Occupations and Terms of Reference › Sterile services manager
Universal terms of reference · POS-177 · version 1.0 · status: draft · next review 2027-10-27
Sterile services manager
To run sterile services, so that every instrument and sterile item is clean, sterile, traceable and available when clinical teams need it.
Each part of this page links to the related trainings, competencies and policies. The links are the same for every facility, so an organisation can see at a glance what a role requires and what it is trained in.
Job description
Job summary. You run sterile services. You manage the decontamination process, sterilisers, staff competence, equipment maintenance and supply to theatres and clinics.
Reports to: Procurement manager.
Leads or supervises: Sterile supplies technicians.
What you do on a typical day
- Review sterilisation cycle records and failures.
- Plan equipment maintenance and validation.
- Check staff competence in the process.
- Plan instrument supply for theatres and clinics.
- Report sterile services performance to the quality committee.
Working conditions and demands
- Process failures can cause serious infection.
- Works to strict regulatory and validation rules.
- Balances supply demand with process safety.
What good looks like
- No unsafe release of sterile items.
- Equipment is validated and maintained.
- Supply meets theatre needs.
Place in the organogram
Reporting line, from the top: see the organogram on the Occupations page. The lines above and below this role are listed in section 3.
1. Golden rules
These rules apply in every setting.
- Services are provided safely, on time and with no shortcuts that put patients or staff at risk.
- Supplies, equipment and systems are fit for purpose before use and are checked regularly.
- Money, stock and data are handled with integrity and recorded fully.
- Every incident or near miss is reported, and learning is shared.
- Staff are trained for their task before they work alone.
- Contractors and suppliers meet the same standards as staff.
- Concerns are raised and investigated without reprisal.
- Support functions are judged by how well they help clinical services deliver safe care.
2. Identification
| Item | Detail |
|---|---|
| Position code | POS-177 |
| ISCO-08 | 1342 (skill level 4) |
| ESCO | to map |
| Department | Supply and logistics |
| Facility types | Hospital, Ambulatory, Transport, Medevac, Fitness, Aesthetic |
3. Reporting line and working relationships
Reports to: POS-171. Supervises: POS-176.
| Works with | Nature of the relationship |
|---|---|
| Chief quality and safety officer | Sterile process standards. |
| Infection prevention and control (IPC) lead | Decontamination and infection control. |
| Theatre manager | Instrument supply to theatres. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Process control | Runs the sterile process to standard with release checks. | Failed cycles reviewed within 24 hours | Weekly | C-01 | T-05 | POL-SAFEG · POL-INC | 2 |
| Equipment | Keeps equipment validated and maintained. | Validation schedule met 100% | Monthly | C-02 | T-05 | – | 2 |
| Supply and team | Plans supply to theatres and develops the team. | Supply plan agreed; team appraisals completed | Quarterly | C-03 | T-08 | POL-EQUAL | 2 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Release decisions for sterile items | Failed cycles that affect patients (CQO and medical director) |
| Instrument supply plans within budget | Equipment replacement above agreed budget (procurement manager and CFO) |
6. Qualifications and experience
| ID | Qualification | Mandatory | Validity |
|---|---|---|---|
| Q-01 | Sterile services or decontamination management qualification | Yes | Lifetime |
| Q-02 | Infection prevention and control certificate | No | Lifetime |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Sterile services or decontamination leadership | 5 | Yes |
7. Training requirements
Recommended common practice. Each facility adapts the list to its national law. Essential items apply in every setting; recommended items apply where resources allow.
| ID | Training | Tier | When | Validity | Linked policies | Linked competencies |
|---|---|---|---|---|---|---|
| T-01 | Facility induction | essential | at_entry | Once | POL-WHISTLE · POL-EQUAL · POL-DATA | – |
| T-02 | Safeguarding adults | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-03 | Safeguarding children | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-04 | Data protection and confidentiality | essential | annual | Every 1 year(s) | POL-DATA | – |
| T-05 | Incident reporting and open disclosure | essential | periodic | Every 2 year(s) | POL-INC | C-01 · C-02 |
| T-06 | Governance, accountability and assurance | recommended | periodic | Every 3 year(s) | – | – |
| T-07 | Emergency and major incident command | essential | annual | Every 1 year(s) | POL-INC | – |
| T-08 | Speaking up, inclusion and equality leadership | essential | periodic | Every 2 year(s) | POL-WHISTLE · POL-EQUAL | C-03 |
8. Health, fitness and language
| ID | Requirement | Frequency | Tier | Minimum in low-resource settings |
|---|---|---|---|---|
| H-01 | Immunity to vaccine-preventable diseases relevant to the setting, documented at entry | At entry or as set | essential | Documented hepatitis B status at entry |
| H-03 | Fitness-to-work assessment at entry and after serious illness or injury | Every 12 months | recommended | Fitness check at entry |
| Language | Level | Mandatory |
|---|---|---|
| Official language of the country of practice | professional | Yes |
| English | working | Yes |
9. Competencies by level
| ID | Competency | Foundation | Practitioner | Expert | Assessed by | Revalidate | Linked trainings |
|---|---|---|---|---|---|---|---|
| C-01 | Decontamination and sterilisation process | Follows the process | Runs the process in a team | Designs the process standards | Process audit | Every 12 months | T-05 |
| C-02 | Equipment validation and maintenance | Records equipment checks | Plans validation | Designs validation programmes | Validation review | Every 12 months | T-05 |
| C-03 | Leading a sterile services team | Works in a team | Leads a team | Develops sterile services leadership | 360 feedback | Every 24 months | T-08 |
10. Performance evaluation
- Probation: 6 months, with a sign-off review (recommended value).
- Appraisal: every 12 months against the competencies and indicators below.
| ID | Indicator | Target | Data source | Frequency |
|---|---|---|---|---|
| PI-01 | Cycles released with checks complete | 100% | cycle register | Daily |
| PI-02 | Equipment validations on time | 100% | validation register | Monthly |
| PI-03 | Failed cycles reviewed in 24 hours | 100% | incident register | Weekly |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Sterile services manager | 5 years (recommended) | Q-01 | C-01 expert, C-02 practitioner | T-05 | Executive appointment and performance review |
12. Policies the post holder follows
Each policy is a standard template that the facility adopts and adapts. Templates are maintained centrally, so every facility works from the same version.
POL-SAFEG · Safeguarding adults and children
Purpose: Protect patients from abuse, neglect and harm, and make sure every concern is recognised and acted on.
Scope: All staff, volunteers and contractors.
Key rules:
Scope: All staff, volunteers and contractors.
Key rules:
- Recognise signs of abuse and neglect and record them factually.
- Report every concern to the designated safeguarding lead the same shift.
- Do not investigate alone.
- Share information only as the safeguarding procedure allows.
POL-DATA · Data protection and confidentiality
Purpose: Keep patient and staff information private, secure and used only for care and legal purposes.
Scope: All staff who access records or systems.
Key rules:
Scope: All staff who access records or systems.
Key rules:
- Access only the records needed for your work.
- Keep records secure; do not leave screens or paper unattended.
- Do not share information without a lawful basis.
- Report any breach to the data protection officer within 24 hours.
Linked trainings: T-10 · Review every 12 months · Template 0.1 (draft)
POL-WHISTLE · Speaking up (whistleblowing)
Purpose: Let staff raise patient safety or conduct concerns without fear of reprisal.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Raise a concern with your line manager or the named speaking-up officer.
- If that route fails, escalate to the board or the national regulator.
- Retaliation against anyone who speaks up is a disciplinary offence.
- Concerns are recorded, investigated and the outcome given to the person raising them.
Linked trainings: T-01 · Review every 12 months · Template 0.1 (draft)
POL-EQUAL · Equality, diversity and inclusion
Purpose: Give every patient and colleague fair access, respectful treatment and reasonable adjustments.
Scope: All staff and patients.
Key rules:
Scope: All staff and patients.
Key rules:
- Treat every person with dignity regardless of background.
- Make reasonable adjustments, including interpreters, for language and disability.
- Report discrimination through the speaking-up route.
- Monitor access and outcomes by group.
Linked trainings: T-01 · Review every 24 months · Template 0.1 (draft)
POL-INC · Incident reporting and open disclosure
Purpose: Report and learn from incidents and near misses, and tell patients honestly when things go wrong.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Report every incident and near miss the same shift.
- Give the patient and family an honest account and an apology where appropriate (open disclosure).
- Take immediate action to protect others.
- Learn: contribute to the review and follow the agreed actions.
13. Standards that name this role
14. Record history
| Date | Change | Approved by |
|---|---|---|
| 2026-10-27 | Draft record, batch 1 of the position build | Awaiting approval |