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
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12: https://www.legislation.gov.uk/uksi/2014/2936/regulation/12
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 15: https://www.legislation.gov.uk/uksi/2014/2936/regulation/15
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 17: https://www.legislation.gov.uk/uksi/2014/2936/regulation/17
- NICE NG125, Surgical site infections, prevention and treatment: https://www.nice.org.uk/guidance/ng125
- WHO, Surgical Safety Checklist: https://www.who.int/teams/integrated-health-services/patient-safety/research/safe-surgery/tool-and-resources
- Royal College of Surgeons of England, Professional Standards for Cosmetic Surgery: https://www.rcseng.ac.uk/standards-and-research/standards-and-guidance/service-standards/cosmetic-surgery/professional-standards-for-cosmetic-surgery/
- Health and Social Care Act 2008, Code of Practice on the prevention and control of infections: https://www.gov.uk/government/publications/the-health-and-social-care-act-2008-code-of-practice-on-the-prevention-and-control-of-infections-and-related-guidance
- HSE, sharps injuries: https://www.hse.gov.uk/healthservices/needlesticks/
3. Scope
This policy applies to:
- procedure-room readiness
- patient identity and procedure confirmation
- site marking where relevant
- surgical safety checklist use
- sterile field preparation
- skin preparation
- instrument traceability
- decontamination and sterilisation records
- surgical site infection prevention
- post-procedure wound advice
- sharps and needlestick incidents
- post-procedure infection response
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:
- patient identity
- procedure planned
- treatment site
- consent status
- allergies
- anticoagulant or medicine risks
- infection risk factors
- local anaesthetic plan
- specimen or histology requirements where relevant
- equipment availability
- emergency support availability
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:
- cleaning status
- hand hygiene facilities
- sterile pack integrity
- instrument availability
- single-use item expiry date
- local anaesthetic stock
- sharps bin availability
- clinical waste route
- specimen pot and label where needed
- emergency call route
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:
- instrument set
- decontamination or sterilisation cycle reference
- date
- operator
- procedure linked to the set
- failed cycle or failed pack integrity
- action taken
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:
- hand hygiene
- personal protective equipment
- skin preparation
- sterile drape use
- sterile instrument handling
- single-use item handling
- separation of clean and contaminated items
- post-procedure room cleaning
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:
- how to keep the wound clean and dry
- signs of infection
- pain and bleeding advice
- who to contact
- when to seek urgent medical help
- follow-up or suture removal date
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:
- make the person safe
- follow first-aid procedure
- preserve relevant information
- record an incident
- seek occupational health or medical advice
- consider RIDDOR where current source material requires it
- assign improvement action where needed
6. Specimens, histology and unexpected findings
Where a procedure produces a specimen, the Clinic follows its specimen-handling process.
The process covers:
- patient identity
- specimen site
- container and preservative
- labelling
- request form
- courier or collection route
- result tracking
- abnormal result escalation
- patient communication
The Clinic records any lost specimen, wrong-label incident or abnormal result not acted on as an incident.
7. Responsibilities
- Registered Manager: owns this policy, ensures premises and equipment governance and signs off annual review.
- Consultant: owns procedural safety, surgical checklist adaptation, infection review and clinical escalation.
- Clinic Nurse: prepares the procedure room, checks sterile items, supports aseptic technique and records equipment issues.
- Aesthetic Practitioner: works only within authorised procedure scope and reports sterility, wound or infection concerns.
- Administration staff: support appointment, specimen tracking and follow-up communication where within local procedure.
- All staff: report infection prevention breaches, sharps injuries and equipment defects immediately.
8. Recording requirements
The Clinic keeps the following records:
- procedure note
- adapted surgical safety checklist
- consent record
- site confirmation record where relevant
- instrument traceability record
- sterilisation or decontamination cycle reference
- cleaning record
- local anaesthetic record
- specimen tracking record where relevant
- wound-care advice record
- post-procedure infection record
- sharps or needlestick incident record
- improvement action record
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:
- Weekly: Staff check procedure-room stock, sterile pack integrity and cleaning records.
- Monthly: the Clinic Nurse audits instrument tracking, decontamination records and sharps-bin management.
- Quarterly: the Consultant audits procedure checklist completion, infection events and specimen tracking.
- Annually: the Registered Manager reviews this policy against current infection prevention, NICE, CQC and RCS source material.
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:
- policy owner
- version number
- date approved
- next review date
- changes made since the last version
- source material checked during the review
11. Related records
- Procedure record
- Surgical safety checklist
- Consent record
- Decontamination log
- Cleaning record
- Specimen tracking log
- Sharps injury record
- Incident register
- Local anaesthetic safety and medical emergency policy
- Improvement action register
Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.