Staff Induction, Training & Competency Assessment Policy

Published:

October 24, 2025

1. Purpose

The purpose of this policy is to ensure all clinical and non-clinical staff at Newcastle Cosmetic Doctor (NCD) are trained, competent, and compliant with Australian medical and legal frameworks. This policy covers all services—anti-wrinkle injections, dermal fillers, laser procedures, threads, and skincare. It aims to protect patient safety, maintain regulatory compliance, and deliver high-quality cosmetic care through evidence-based practice. ¹ ² ³

2. Scope

This policy applies to all staff within NCD, including doctors, registered nurses, laser therapists, and administrative personnel. It covers clinical tasks such as injection technique, consent processes, infection control, and emergency preparedness, as well as governance tasks like documentation, privacy, and communication with patients. The scope ensures every staff member is aware of their professional responsibilities and is held accountable for competency within their scope of practice. ¹ ⁴ ⁵ ⁴

3. Governance & Accountability

Clinical governance is overseen by the Medical Director, Dr Bart Scanlon, who is responsible for ensuring compliance with Ahpra, NSW Health, and TGA regulations. The Governance Manager maintains audit trails and manages version-controlled documentation. Laser Safety Officers (LSOs) are designated to oversee compliance for laser devices. Regular governance meetings review compliance, incident trends, and staff credentialing records. ¹ ⁴ ⁵ ⁶ ⁵

4. Staff Induction Program

All new staff undergo a structured induction program within 14 days of joining. The induction includes infection prevention training, medicine storage requirements, laser room safety, WHS hazard identification, privacy training, and clinical emergency procedures. This ensures staff understand NCD’s governance framework and meet standards from NSW Health, Ahpra, and ACSQHC before engaging in patient care activities. ¹ ⁴ ⁵ ⁶ ⁶ ⁷

5. Training & Competency Framework

The training framework at NCD ensures both clinical and administrative staff maintain technical and ethical standards. Clinical modules include anatomy for injectables, aseptic technique, pharmacology, adverse event recognition, and product verification. Support staff complete communication, consent, and privacy modules. All staff must demonstrate understanding through observation, simulation, or written assessment, documented annually. ¹ ⁸ ⁹ ⁵ ⁷ ¹⁰

6. Supervision & Credentialing

All medical practitioners hold current Ahpra registration and appropriate indemnity insurance. Nurses perform injectables only under direct or delegated supervision by a prescriber. Laser operators are credentialed per ARPANSA and AS/NZS 4173:2018 standards. Credentialing files include qualifications, CPD certificates, and device-specific approvals. Supervision logs are retained for three years for audit purposes. ¹ ³ ⁵ ⁸

7. Ongoing Professional Development (CPD)

Each clinician maintains evidence of annual CPD aligned with their professional body’s requirements. Topics include cosmetic pharmacology, infection control, emergency response, and ethics. The Governance Manager verifies CPD logs during annual performance reviews. Continuing education ensures safe, current, and patient-centered cosmetic practice in accordance with RACGP and ACSQHC standards. ¹ ⁵ ¹⁰

8. Competency Re-Assessment & Audit

Competency reassessment occurs annually and includes observed procedures, peer reviews, and case audits. Random audits check completeness of patient consent, batch tracking, and compliance with cooling-off periods. Practitioners who do not meet standards must undergo targeted retraining. Findings are reviewed in governance meetings and feed into continuous improvement plans. ¹ ⁴ ⁵ ⁶ ¹⁰

9. Documentation & Recordkeeping

Training records, supervision logs, and competency assessments are securely stored in NCD’s HR management system. Access is restricted to authorized managers only. Records are retained for a minimum of seven years per OAIC and NSW Health requirements. All records must be auditable and version controlled to ensure transparency and compliance. ⁴ ⁵ ⁶ ⁹

10. Continuous Improvement

All staff induction and training programs are reviewed annually to reflect new legal, regulatory, and clinical updates from Ahpra, TGA, NHMRC, or ACSQHC. Policy revisions are version-controlled and communicated to staff via formal training sessions and electronic policy updates. This ensures NCD continuously evolves alongside Australian best practice standards. ¹ ² ³ ⁵ ⁶ ⁷

Sources

Ahpra (2025), Guidelines for Non-Surgical Cosmetic Procedures, viewed 24 October 2025, https://www.ahpra.gov.au/News/2025-01-31-Guidelines.aspx ↩
TGA (2024), Therapeutic Goods Administration, Cosmetic Injections Checklist, viewed 24 October 2025, https://www.tga.gov.au/sites/default/files/cosmetic-injections-checklist.pdf ↩
Medical Board of Australia (2024), Cosmetic Medical and Surgical Procedures Guidelines, viewed 24 October 2025, https://www.medicalboard.gov.au/Codes-Guidelines-Policies/Cosmetic-medical-and-surgical-procedures-guidelines.aspx ↩
NSW Health, Clinical Governance and Patient Safety Framework (PD2017_043), viewed 24 October 2025, https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2017_043.pdf ↩
ACSQHC, NSQHS Standards (2nd ed.), viewed 24 October 2025, https://www.safetyandquality.gov.au/standards ↩
SafeWork NSW, WHS Legislation and Model Codes of Practice, viewed 24 October 2025, https://www.safework.nsw.gov.au/law-and-policy/work-health-and-safety-legislation ↩
NHMRC (2019), Infection Prevention and Control in Healthcare, viewed 24 October 2025, https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019 ↩
ARPANSA, Advice for Providers: Lasers, IPL and LED Devices, viewed 24 October 2025, https://www.arpansa.gov.au/understanding-radiation/sources-radiation/more-radiation-sources/lasers-and-intense-pulsed-light-1 ↩
OAIC, Australian Privacy Principles, viewed 24 October 2025, https://www.oaic.gov.au/privacy/australian-privacy-principles ↩
RACGP, Clinical Resources and Guidelines, viewed 24 October 2025, https://www.racgp.org.au/clinical-resources/clinical-guidelines ↩

Disclaimer for Newcastle Cosmetic Doctor Policies & Procedures

The policies and procedures contained within this document are the exclusive property of Newcastle Cosmetic Doctor and are provided for internal clinical governance and educational purposes only. These materials represent the internal operational framework, safety standards, and evidence-based protocols developed and implemented by Dr. Bart John Scanlon and the Newcastle Cosmetic Doctor team. They are designed specifically for use within Newcastle Cosmetic Doctor and reflect our clinic’s own professional standards, risk assessments, and compliance obligations under Australian law and regulatory authorities. External individuals, practitioners, or organisations must not copy, reproduce, distribute, or rely upon these materials, in whole or in part, for their own clinical, commercial, or educational use without prior written consent from Newcastle Cosmetic Doctor. These materials do not constitute medical, legal, or professional advice and are not intended to be adopted as official protocols or procedures by any other entity. Any external use or adaptation must be independently reviewed and modified to meet the relevant laws, guidelines, and standards applicable to the user’s own jurisdiction, scope of practice, and facility operations. Newcastle Cosmetic Doctor and Dr. Bart Scanlon accept no liability for any loss, injury, or damage arising from the unauthorised use, reliance upon, or misinterpretation of this material.