Premises and equipment policy (Reg 15)

1. What the regulation says

All premises and equipment used by the service provider must be … clean, secure, suitable for the purpose for which they are being used, properly used, properly maintained, and appropriately located for the purpose for which they are being used.

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/15. Where this policy and the regulation diverge, the regulation wins.

2. Plain British summary

Premises and equipment must be clean, secure, suitable for purpose, properly used and maintained, and appropriately located. You have to maintain hygiene standards appropriate to the use. Equipment in the service user's own home that you did not supply and is unrelated to the care or treatment is out of scope.

3. Scope

This policy applies to all premises operated under the control of and all equipment used in the delivery of any regulated activity. It covers clinical and clinical-adjacent rooms, shared services (reception, waiting areas, kitchen, laundry, waste), plant rooms, vehicles (where used for patient transport), portable equipment carried between sites, and equipment that the provider supplies into a service user's home (where this applies to the service).

(Tenant updates the angle-bracket placeholder.)

4. Roles and responsibilities

• Registered Manager: accountable for premises and equipment compliance across every site. Reviews any equipment-related incident; signs off any premises-or-equipment change.
• Nominated Individual: holds provider-side accountability.
• Facilities Lead (named individual; in small services often the Registered Manager): the day-to-day premises authority. Coordinates the maintenance schedule, equipment servicing register, cleaning specification, and compliance certifications (fire, gas, electrical, water, lift).
• Clinical Lead: accountable for the clinical-suitability assessment of equipment in clinical use.
• All staff: report any premises or equipment fault, dirt, or hazard the same shift; do not use equipment that appears unsafe.

(Tenant updates the named role-holders.)

5. Procedure

The Reg 15 procedure operationalises the premises-and-equipment duty.

1. Premises specification. Every site has a written premises specification: what regulated activity is delivered, what areas are clinical versus non-clinical, capacity per area, accessibility features (lifts, ramps, accessible toilets, hearing loops), shared services, vehicle parking where applicable. Reviewed annually.
2. Equipment register. Every piece of clinical equipment is on the equipment register with: make, model, serial number, date of purchase or lease, location, last service date, next service date, last calibration where applicable, certification or compliance status. New equipment is added at purchase; retired equipment is marked decommissioned with the date.
3. Cleaning specification. A cleaning specification names what is cleaned, by whom, at what frequency, with what product, to what standard. Per the IPC Code of Practice, the cleaning specification distinguishes clinical and non-clinical areas. Cleaning records are kept.
4. Maintenance schedule. Building services (gas safety, electrical, lift, water hygiene legionella, fire-detection, escape lighting, fire extinguishers) are serviced on the relevant statutory or recommended cycle by competent contractors. Certificates are filed.
5. Equipment servicing. Clinical equipment is serviced per the manufacturer's recommendation, the relevant standard (HTM, BS), or the contract terms. Critical equipment (resuscitation, anaesthetic, point-of-care testing, sterilisation, controlled-drugs storage) has additional pre-use checks recorded.
6. Decontamination. Reusable medical devices are decontaminated per the relevant HTM (HTM 01-01 in general healthcare; HTM 01-05 for dental). Traceability links the decontamination cycle to the patient on whom the device was used.
7. Fault reporting. Any equipment fault or premises hazard is reported the same shift on the incident reporting register. The equipment is taken out of use until repaired or replaced. Service users at risk are managed safely until normal service resumes.
8. Pre-use check. Critical equipment is checked at the start of every clinical session (working order, calibration, stock, expiry). The check is recorded.
9. Security. Premises are secure: external doors and gates lock, access-controlled clinical areas operate as designed, medication and controlled-drug storage is to BS 2881 spec for CDs, confidential records are stored securely. Visitor management runs through the visitor-log.
10. Annual premises review. The Facilities Lead presents the annual premises review at the governance meeting: cleaning audit results, maintenance compliance, equipment service compliance, incident pattern, accessibility audit findings, any premises-change plans for the year ahead.

6. Training requirement

• All staff complete premises and equipment safety awareness at induction and every three years.
• Clinical staff complete equipment-specific training before using any piece of clinical equipment unsupervised.
• The Facilities Lead completes facilities management training at appointment and refresher every two years.
• Cleaning staff and contractors complete IPC-aligned cleaning training at appointment and annually.

Training records held in the tenant's training matrix register.

6. Training requirement

All staff in scope complete at induction and at . Records are kept in .

(Tenant completes.)

7. Audit

Compliance with this policy is monitored by the Facilities Lead and the Registered Manager:

• Daily / per-session check: critical equipment pre-use checks (resuscitation, anaesthetic, point-of-care testing) recorded.
• Weekly check: fire-detection call-point rotation, cleaning records review, escape-route inspection.
• Monthly: equipment register review (servicing due, calibration due), maintenance schedule compliance, fire extinguisher and escape lighting check.
• Quarterly: premises audit (cleaning standards, accessibility, security, equipment fitness for purpose), waste management audit.
• Annual: the annual premises review at the governance meeting; renewal of all statutory compliance certifications (gas, electrical, water hygiene, lift, fire-detection).

Audit findings recorded in the tenant's audit register; actions logged in the improvement-actions register.

8. Record-keeping

Premises and equipment records (equipment register entries, servicing certificates, maintenance schedules, cleaning records, statutory compliance certifications, premises audits) are held for a minimum of 8 years from the date of the last entry per the NHS Code of Practice on Records Management. Records linked to a specific patient (decontamination traceability for a sterilised device used on a named patient) follow the patient-record retention.

Statutory certifications that are routinely re-issued (annual gas safety, periodic electrical inspection, water hygiene, lift LOLER) are retained for the duration of validity plus the same NHS Code period; this means each certificate stays accessible across the audit window even after its replacement has been issued.

Verivius preserves the per-record audit trail indefinitely while the workspace is active.

9. Related policies in this pack

• Safe Care and Treatment Policy (hscra-reg-12-safe-care-and-treatment)
• Infection Prevention and Control Policy (ipc-code-of-practice)
• Fire Safety Policy (fire-safety-order-2005)
• Health and Safety Reporting (RIDDOR) Policy (riddor-health-and-safety-reporting)

10. Document control

This sample policy template was issued by Verivius as part of the Mock Inspection design partner onboarding pack. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and the live regulation diverge, the live regulation wins.