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. Recording requirements

The Clinic keeps the following records:

Records are kept in the clinical record and Clinic governance records 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: 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 tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

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Last reviewed 10 June 2026