Sample policy · Private clinic

Minor surgical procedure and infection prevention policy (private clinic)

Statutory anchor: Regulation 12 (safe care and treatment), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 15 (premises and equipment) and Regulation 17 (good governance). · 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 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))

assessing the risk of, and preventing, detecting and controlling the spread of, infections, including those that are health care associated, (Reg 12(2)(h) (infection control))

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 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.

4. Scope

This policy applies to:

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

5. Procedure safety process

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

5.1 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.

5.2 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.

5.3 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.

6. Infection prevention and wound care

The Clinic keeps an infection prevention process for minor surgery.

6.1 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.

6.2 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.

6.3 Sharps and needlestick management

Staff manage sharps safely throughout the procedure.

If a sharps injury or needlestick occurs, Staff:

7. 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.

8. Responsibilities

9. Training and competence

The Clinic keeps a procedure-scope and competence record for every clinician and member of Staff who prepares, assists with or follows up minor surgery.

Before working without direct supervision, Staff complete role-specific training and practical assessment covering:

The assessor records the task observed, standard used, outcome, any restriction, supervision required, sign-off date and review date. The Consultant or Clinic Nurse reassesses competence after a material incident, extended absence, new procedure, new device or repeated audit failure. A course certificate alone does not authorise a person to perform a procedure or task.

10. Recording requirements

The Clinic keeps the following records:

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

11. 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.

12. Version control and review date

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

13. Related policies and records

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

14. 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.

15. 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.

16. Document control

Version Date Author Changes
v1.1 2026-07-21 Verivius (sample) Added role-specific training, observed competence sign-off, reassessment triggers and published companion-policy links.
v1 2026-06-10 Verivius (sample) Conformed to the Verivius policy standard: added the Regulation 12 verbatim anchor, plain-English summary, standard sources and document-control blocks. All 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 provider'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.

Minor surgery in a private clinic carries a particular shape of risk: the procedure is short, the person walks out the same day, and nobody from the clinic is in the room when the wound declares an infection or when the histology report lands. Two threads leave the building and have to be pulled back in, the wound and the specimen, and both depend on a record somebody owns rather than on the patient noticing that something is wrong. Decontamination is commonly done in-house on a benchtop steriliser by the same person assisting with the procedures, so the link between a cycle and a patient is the only way to answer the question that matters when a cycle is later found to have failed: who was exposed, and who has to be told. The specimen trail is the one that changes lives, because an excised skin lesion can come back as a melanoma and an unread report is a diagnosis the person never receives. Kept properly, these records are how a clinic keeps hold of a patient it can no longer see, and only secondarily how it shows that care was safe and well-led.

  1. Every reusable instrument set is traceable to a decontamination or sterilisation cycle and to the patient it was used on, and a failed cycle stops the set being used. That link is what lets the clinic work out who was affected if a cycle failure comes to light weeks later. What goes wrong in practice is instruments in use with no cycle reference, or a failed pack pressed on regardless.

    Strong evidence: Instrument traceability record holding the instrument set, decontamination or sterilisation cycle reference, date, operator, linked procedure, any failed cycle or pack-integrity failure and the action taken (sections 5.3, 9).

    Weak evidence: A traceability log with the instrument set and the date filled in, but the cycle reference column blank or carrying the same number for a whole day of procedures, and no line anywhere linking a set to the patient it was used on. Failed cycles show up as a gap in the log rather than as a recorded failure with a recorded decision to quarantine and reprocess the set.

    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.

  2. Sterility, cleaning and pack integrity are verified before the room is used, and staff actually stop when uncertain rather than proceeding. Stopping costs a patient a delayed appointment, while carrying on risks giving them an infection they need not have had. What goes wrong in practice is a patient taken into an unchecked room, or a procedure run with a compromised sterile pack.

    Strong evidence: Procedure-room readiness check (cleaning status, sterile pack integrity, single-use item expiry, sharps bin, clinical waste route) plus the weekly sterile-pack-integrity and cleaning-record checks, backed by the rule that staff do not proceed where missing equipment, failed cleaning or uncertain sterility affects safety (sections 5.2, 10).

    Weak evidence: Readiness checks signed off in one batch at the end of the session, or ticked before the room had actually been cleaned and reset, with sterile packs sitting on the shelf past the shelf life the manufacturer states and single-use item expiry dates never recorded. The clearest weak spot is that nobody can point to a single occasion when a procedure was delayed because a pack looked compromised or the room had not been cleaned.

    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.

  3. The adapted surgical safety checklist is completed for each procedure and its completion is audited, not just held on file as a template. The checklist is the moment the team stops and confirms it has the right patient, the right site and the right plan. What goes wrong in practice is a procedure done with no recorded checklist.

    Strong evidence: Adapted World Health Organization (WHO) Surgical Safety Checklist kept in the procedure record, with the quarterly Consultant audit of checklist completion (sections 5.1, 9, 10).

    Weak evidence: A blank adapted checklist filed with the policy, and completed copies present in only some procedure records, usually the ones that turned out to be complicated. The audit reads as a line in the meeting minutes saying checklists are in use, with no count of procedures performed set against checklists actually found in the records.

    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.

  4. A possible surgical site infection is reviewed by the Consultant, and both the external-reporting decision and the duty-of-candour question are recorded, not closed quietly. Where the clinic is carrying on a CQC-regulated activity, the Regulation 20 duty of candour is owed to the patient in person and is not a notification, so an external report does not discharge it and candour does not stand in for one. What goes wrong in practice is a wound infection managed informally, with no recorded decision either way.

    Strong evidence: Post-procedure infection record with Consultant review, the recorded decision on external reporting, and a separate duty-of-candour assessment against the notifiable safety incident threshold in Regulation 20(9), which is the threshold for a registered person that is not a health service body (sections 6.2, 9).

    Weak evidence: A possible wound infection captured as a free-text sentence in the consultation note, antibiotics prescribed and the episode closed, with no recorded Consultant review. Nothing in the record shows whether the Regulation 20 threshold of a notifiable safety incident was considered and why it was or was not met, because candour is treated as paperwork reserved for serious harm rather than as a question asked about this patient.

    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.

  5. A break in aseptic technique or a sharps injury is recorded and routed for advice, not treated as routine. The colleague who was injured needs first aid and occupational-health or medical advice, and the team needs the entry in the incident register to see the pattern. What goes wrong in practice is a needlestick handled informally, with nothing in the incident register and no occupational-health referral.

    Strong evidence: Break in aseptic technique logged as an incident or near miss, and a sharps or needlestick incident record with first aid and occupational-health or medical advice, plus a separate consideration of whether the injury is reportable to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR), which occupational-health advice does not answer (sections 6.1, 6.3, 9).

    Weak evidence: A needlestick that exists in the occupational health referral and in the staff member's memory but never reached the incident register, or an incident form with first aid ticked and the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) consideration left blank. Breaks in aseptic technique are almost never logged, which reads as a team that does not report them rather than a team that does not have them.

    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 Safety (Sharp Instruments in Healthcare) Regulations 2013, reg 6 (arrangements in the event of injury); RIDDOR 2013 for the reporting consideration

  6. Specimens are tracked through to result, and an abnormal result that is not acted on is itself logged as an incident. The patient goes home assuming no news is good news, so the loop has to be closed by the clinic and not by the patient chasing. What goes wrong in practice is a lost specimen, a mislabelled pot, or a histology result nobody follows up.

    Strong evidence: Specimen tracking record (patient identity, specimen site, container and preservative, labelling, request form, courier or collection route, result tracking, abnormal result escalation, patient communication), with any lost specimen, wrong-label incident or unactioned abnormal result recorded as an incident (sections 7, 9).

    Weak evidence: A specimen book that records what was sent but has no column for the result coming back, so the trail stops at the courier and the loop is closed by whoever happens to remember. Only lost pots and wrong labels are counted as incidents, so the histology report that sat unread for weeks generates no record at all and no improvement action.

    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.

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Last verified 20 July 2026

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Last reviewed 21 July 2026