11. Related records

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

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Last reviewed 21 May 2026