WHTM can be accessed directly from the NHS Wales Shared Services Partnership, Facilities Service.

Transcription

1 Dental Postgraduate Section Dental Postgraduate Department Wales Deanery 8 th Floor Neuadd Meirionnydd Heath Park Cardiff CF14 4YS StewartH5@cardiff.ac.uk T +44 (0) Director: David Thomas An Audit of Compliance with Welsh Health Technical Memorandum 01-05, 2014 Edition Foreword from Director of Dental Postgraduate Education in Wales Effective decontamination in the dental surgery presents a challenge. During the development of Welsh Health Technical Memorandum 01-05, 2014 edition (WHTM 01-05), a multidisciplinary group of colleagues have been working to assist the Welsh Government dental team with some of the key issues, and to develop this audit. It has been designed by dentists working in primary dental care and the Community Dental Service and is intended to provide a systematic review of the processes you use in your practice. I commend this audit to you and hope it helps you to confirm that your practice complies with the key requirements for decontamination, and identify what needs to be done to make further progress. WHTM can be accessed directly from the NHS Wales Shared Services Partnership, Facilities Service. David Thomas Director Dental Postgraduate Education in Wales Dental Postgraduate Department Wales Deanery 8 th Floor Neuadd Meirionnydd Heath Park Cardiff CF14 4YS T +44 (0) Version 19 October

2 Introduction Auditing clinical practice against agreed standards is a well-established process which enables dental teams to recognise good practice, identify areas for improvement and provide assurance to patients, staff and Health Boards. Issues identified for improvement must be followed by timely action to make improvements. A definition of audit: Audit seeks to improve quality by using a structured review to look at systems, practices and results against agreed standards and then making improvements when indicated. From - CGSDU Clinical Audit Toolkit 2002 & NHS Wales Audit Committee Handbook 2012 The need for all healthcare providers to use audit is underpinned by Standard 3.3 of the Health and Care Standards for Wales, while Standard 2.4 deals with Infection Prevention and Control / Decontamination. This audit has been developed by and for general dental practices and the Community Dental Services in Wales and allows dental teams to self-asses their practice against the policy and guidance set out in the WHTM. The audit tool is separated into a number of sections. 1. Policies and Procedures 2. Application of Policies 3. Instrument Processing and reprocessing procedures Cleaning Methods 4. Storage and Movement of Instruments 5. Training and Staff Safety 6. Quality Assurance, including hand hygiene, personal protective equipment, keeping the environment clean, water systems, and waste disposal This audit tool primarily enables practices to assess compliance with WHTM 01-05, but some questions deal with broader issues of infection prevention and hygiene extending beyond the scope of the WHTM. These questions have been included as they are considered good practice and are compatible with sound hygiene practice. This audit pack includes all the information and documentation you need to complete the audit: Audit Registration Form, WHTM Form 1 (on request from Heather Stewart, PGMDE. StewartH5@Cardiff.ac.uk ) (Appendix 1) The Audit Tool, WHTM Form 2 (Appendix 2) Template Improvement Plan, WHTM Form 3 (Appendix 3) Claim Form, WHTM Form 4 (Appendix 4) Dental Postgraduate Department Wales Deanery 8 th Floor Neuadd Meirionnydd Heath Park Cardiff CF14 4YS T +44 (0) Version 19 October

3 Claim for Funding and Verifiable CPD - Clinical Audit and Peer Review Support This audit is linked to the School of Postgraduate Medical and Dental Education CAPR Audit programme. GDPs providing NHS funded treatment are eligible for PGMDE CAPR funding and verifiable CPD. Participating DCPs, wholly private dentists and Community Dental Services are eligible for verifiable CPD. You will need to consider how best to do the audit in your practice. For example: Every dentist / nurse team does it in their own surgery. You could then collate and compare the results in a practice team meeting. This would enable all dentists who hold an NHS Contract in the practice to claim 3hrs funding ( ) and the whole team will qualify for 4hrs verifiable CPD (which includes 1hr CPD for attending a practice meeting). Practices involving the whole dental team (i.e. each dentist and nurse undertakes the audit in their own surgery) who satisfactorily complete all parts of the audit will be awarded a certificate to display on their practice wall for 4hrs verifiable and approved CPD. One dentist and/or DCP does the audit for the whole practice and then discuss it at a team meeting, this would only qualify for dentists holding an NHS contract to receive 3hrs funding ( ) and 4hrs verifiable CPD. The rest of the audit group who attend the practice team meeting to discuss the audit will receive 1hr verifiable CPD. If you want to apply for funding / verifiable CPD you need to complete the relevant registration form before starting the audit, and the report /claim form on completion. To do this you need to register with Heather Stewart, PGMDE (StewartH5@Cardiff.ac.uk) by completing electronically the Audit Registration Form, WHTM Form 1. Please complete and return electronically to Heather Stewart. Handwritten Forms will NOT be accepted. You can claim for this audit over and above any standard CAPR claim you have made in your 3 year audit cycle. On completion of the audit you submit your claim form and Improvement Plan to the dental postgraduate section. Your audit Tutor / dental postgraduate department will provide feedback to your practice. In addition they will collate anonymised data by Health Board area so you will be able to benchmark yourself against the average practice in your area. Health Board data will only be collated when at least 50% of practices in that area have completed the audit. For further information on CAPR please contact your local Audit Tutor. Doing the audit In line with other PGMDE audits, this audit is completed electronically and can be retained and updated as required. For practical purposes you may choose to print it and use as hard copy. You may like to identify an individual to take a lead role with the audit but every member of practice team / staff needs to be aware of WHTM01-05 and the fact that the audit is taking place. The NHS contract holder or private practice clinical lead is ultimately responsible for effective decontamination in the practice. It is not necessary to complete the audit in one go. You may want to complete it a section at a time but make sure you set a timeframe to complete the audit (suggest no more than 4 weeks). All members of the practice team who actively participate in the audit are eligible for 3 hours verifiable CPD on satisfactory completion of the audit. Dental Postgraduate Department Wales Deanery 8 th Floor Neuadd Meirionnydd Heath Park Cardiff CF14 4YS T +44 (0) Version 19 October

4 Practice team members who participate in a team meeting to discuss the audit are eligible for 1 hour verifiable CPD. The audit consists of both questions and statements, and there are 2 possible answers: Fully or Not fully Make sure you only answer fully if you are sure this is true for the whole practice. You will not be fully if some surgeries or some staff are some of the time. Most of the questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to continuously improving practice. These are highlighted in yellow and your practice may be or working towards this. It may not always be possible to comply with all aspects of continuously improving practice (E.G. where the building does not allow for certain modifications). every question / statement has an evidence column. You do not need to gather up or submit evidence. However you may find it helpful to store evidence in a physical or electronic folder. This will be useful when you come to re-audit and when discussing results in the practice. this column can be used as required. E.G. to note if an issue needs urgent attention or if something needs to be clarified with other dental team members. What happens with the results? Results stay in the practice you retain form WHTM Form 2; they are not shared with any external organisation. During contract reviews you may choose to tell your Health Board that you have completed the audit, and that you are addressing necessary improvements. You may also choose to share your improvement plan. Completing the audit supports aspects of Quality Assurance System (QAS) return. Your Health Board may ask you to undertake the audit if you have not already completed an audit of infection control. Welsh Government and Health Boards need to be made aware of any commonly occurring barriers to progress. The Postgraduate section will collate findings to inform WG and HBs of trends and themes which emerge from the audits. Dental Postgraduate Department Wales Deanery 8 th Floor Neuadd Meirionnydd Heath Park Cardiff CF14 4YS T +44 (0) Version 19 October

5 NO DATA WILL BE SHARED WHICH IDENTIFIES INDIVIDUAL DENTAL TEAM MEMBERS OR PRACTICES Making Improvements Every practice will have some areas they could do better and the audit will help you prioritise areas for improvement. These should be noted in an Improvement Plan (see appendix 3: template for suggested improvement plan). A single staff member can write the plan, but the practice team is responsible for delivering the plan in an agreed timeframe. Some improvements can be made there and then and don t necessarily need to be included in an improvement plan. Re-audit It is good practice to undertake the audit annually, but note that CAPR funding is not available for these annual review audits. However there are aspects of WHTM which require continuous review (For example daily and weekly equipment checks and DUWL checks). This is consistent with 1000 Lives Plus Improving Quality Together which promotes ongoing quality review rather than a one off process. Sources of support and additional advice Websites PGMDE Wales Dental Deanery BDA (Non members will not have access to full range of information and support) NHS Wales Shared Services Partnership Facilities Services - Decontamination engineers : Authorising Engineers AE(D) at NWSSP-FS Mr Graham Stanton and John Prendergast NHS Shared Services Partnership/Facilities Services Tel No: Royal Mail (sending impressions and appliances/equipment through the post)- What to do in the event of a needle-stick injury Public Health Wales Bibliography WHTM (2014) CDO Letter (2012) 2 Standards for Health Services in Wales Welsh Government, 2010 National Clinical Audit and Outcomes Review Plan Welsh Government, 2012 Cross Infection Control Policies NPHS, PHW Dental Postgraduate Department Wales Deanery 8 th Floor Neuadd Meirionnydd Heath Park Cardiff CF14 4YS T +44 (0) Version 19 October

6 Appendix 1 WHTM Audit Registration Form WHTM Form 1 This form should be completed by the project leader and returned electronically to Heather Stewart, StewartH5@cardiff.ac.uk The project leader will be responsible for submitting all relevant paperwork for all members of the group. Handwritten Forms will NOT be accepted. Please indicate how your practice will be undertaking the audit: Every dentist / nurse team will carry out the audit in their own surgery. We will then collate and compare the results in a practice team meeting. This would enable all dentists who hold an NHS contract to claim 3hrs funding ( ) and the whole team will qualify for a total of 4hrs verifiable CPD (which includes 1hr CPD for attending a practice team meeting). Practices who satisfactorily complete all parts of the WHTM audit will be awarded a certificate to display in the practice. One dentist and/or DCP will undertake the audit for the whole practice and then discuss it at a team meeting. Should a dentist providing NHS funded treatment lead the audit that person would be eligible to qualify for 3hrs funding ( ) and 4hrs verifiable CPD. The rest of the audit group who attend the practice team meeting to discuss the audit will receive 1hr verifiable CPD. Section I Please complete the following Title Please select title Forename Surname Status Please select your status. Other Please specify. GDC Registration Number LHB Contract Number NHS Performer Number Please specify if NOT an NHS Dentist Practice Name and Address Town Postcode Practice Phone Number Out of Hrs Number Address Proposed Start Date a date. N.B Projects cannot commence until approval has been given by CAPRO No of Dentists in the Group Enter no of GDPs No of DCPs in the Group Enter no of DCPs Dental Postgraduate Department Wales Deanery 8 th Floor Neuadd Meirionnydd Heath Park Cardiff CF14 4YS T +44 (0) Version 4: 24/02/2014 3

7 Section II Please provide details of all members taking part in the proposed project. Full Name Status Status GDC No GDC No LHB Contract No NHS Performer No Address Phone No(s) Full Name Status Status GDC No GDC No LHB Contract No NHS Performer No Address Phone No(s) Full Name Status Status GDC No GDC No LHB Contract No NHS Performer No Address Phone No(s) Full Name Status Status GDC No GDC No LHB Contract No NHS Performer No Address Phone No(s) Full Name Status Status GDC No GDC No LHB Contract No NHS Performer No Address Phone No(s) Full Name Status Status GDC No GDC No LHB Contract No NHS Performer No Address Phone No(s) Full Name Status Status GDC No GDC No LHB Contract No NHS Performer No Address Phone No(s) Full Name Status Status GDC No GDC No LHB Contract No NHS Performer No Address Phone No(s) Dental Postgraduate Department Wales Deanery 8 th Floor Neuadd Meirionnydd Heath Park Cardiff CF14 4YS T +44 (0) Version 8: January

8 Full Name Status Status GDC No GDC No LHB Contract No NHS Performer No Address Phone No(s) Full Name Status Status GDC No GDC No LHB Contract No NHS Performer No Address Phone No(s) Full Name Status Status GDC No GDC No LHB Contract No NHS Performer No Address Phone No(s) Full Name Status Status GDC No GDC No LHB Contract No NHS Performer No Address Phone No(s) Full Name Status Status GDC No GDC No LHB Contract No NHS Performer No Address Phone No(s) Full Name Status Status GDC No GDC No LHB Contract No NHS Performer No Address Phone No(s) Full Name Status Status GDC No GDC No LHB Contract No NHS Performer No Address Phone No(s) Full Name Status Status GDC No GDC No LHB Contract No NHS Performer No Address Phone No(s) Dental Postgraduate Department Wales Deanery 8 th Floor Neuadd Meirionnydd Heath Park Cardiff CF14 4YS T +44 (0) Version 8: January

9 Dental Postgraduate Department Wales Deanery 8 th Floor Neuadd Meirionnydd Heath Park Cardiff CF14 4YS T +44 (0) Version 8: January

10 Appendix 2 WHTM Audit The Audit Tool, Form 2 Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to continuously improving practice. These are highlighted in yellow. The relevant chapter or paragraph number of WHTM is noted after each question or statement. References to other guidance are noted at the end of this document. Section A : Policies and procedures including records, logbooks and nominated leads. The following policies and procedures may be included in one document, or they may be individual documents. Either way it is essential that they are up-to date, available to all staff, and used to support good practice. NUMBER STATEMENT/QUESTION Fully 1 The practice has a nominated lead *responsible for infection control and decontamination (Ch 1 and 9) 2 The practice has an identified individual with responsibility and authority to ensure that all staff comply with medical device procedures.(ch 9) 3 Does the practice have a policy or procedure that includes all appropriate aspects of decontamination within the practice e.g. cleaning, disinfection, inspection, packaging, disposal, sterilisation, transport and storage of reusable and single-use instruments? (An infection control policy) (Ch 1) Dental Postgraduate Department Wales Deanery 8 th Floor Neuadd Meirionnydd Heath Park Cardiff CF14 4YS T +44 (0) Version 4: 24/02/2014 7

11 NUMBER STATEMENT/QUESTION Fully 4 Does the infection control policy include procedures to minimise infection risks associated with the use, maintenance, service and repair of all medical devices? (Ch 1) 5 Does the practice have a policy and procedure/s in place for the prevention and management of blood-borne virus exposure, including management of spillages, sharps and inoculation incidents in accordance with national guidance? (Ch 1 and all Wales Inoculation Injury Guidelines) 6 Is there a readily-accessible protocol in place that ensures staff are dealt with in accordance with national guidance in the event of blood-borne virus exposure? (para 2.6 and all Wales Inoculation Injury Guidelines) 7 Does the practice have a policy and procedure/s for : I. the management and disposal of waste? (Appendix 1) II. the use of Personal Protective Equipment? (Ch 6) III. hand hygiene? (Ch 6) IV. spillages in accordance with COSHH? (para 2.6 and 6.74) V. cleaning and maintaining the environment? (para 6.61 onwards) Version 8: January

12 NUMBER STATEMENT/QUESTION Fully 8 The practice has policies and procedures in place to ensure all equipment and instruments that cannot be effectively decontaminated with-in practice premises are processed to the appropriate standards e.g., miscellaneous sedation equipment and implant materials (para 8.9 and Ch 2 manufacturers instructions) 9 Has the practice carried out a risk assessment for legionella under the Health & Safety Commission s Legionnaires disease the control of legionella bacteria in water systems: Approved Code of Practice & Guidance (also known as L8)? (para 6.75 and 6.81) 10 Log books are available and up to date for ultrasonic cleaners, sterilizers and washer disinfectors (if used) which include maintenance and repair records (Ch 11,12,13 and 14) 11 Log books are available and up to date for ultrasonic cleaners, sterilizers and washer disinfectors (if used) which include weekly, quarterly and annual test results for WHTM test schedules (Ch 11,12,13,14) *A nominated lead need not necessarily be a dentist, but must be an indemnified GDC registrant such as a DCP or Practice Manager. See Chapter 9, para 9.3 for Registered Manager role. Version 8: January

13 Section B. APPLICATION OF POLICIES B(i) SINGLE USE EQUIPMENT NUMBER STATEMENT/QUESTION Fully 12 Single-use instruments are never reprocessed (para 2.17 to 2.19) 13 Are difficult-to-clean instruments/devices (e.g. matrix bands, saliva ejectors, aspirator tips and three-in-one tips etc) identified as single-use? (para 2.20) 14 Endodontic files and reamers are never reused (para 2.21) 15 Disposable single-use covers are discarded after each patient contact (para 6.65) B (ii) SHARPS (Ref The Public Health Wales Standard Infection Precautions Policy and WHTM 07-01, Safe Management of Healthcare Waste) 16 Sharps containers are correctly assembled according to manufacturer s instructions 17 Sharps containers are available at the point of use and positioned safely Version 8: January

14 NUMBER STATEMENT/QUESTION Fully 18 In-use sharps containers are labelled with date, location and a signature to enter 19 Needles are never re-sheathed except with the use of an approved re-sheathing device. to enter 20 Are disposable needles and disposable syringes discarded as a single unit? to enter 21 Sharps containers are never filled beyond the indicator mark to enter 22 Are sharps containers locked with the integral lock when filled to the indicator mark? to enter 23 Full sharps containers are stored in a secure facility away from public access to enter 24 The use of safety syringes and other sharps safety devices, as appropriate to clinical practice (e.g. safety IV canulas) has been considered. to enter 25 Do all staff know what to do in the event of a sharps injury? to enter Version 8: January

15 26 All sharps injuries are recorded in accident book. (para 2.6) to enter NUMBER STATEMENT/QUESTION Fully B (iii) INSTRUMENT CLEANING 27 All new reusable instruments are decontaminated prior to use (para 3.4) 28 Instrument trays are appropriately decontaminated prior to use (para 2.14) 29 All instruments (used or unused) left on trays at the end of each session are decontaminated (cleaned/disinfected and sterilised) before further use (para 2.10) 30 Instruments are cleaned prior to disinfection and sterilisation in line with manufacturer s instructions. (Ch 3.0) 31 In practices that do not have a washer-disinfector, are all instruments cleaned manually and/or in an ultrasonic cleaner before steam sterilisation? (para 3.2) Version 8: January

16 32 There is a separate dedicated sink for handwashing in each room where decontamination of equipment takes place (para 2.4r) NUMBER STATEMENT/QUESTION Fully B (iv) DECONTAMINATION ENVIRONMENT 33 In the practice, are there dedicated decontamination areas? OR dedicated decontamination room(s)? 34 If you have separate, dedicated decontamination room/s are they used only for decontamination duties? (para 1.9) 35 Is the decontamination environment segregated from the clinical activity? (para 1.9, 5.1) 36 Are decontamination areas and work surfaces clean and uncluttered? (para 4.29) 37 Is there a clear workflow from dirty to clean activity? (chapter 5) 38 There is adequate ventilation to serve the area containing decontamination equipment (para 6.41 and 6.42) Version 8: January

17 39 There is adequate ventilation to remove any fumes, including those from chemicals used in cleaning / decontamination (para 6.41 and 6.42) Version 8: January

18 NUMBER STATEMENT/QUESTION Fully 40 There are no portable fans used in clinical/decontamination areas (in line with good infection control) (para 6.41) 41 Where full mechanical ventilation is used, does the direction of air flow from the clean to dirty area and has it been checked and verified with a report issued?(para 6.45) Section C CLEANING METHODS C (i) MANUAL CLEANING 42 As an interim arrangement, manual cleaning is performed using a two bowl system [preferably colour coded] for the cleaning and rinsing of instrumentation? (para 2.4r) OR The decontamination area has two separate sinks for cleaning and rinsing contaminated instruments? (para 2.4r) 43 Staff do not use clinical gloves for manual cleaning. Heavy duty domestic gloves are used (Ch 16) 44 Instruments are fully immersed during cleaning, in line with manufacturer s advice (para 16.3c) Version 8: January

19 NUMBER STATEMENT/QUESTION Fully 45 The temperature of water for manual cleaning is monitored to 45 C or lower (para 16.3b) 46 Detergents used are specifically formulated for the cleaning of re-usable dental instruments ( para 16.3) 47 Detergents used for manual cleaning are designed for the manual cleaning of dental instruments.(para 16.3a) 48 Brushes used to clean instruments are single-use or washed after each use and replaced at the manufacturers recommended interval or when damaged (para 16.3f) 49 Instruments that are not decontaminated immediately are kept moist until they are decontaminated (paras 2.15 and 3.5) C (ii) ULTRASONIC CLEANERS 50 Instruments are clearly segregated and placed in instrument baskets or cassettes and fully immersed, ensuring that all surfaces are in contact with the solution (para 3.30) 51 Hinged or jointed instruments are opened prior to placing them in the instruments basket or cassette (3.30) Version 8: January

20 NUMBER STATEMENT/QUESTION Fully 52 Is the lid of the ultrasonic cleaner closed during cleaning cycles and whilst not in use to prevent contamination of the ultrasonic cleaning solution? (3.30) 53 Instruments are thoroughly rinsed after being cleaned in the ultrasonic cleaner, prior to disinfection and sterilisation (3.30) 54 Is the solution in the chamber emptied either when visibly contaminated or otherwise at the end of every clinical session? (3.30) 55 Is there a maintenance contract in place to ensure the Ultrasonic cleaner is serviced in line with manufacturer s schedule? (para 14.1) 56 Is there a schedule in place to ensure the Ultrasonic cleaner is validated? (para 14.2) 57 Are the records and reports for daily, weekly, quarterly and annual tests available for inspection? (Ch 14) C (iii) WASHER/DISINFECTORS 58 Daily checks are carried out prior to use, i.e. spray arms are free to rotate and drain filter is emptied as required (para 13.4). Version 8: January

21 NUMBER STATEMENT/QUESTION Fully 59 Records are kept of these daily checks (para 3.19) 60 Instruments are correctly loaded into the washer/disinfector, clearly segregated (shadowing) and cannulated instruments arranged appropriately and connected to the correct connections on the specified loading carriage. (para 3.17) 61 Is there a daily check in place to compare and monitor variables of a standard operating cycle? (para 13.4) 62 Contractual arrangements are in place to ensure all automated washer-disinfectors are routinely maintained correctly to the manufacturer s instructions and recorded (Ch 13) 63 Contractual arrangements are in place for carrying out the testing requirements as specified in WHTM chapter 13 C (iv) INSPECTION 64 Instruments are inspected under an illuminated magnification device for cleanliness and condition following cleaning (paras 3.18, 3.49, 3.50, 3.52) Version 8: January

22 NUMBER STATEMENT/QUESTION Fully C (v)sterilization 65 Instruments that are not clean are returned to the cleaning cycle (para 3.52) 66 Instruments sterilized in a non-vacuum (type N) steriliser are dried appropriately prior to packing using disposable non-linting cloth (para 2.4j) 67 All instruments sterilised in a non- vacuum (type N) bench top sterilizer are unwrapped prior to sterilization (para 4.24b) 68 Instruments sterilized in a vacuum B or S type bench top steriliser are dried and appropriately wrapped prior to sterilization (para 4.24 and 4.25) 69 Packs are inspected to ensure there is no visible moisture present in the packs prior to storage (para 1.25) 70 Are all instruments compatible with the configured sterilization cycle (time and temperature), and the manufacturers instructions? (para 10.23) 71 The sterilizer is correctly loaded as identified in the manufacturers operating manual using appropriate shelving for the instruments being sterilized. (para 4.21) (also see Sterilizer Operating Manual) Version 8: January

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24 NUMBER STATEMENT/QUESTION Fully 72 Freshly distilled water, sterile water for irrigation or reverse osmosis (RO) water are used to generate steam in the steriliser (para 4.13) 73 Are all stored sterilized instruments packaged and dated with the date of sterilisation? (para 4.26) 74 The autoclave reservoir is drained and left clean and dry at the end of each day. (para 4.13) 75 Are opened bottles of sterile or distilled water discarded at the end of each working day? (para 17.6) 76 A record is made of daily checks including date, temperature and pressure achieved and satisfactory completion for each cycle (para 4.18) 77 Documentation is available to provide evidence of sterilizer management, to include daily, weekly, quarterly and annual testing reports, maintenance records and service reports (para 4.15) 78 Is there a maintenance contract in place to ensure the sterilizer is serviced in line with manufacturer s schedule? (para 12.1) Version 8: January

25 79 Are there systems in place to check that that the maintenance contract is properly met? Ref: Service level agreement NUMBER STATEMENT/QUESTION Fully 80 Is there a contract in place to ensure the sterilizer is validated in line with WHTM 01/05? (para 12.2) 81 The practice / organisation has a written scheme of examination and insurance systems in place for steam sterilizers in accordance with the Pressure Systems Safety Regulations? (para 4.12) 82 Are procedures in place to remove Sterilizers from service that fail to meet testing requirements until the fault is rectified (para 4.23) 83 Does the sterilizer have a printer/independent monitor to record data from each cycle used or a manual log to record such data? (para 4.16) C (vi) HANDPIECES 84 Handpieces are decontaminated between each patient in accordance with manufacturers instructions (para 2.4q) 85 Handpieces that are manually cleaned/disinfected are lubricated with oil before steam sterilization in accordance with manufacturers instructions (para 3.55) 86 Handpieces washed by a specific handpiece cleaning device are lubricated with oil before sterilization in Version 8: January

26 accordance with manufacturers instructions (para 2.4q, Ch3 note 2) NUMBER STATEMENT/QUESTION Fully 87 Handpieces decontaminated by an automated washer disinfector and or with a specific handpiece irrigation system are lubricated with oil before sterilization in accordance with manufacturer s instructions (para 3.24) 88 Are separate canisters of lubricant used for unclean, cleaned and sterilised handpieces / instruments?(para 3.56) C (vii) MISCELLANEOUS 89 Prosthetic and orthodontic appliances are decontaminated before being placed in the patient s mouth.(ch 7) 90 Are disinfectant solutions changed regularly in accordance with manufacturer s guidelines? (para 3.30j) 91 Reusable trays are decontaminated and sterilized after every use OR the practice uses disposable instrument trays (para 2.17, 2.18) Version 8: January

27 92 Are film holders used in intra-oral radiography subject to decontamination after every patient use in accordance with manufacturers instructions? (para 6.72) NUMBER STATEMENT/QUESTION Fully C (viii) SEDATION EQUIPMENT 93 Are ISM flowmeters used and maintained in accordance with original equipment manufacturers or suppliers instructions? 94 Are ISM breathing systems (tubing, masks, nasal hood and nose pieces) used and cleaned in accordance with manufacturers or suppliers instructions? C (ix) CLEANING EQUIPMENT 95 Cleaning equipment is stored in a non-clinical area (para 6.54) 96 Are chlorine-releasing agents available for blood/bodily fluid spillages and used as per manufacturers instructions? (para 6.74) Section D STORAGE AND MOVEMENT OF INSTRUMENTS / MEDICAL DEVICES / OTHER DEVICES D (i) STORAGE Version 8: January

28 97 Instruments are stored in a dedicated, secure, dry and cool environment (para 4.27 to 4.31) Version 8: January

29 NUMBER STATEMENT/QUESTION Fully 98 Does the practice have a system in place to record reprocessing dates and storage time for wrapped instruments? (para 2.4k) 99 Instruments wrapped and packed after processing in a type N sterilizer are stored for no more than 1 year (para 2.4k) 100 Instruments wrapped and packed and processed in a type B or S sterilizer are stored for no more than 1 year (para 2.4k) 101 Is there a system in place to ensure that wrapped instruments are stored away from the clinical environment and used in strict rotation? (para 4.29) 102 Intra-oral films, digital sensors and cassettes are handled and stored safely in accordance with manufacturers instructions (para 6.72) D (ii) MOVEMENT WITHIN THE PRACTICE and OUT OF THE PRACTICE 103 There are procedures in place for the safe transfer of instruments within the practice to prevent recontamination (para 2.6) Version 8: January

30 NUMBER STATEMENT/QUESTION Fully 104 Is there a procedure for transportation of instruments to and from other locations, including domiciliary visits, which ensures the segregation and identification of contaminated instruments from clean/sterilized instruments? (para ) 105 There is a clear policy in place for transport of instruments in and out of the practice (para 2.26 and 2.30) 106 Are impressions, prosthetic and orthodontic appliances decontaminated in the surgery prior to despatch to laboratory in accordance with manufacturer s instructions and in line with postal regulations? (Ch 7 and para 2.31) 107 Instruments sent for repair are labelled to identify that they have been through the decontamination process (para 3.54) 108 Contaminated medical devices are decontaminated prior to inspection, maintenance or repair (para 3.54) 109 If transport containers are in use, are they lidded, clean, leakproof and in good working order? (para 2.27) Version 8: January

31 NUMBER STATEMENT/QUESTION Fully 110 Are transport containers cleaned, disinfected and dried following each use? (para 2.28) Section E. TRAINING and STAFF SAFETY 111 Have all relevant staff received formal training in relation to para 1.26 i) the decontamination procedures which they are expected to perform including correct use of equipment? ii) iii) cleaning duties? the prevention and management of bloodborne virus exposure? 112 Are staff trained in the use of personal protective equipment as part of the practice induction? (para 6.14) 113 Have all staff attended induction and ongoing training in the process of waste segregation and disposal? (Appendix 1) 114 Have all staff at risk from sharps injuries received training on risk reduction in relation to blood-borne virus transmission and general infection? (para 1.26) Version 8: January

32 NUMBER STATEMENT/QUESTION Fully 115 A record of all staff training is maintained.(para 1.26) 116 Can decontamination and clinical staff provide documentary evidence of previous successful immunisation with hepatitis B vaccine? (para 2.4p) 117 All inoculation injuries are documented and records maintained. (Ref -PHW. All-Wales Inoculation Injury Guidelines for Primary Care) Section F. QUALITY ASSURANCE F (i) HAND WASHING 118 Are hand hygiene facilities clean and intact (check sinks taps, splash-backs, liquid soap and paper-towel dispensers)? (Ref Public Health Wales Standard Infection Precautions Policy) 119 Are wash-hand basins free from equipment and other utility items? (Ref Public Health Wales Standard Infection Precautions) 120 Are sensor or lever operated (elbow/wrist/foot-operated) mixer taps available at all wash-hand basins in clinical and decontamination areas? (para 6.11) Version 8: January

33 NUMBER STATEMENT/QUESTION Fully 121 Are thermostatically controlled taps in use? 122 Does the sink have a plug or an overflow and is fitted with a remote running trap? (U-bend is not directly under the plughole) (para 6.11) 123 Good quality liquid soap is available at each wash-hand basin (para 6.12) 124 The soap cartridges within the dispensers are single use and are never refilled. (para 6.12) 125 Bar soap is not used at wash-hand basins (para 6.6) 126 Reusable nail brushes are not present at wash-hand basins (para 6.9 and Appendix 2) 127 Are disposable absorbent paper towels or hand dryers available at all wash-hand basins? (para 6.7) 128 Are hand-cream dispensers with disposable cartridges available for all clinical and decontamination staff? (para 6.8) Version 8: January

34 129 Skin disinfectant e.g. alcohol gel is available for hand hygiene (Ref The Public Health Wales Standard Infection Precautions Policy and Appendix 2) NUMBER STATEMENT/QUESTION Fully 130 Is there a separate dedicated hand basin provided for hand hygiene in each surgery where clinical practice takes place? (para 6.11) 131 Laminated or wipe-clean posters promoting hand hygiene are on display (para 6.13) 132 Clinical and decontamination staff i) remove wrist watches, wrist jewellery, rings with stones during clinical and decontamination procedures (para 6.10) ii) Are bare below elbows or use disposable forearm covers (para 6.34) 133 Staff involved in any clinical and decontamination procedures have short nails that are clean and free from nail extensions and varnish.(para 6.9) 134 Is hand hygiene performed before i) donning and after the removal of gloves? (para 6.5) Version 8: January

35 ii) before and after every new patient contact? (para 6.5) NUMBER STATEMENT/QUESTION Fully 135 Is hand hygiene an integral part of staff induction? (para 6.3) 136 Is hand hygiene training provided periodically throughout the year? (para 6.3) 137 Hand hygiene training records are maintained (para 6.3 and 1.26) F (ii) PERSONAL PROTECTIVE EQUIPMENT (Ref Ch6, 6.14 to 6.37) 138 Are plastic gowns/aprons, goggles, masks or face shields used for any clinical and decontamination procedures where there is a danger of splatter or aerosol formation? 139 Eye protection provided for patients and staff is decontaminated after each episode of patient care 140 Eye protection for staff used during decontamination procedures is cleaned after each session or sooner if visibly decontaminated Version 8: January

36 141 Items of PPE are stored in accordance with manufacturers instructions NUMBER STATEMENT/QUESTION Fully 142 Masks are disposed of as clinical waste after each use 143 Single-use plastic aprons are disposed of as clinical waste 144 All single-use PPE items are disposed of after each episode of patient care 145 Alternatives to latex gloves are available 146 Powder-free CE-marked gloves are used routinely 147 Surgery wear worn by all staff is changed at the end of each day or when visibly contaminated Version 8: January

37 148 Disposable plastic aprons are worn during all decontamination processes or clinical procedures where there is a risk that clothing/uniform may become contaminated NUMBER STATEMENT/QUESTION Fully 149 Are clean, heavy-duty domestic gloves i) available in a range of sizes? ii) iii) iv) Used for domestic cleaning and decontamination procedures where necessary? replaced weekly or more frequently if torn? washed with detergent and hot water and left to dry after each use? (ref Appendix 2) F (iii) KEEPING THE ENVIRONMENT CLEAN 150 Is the overall appearance of the clinical and decontamination environment tidy and uncluttered and is the environment safe for staff to work in? (Ref The Public Health Wales Standard Infection Precautions Policy) Version 8: January

38 151 Do all floor coverings in clinical and decontamination areas have coved edges that are sealed and impervious to moisture? (para 6.46) 152 Are floor coverings in clinical and decontamination areas impervious and easy-to-clean?(para 6.47) NUMBER STATEMENT/QUESTION Fully 153 Floors, cupboard doors and accessible high-level surfaces are cleaned daily (para 6.63) 154 Rooms where clinical procedures take place are not carpeted (para 6.46) 155 Are keyboard covers or easy-clean waterproof keyboards used in clinical areas? (para 6.66) 156 Are all surfaces in clinical and decontamination areas impervious and easy to clean? (para 6.46) 157 Are the surfaces of accessible ventilation fittings/grills cleaned weekly? (para 6.64) 158 Are all surfaces (i.e. walls, floors, ceilings, fixtures and fittings, and chairs) free from dust and visible dirt?(para 6.63) Version 8: January

39 159 Are all work-surface joints intact and seamless with no visible damage? (para 6.46) 160 Are all surfaces (i.e. walls, floors, ceilings, fixtures and fittings, and chairs) free from damage and abrasion? (para 6.39) NUMBER STATEMENT/QUESTION Fully F (iv) DECONTAMINATION OF CLINICAL AREAS 161 Soft toys are not available (para 6.73) 162 The dental chair is free from rips or tears (para 6.62) 163 The dental chair is cleaned between each patient (para 6.62) 164 Are the surfaces of equipment cleaned between each patient (for example, work surfaces, dental chairs, curing lamps, delivery units, inspection handles and lights, spittoons, external surfaces of aspirators and X-ray heads)? (para 6.62) 165 Are all taps, drainage points, splashbacks, sinks, aspirators, drains and spittoons cleaned after every session with a surfactant/detergent? (para 6.63) F (v) WATER SYSTEMS (Paras 6.80 to 6.91 and Ch 19) Version 8: January

40 166 Are dental unit waterlines and handpieces fitted with antiretraction valves as appropriate? 167 Where bottled water systems are not used, is there a physical air gap separating DUWLs from mains water systems (Type A)? Version 8: January

41 NUMBER STATEMENT/QUESTION Fully 168 Are dental unit waterlines flushed for 2 minutes at the start of each working day and for seconds between every patient? 169 Are dental unit waterlines treated with an appropriate biocide according to manufacturer s instructions? 170 Are self-contained water bottles (bottled water system) removed, flushed with distilled or clean RO water and left open to the air for drying on a daily basis and if necessary overnight, and in accordance with manufacturers guidance? 171 For dental surgical procedures involving irrigation, is a separate single-use sterile water source used for irrigation? 172 Is an independent bottled-water system used to dispense fresh distilled, reverse osmosis (RO) or sterile water to supply the DUWL? 173 Are in-line filters cleaned /replaced as per manufacturer s instructions? 174 Does the practice have a written scheme for prevention of legionella contamination in water pipes and other water lines? (para 19.2) Version 8: January

42 NUMBER STATEMENT/QUESTION Fully F (vi) WASTE DISPOSAL (Appendix 1) 175 The Registered Manager (or nominated other) is identified as being the lead person for waste disposal 176 The Registered Manager is aware of the Hazardous Waste (England and Wales) Regulations and ensures the practice complies with them. 177 The Registered Manager (or nominated other) ensures that waste is:- i. Correctly segregated ii. iii. iv. Stored safely and securely away from areas of public access Packaged appropriately to be transported Described accurately and fully on the accompanying documents when removed from the premises v. Transferred to an Authorised Person for transport to an authorised waste site vi. Appropriately registered, with necessary records and returns kept in the practice. ( Records and Version 8: January

43 returns means records of any hazardous waste consignment notes etc) Section G Mobile Dental Units (MDU) For Community Dental Services 178 There is a policy for decontamination and disinfection on mobile dental units 179 Staff working on mobile dental units have been trained in MDU decontamination and disinfection procedures 180 All MDU waste is disposed of according to HB policies 181 MDUs are cleaned externally and internally in line with HB timetable Additional references as noted:- NPHS for Wales. All-Wales Inoculation Injury Guidelines for Primary Care. (NPHS is now Public Health Wales) Public Health Wales Standard Infection Precautions Policy WHTM Safe Management of Health Care Waste Version 8: January

44 Appendix 3 WHTM Audit Template Improvement Plan, Form 3 NUMBER of Statement / Question What improvements are needed and what we will do Who is responsible to enter Date for completion to enter to enter to enter to enter Version 8: January

45 NUMBER of Statement / Question What improvements are needed and what we will do Who is responsible to enter Date for completion to enter to enter to enter to enter to enter to enter Version 8: January

46 Appendix 3 WHTM Audit Template Improvement Plan, Form 3 To be completed by the Dental Practice Team Comments or Barriers to Improvement: Tutor Feedback: Version 8: January

47 Appendix 4 WHTM Audit Claim Form WHTM Form 4 This form should be completed when claiming funding. Please submit your claim form in Hard Copy and send to Heather Stewart to the address below. Your Name and Initials Local Health Board GDC Registration Number LHB Contract Number NHS Performer Number Please tick if NOT an NHS Dentist Payment Details No of hours claimed /hour (N.B All NHS Contract Numbers for the duration of the audit must have been open in order to receive funding) Total Claim Claim Form Declaration I declare that (please tick boxes below) I confirm that I have undertaken a Decontamination Audit and written an Improvement Plan. I understand that I am liable to declare payments to the Inland Revenue and that Income Tax and NI will NOT be deducted on my behalf from the amounts claimed above. I confirm that my NHS contract number was open for the duration of the audit. Signature of Claimant Date Verification and Payment Approval: I certify that the above named dentist has satisfactorily completed the Decontamination Audit above in accordance with the guidance issued by the The Dental Postgraduate Section, Wales Deanery Examined & Verified by Signature Date Director/Deputy Director of Dental Postgraduate Education in Wales Any queries with regard to the payment process should be directed to the Dental Postgraduate Section. Dental Postgraduate Department Wales Deanery 8 th Floor Neuadd Meirionnydd Heath Park Cardiff CF14 4YS T +44 (0) Version 8: January