HIW Dental Practice Inspections. Rebecca Jewell Primary & Community Healthcare Manager, Healthcare Inspectorate Wales Ali Jahanfar, Peer Reviewer

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1 HIW Dental Practice Inspections Rebecca Jewell Primary & Community Healthcare Manager, Healthcare Inspectorate Wales Ali Jahanfar, Peer Reviewer 1

2 About HIW Who we are HIW is the independent inspectorate and regulator of all healthcare in Wales What we do We review and inspect NHS and independent healthcare organisations in Wales to provide independent assurance for patients, the public, the Welsh Government and healthcare providers Our purpose To provide the public with independent and objective assurance of the quality, safety and effectiveness of healthcare services, making recommendations to healthcare organisations to promote improvements. 2

3 Our values Patient-centred: we place patients, service users and public experience at the heart of what we do Openness and honesty: in the way we report and in all our dealings with stakeholders Collaboration: building effective partnerships internally and externally Professionalism: maintaining high standards of delivery and constantly seeking to improve Proportionality: ensuring efficiency, effectiveness and proportionality in our approach 3

4 Our outcomes Provide assurance: Provide independent assurance on the safety, quality and availability of healthcare by effective regulation and reporting openly and clearly on our inspections and investigations. Promote improvement: Encourage and support improvements in care through reporting and sharing good practice and areas where action is required. Strengthen the voice of patients: Place patient experience at the heart of our inspection and investigation processes. Influence policy and standards: Use our experience of service delivery to influence policy, standards and practice. 4

5 Our Work 5

6 Give Clear Reassurance that: 1.This is not intended to be a Gestapo type experience 2. Much more a discussion between professional colleagues 3. We are listening to your comments and experiences and acting upon them where appropriate 4. We are refining our processes 6

7 The Visit Workbook Components 1. Patient Experience 2. Management and Leadership 3. Written Documents 4. The Environment internal and external premises 5. Standards (IRMER, Medical Emergencies and Waste 6. Decontamination Processes 7. Clinical Facilities 8. Patient Records 7

8 The Inspection Team The Inspection Manager & The Clinical Reviewer 8

9 HIW Dental Inspection Programme the journey so far Stakeholder Reference Group established including representatives from LHBs, WG, PHW, BDA, GDC and Deanery Methodology and reporting style developed Clinical Dental Lead (Dr Brent Weller) and Dental Reviewers appointed Pilot inspection undertaken to test HIW s inspection processes 2014/15 inspection programme 75 practices inspected 2015/16 inspection programme 133 practices inspected 9

10 Dental Inspection Programme the journey so far Positive impact and engagement Findings used by Wales Postgraduate Deanery, Public Health Wales and Welsh Government First annual report published in June 2015 Second annual report to be published summer

11 HIW Dental Inspection Programme the process BEFORE THE INSPECTION: 8 weeks notice by letter What to expect from an inspection guidance List of documents for inspectors to view Patient Questionnaires Telephone call approximately one week before from inspector - workbook and guidance 11

12 HIW Dental Inspection Programme the process THE DAY OF THE INSPECTION: Inspection team - HIW inspection manager + dentist One day on site Complete inspection workbook Observe (eg decontamination process) Talk (speak to patients and all staff) Check (documentation and records) Immediate verbal feedback 12

13 The role of the Peer Reviewer The Peer reviewer inspects the following areas Radiographic equipment & documentation Including the Radiation Protection File, The radiation equipment certification for each machine, Quality assurance audits Records of Radiation Protection Training (IRMER)

14 Radiography Issues Registration of equipment Age of equipment Condition Location relative to staff/patient positioning? Local rules Appointed persons? 14

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17 Radiography Issues Quality Assurance QA 1,2,3 recording and auditing Diagnostic reporting in patient notes Film storage if wet films Data back up if digital Start of day wedge testing? 17

18 Daily Wedge Tests? 18

19 The role of the Peer Reviewer The Peer reviewer inspects the following areas Resuscitation and First Aid Practice resuscitation policy Up to date training in CPR Appointed first aider Does the practice has adequate resuscitation equipment? Are all emergency drugs within date? Log book to show regular checks of emergency drugs and resuscitation equipment. What systems are in place to ensure the security of drugs and prescription pads?

20 The role of the Peer Reviewer The Peer reviewer inspects the following areas Decontamination of instruments and compliance with WHTM01-05 Daily maintenance programme including log books for checking each autoclave, start and end of day checks. Pre-cleaning methods Washer disinfector Ultrasonic bath Manual cleaning Instrument storage including transport between surgeries and decontamination room Hand washing facilities available? Designated contamination room available? Decontamination training protocol with individual records Routine audits of infection control requirements WHTM01-05 Inspection certificates for autoclaves

21 Cross Infection Control Basic cleanliness issues Work surfaces clear Sealed surfaces Sealed flooring Important to separate what is essential and what is advisable/desirable/ Gold Standard 21

22 Clutter worth commenting on but hardly a reportable issue! 22

23 Rethinking and tidying needed 23

24 Less Clutter 24

25 Wipe clean keyboard 25

26 Cross Infection Control AUTOCLAVE ISSUES Type B, N or S? (B- pre-wrapped and storage 12 months) (N- post wrapped and storage 12 months) (S- see manufacturer s guidance) Type B may be best but not compulsory 26

27 Autoclaves Location Use of a Sterilising room / CSSD Autoclaves still in surgeries? 27

28 Clear Labelling and Expiry Dates 28

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31 We All Make Mistakes!! 31

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34 Pre- Autoclave Cleaning Process Pre soaking? PPE Ultrasonic cleaning Manual cleaning Visual Inspection good light + magnification Use of washer-disinfectors? 34

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37 Clear Visual Inspection 37

38 Hand Cleaning and Instructions 38

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40 Post Sterilisation Storage Where? How long? 40

41 Storage away from surgery - labelled 41

42 Autoclaving of Ultrasonic Tips AND Handpieces 42

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45 The role of the Peer Reviewer The Peer reviewer inspects the following areas Handling, storage and disposal or clinical and non-clinical waste Contracts in place for clinical waste, amalgam waste, sharps, non-clinical waste Where is the clinical waste stored? Is the clinical waste stored securely? What happens to unused medicine? Extracted teeth with/without amalgam Domestic waste such as black bags Amalgam separators installed?

46 Waste Storage Clinical waste Contaminated Teeth Amalgam waste Amalgam capsules Lockable storage? 46

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49 Sharps Management Needle resheathing? Or not? Holders Sharps containers and location 49

50 The role of the Peer Reviewer The Peer reviewer inspects the following areas Clinical Facilities Dental Surgeries Dental unit and cabinetry in good condition? Is the surgery clean? X-ray equipment Local rules visible Film holding kit available Dental Equipment and Instruments Sufficient number of fast, slow and straight handpieces Ultrasonic scaler and tips Surgical kit Filling mixer Disposable or single use items. Regular serving of compressor

51 Audit Recording of audits Which are being done? Which are essential NB some contain confidential data that we do not need to view 51

52 CPD Records Should be recorded And available on the day to view Staff training and updates CPR Training when and who? Defibrillator - Compulsory or not? 52

53 BPEs and Periodontal Care Ensure that 1. BPEs are being recorded and updated 2. Treatments prescribed match the BPE score 53

54 The role of the Peer Reviewer The Peer reviewer inspects the following areas Patient records Previous dental history Social history including alcohol and tobacco use Smoking cessation advice offered? Reason for attendance Symptoms Initial medical history signed and dated by patient. Updated medical history for each course of treatment Full Base charting Baseline BPE recorded Oral cancer screening Treatment planning evidence Treatment options recorded Informed consent Treatment provided Recall recorded Radiograph justification Clinical findings noted Quality grade noted (QA1, 2 or 3) Referrals recorded

55 Medical History Initial Updated? 55

56 Batch Numbers and Expiry Dates 56

57 HIW Dental Inspection Programme the process AFTER THE INSPECTION: Immediate Assurance letter within 2 days (if necessary) Draft report for factual accuracy check within 3 weeks 3 domains: Quality of patient experience Delivery of safe and effective care Quality of management and leadership Respond to Improvement Plan within 2 weeks Report translated and published on HIW website 3 months after date of inspection 57

58 Typical Issues Radiation IRR 1999 and IR(ME)R 2000 Decontamination WHTM01-05 Patient records medical histories; justification and clinical findings from radiographs No mechanism for patient feedback No evidence of indemnity insurance CPR training out of date No hepatitis B vaccination records Out of date drugs/equipment Staff appraisals 58

59 Issues That Have Warranted the Immediate Assurance Process Lack of IRMER training X-ray equipment lacking certification registration and servicing Ultrasonic scaler handpieces and 3-in-1 tips not sterilised after each use. (This has arisen at 3 inspections.) Inappropriate PAT testing Medications out of date No CPR training records 59

60 Endodontic files being re-used Lack of audit (in compliance with WHTM 01-05) No maintenance certificates for autoclaves (twice) Infection control issues Breach of Care Standards Act 2000 private practice not registered with HIW & use of class 4 laser unregistered Poor clinical practice (GDC?) 60

61 Issues Leading to Recommendations in Reports Complaints procedure either not clearly displayed or compliant with Putting Things Right Patient s views not sought e.g. by questionnaires etc X-ray justification not recorded &/or quality of images not recorded X-rays not reported upon Practices unaware of their DBS obligations Corporates and shared practice managers 61

62 Other Comments Inspection workbook is now published on the HIW website to assist practices to prepare in advance of inspections We have occasionally found disparity between the QAS returns and the actual inspections!! 62

63 Thank you Any questions or suggestions? 63