The Code of Practice Health and Social Care Act 2008 on the prevention and control of health care associated infections and related guidance, provides the standard for this aspect of patient care. Complementing this is the Department of Health guidance Choice Framework for Local Policy and Procedures which are being withdrawn and the implementation in January 2018 of Health Technical Memorandum HTM 01 series which assist NHS Trusts in complying with the decontamination guidance and in meeting the Care Quality Commission (CQC) registration requirement on hygiene and infection control.

For the purpose of this policy, the main focus is on reusable surgical instruments and that they are properly decontaminated prior to use or repair, and that the risk associated with decontamination facilities, are properly managed ensuring the safety of patients, staff and visitors. This policy should be read in conjunction with the above referenced Trust policies.

This guidance has been developed to support health organisations in delivering the required standard of decontamination of surgical instruments and builds on existing good practice to ensure that high standards of infection prevention and control are developed and maintained. The guidance in the Health Technical Memorandum should inform your local continuous improvement programme on decontamination performance.



The purpose of this policy is:

  • To increase the awareness of staff involved in handling of medical devices in procedures and bring to their attention the suite of guidance documents from Department of Health “Choice Framework for local Policy and Procedures” (CFPP) and HTMs.
  • To ensure that managers and individual members of staff are aware of their responsibilities in relation to decontamination of medical devices.
  • To assure that safe, managed and effective decontamination processes are adopted for all re-usable medical devices/equipment after and between patient use. This is an essential element of routine infection control practice and the monitoring process for this is outlined in section 11.


Policy Details

Download: PDF version
Compiled by: Keith Hayward, Head of Estates Operational Services
Ratified by: Risk Scrutiny Committee
Date Ratified: December 2016
Date Issued: February 2017
Review Date: October 2019
Target Audience: All Clinical Staff
Contact name: Keith Hayward, Head of Estates Operational Services


See also:

  • Single-Use, Single Patient Use and Limited Use Medical devices
  • Policy for Management, Use and Disposal of Medical Devices
  • Policy for Cleaning and Disinfection Policy
  • Policy for Precautions During Clinical Procedures/Surgery for Known or Suspected CJD Patients